{% block scripts %}

    {% if mode is defined %}
        <script src="{{ asset('bundles/main/js/jquery-1.9.1.js') }}"></script>
    {% endif %}

    <script  type="text/javascript">
        $(document).ready(function(){
            {% if mode is defined %}
            var errorAjax = '{{ 'messages.ajax.errorProcess'|trans([], 'LocalizationBundle') }}';
            var url_buscar_encuestaMR = '{{ path('DataEncuestaMR') }}';
            $.ajax({
                url: url_buscar_encuestaMR,
                type: "POST",
                data: {
                    'appCode': '{{ appCode }}'
                },
                success: function (resp) {
                    var jsonResp = JSON.parse(resp);
                    for (var i = 0; i < jsonResp.length; i++) {
                        $("#encrm1").val(jsonResp[i]['campo1']);
                        $("#encrm2").val(jsonResp[i]['campo2']);
                        $("#encrm3").val(jsonResp[i]['campo3']);
                        $("#encrm4").val(jsonResp[i]['campo4']);
                        if (jsonResp[i]['campo5'] === '1') {
                            $("#encrm5").prop('checked', true);
                        }else if (jsonResp[i]['campo5'] === '2') {
                            $("#encrm6").prop('checked', true);
                        }
                        $("#encrm7").val(jsonResp[i]['campo7']);
                        $("#encrm8").val(jsonResp[i]['campo8']);
                        $("#encrm9").val(jsonResp[i]['campo9']);
                        $("#encrm10").val(jsonResp[i]['campo10']);
                        $("#encrm11").val(jsonResp[i]['campo11']);
                        if (jsonResp[i]['campo12'] === '1') {
                            $("#encrm12").prop('checked', true);
                        }
                        if (jsonResp[i]['campo13'] === '1') {
                            $("#encrm13").prop('checked', true);
                        }
                        if (jsonResp[i]['campo14'] === '1') {
                            $("#encrm14").prop('checked', true);
                        }
                        $("#encrm15").val(jsonResp[i]['campo15']);
                        if (jsonResp[i]['campo16'] === '1') {
                            $("#encrm16").prop('checked', true);
                            $("#encrm18").prop('disabled', false).css('background', '#fff');
                        }else if (jsonResp[i]['campo16'] === '2'){
                            $("#encrm17").prop('checked', true);
                            $("#encrm18").prop('disabled', true).css('background', '#aeaeae');
                        }
                        $("#encrm18").val(jsonResp[i]['campo18']);
                        $("#encrm19").val(jsonResp[i]['campo19']);
                        $("#encrm20").val(jsonResp[i]['campo20']);
                        $("#encrm21").val(jsonResp[i]['campo21']);
                        $("#encrm22").val(jsonResp[i]['campo22']);
                        $("#encrm23").val(jsonResp[i]['campo23']);
                        if (jsonResp[i]['campo24'] === '1') {
                            $("#encrm24").prop('checked', true);
                        }else if (jsonResp[i]['campo24'] === '2'){
                            $("#encrm25").prop('checked', true);
                        }
                        if (jsonResp[i]['campo26'] === '1') {
                            $("#encrm26").prop('checked', true);
                            $("#encrm28").prop('disabled', false).css('background', '#fff');
                        }else if (jsonResp[i]['campo26'] === '2'){
                            $("#encrm27").prop('checked', true);
                            $("#encrm28").prop('disabled', true).css('background', '#aeaeae');
                        }
                        $("#encrm28").val(jsonResp[i]['campo28']);
                        if (jsonResp[i]['campo29'] === '1') {
                            $("#encrm29").prop('checked', true);
                        }else if (jsonResp[i]['campo29'] === '2'){
                            $("#encrm30").prop('checked', true);
                        }
                        $("#encrm31").val(jsonResp[i]['campo31']);
                        if (jsonResp[i]['campo32'] === '1') {
                            $("#encrm32").prop('checked', true);
                        }else if (jsonResp[i]['campo32'] === '2'){
                            $("#encrm33").prop('checked', true);
                        }
                        if (jsonResp[i]['campo34'] === '1') {
                            $("#encrm34").prop('checked', true);
                            $("#encrm36").prop('disabled', false).css('background', '#fff');
                        }else if (jsonResp[i]['campo34'] === '2'){
                            $("#encrm35").prop('checked', true);
                            $("#encrm36").prop('disabled', true).css('background', '#aeaeae');
                        }
                        $("#encrm36").val(jsonResp[i]['campo36']);
                        if (jsonResp[i]['campo37'] === '1') {
                            $("#encrm37").prop('checked', true);
                        }else if (jsonResp[i]['campo37'] === '2'){
                            $("#encrm38").prop('checked', true);
                        }
                        if (jsonResp[i]['campo39'] === '1') {
                            $("#encrm39").prop('checked', true);
                        }else if (jsonResp[i]['campo39'] === '2'){
                            $("#encrm40").prop('checked', true);
                        }
                        if (jsonResp[i]['campo41'] === '1') {
                            $("#encrm41").prop('checked', true);
                        }else if (jsonResp[i]['campo41'] === '2'){
                            $("#encrm42").prop('checked', true);
                        }
                        if (jsonResp[i]['campo43'] === '1') {
                            $("#encrm43").prop('checked', true);
                        }else if (jsonResp[i]['campo43'] === '2'){
                            $("#encrm44").prop('checked', true);
                        }
                        if (jsonResp[i]['campo45'] === '1') {
                            $("#encrm45").prop('checked', true);
                        }else if (jsonResp[i]['campo45'] === '2'){
                            $("#encrm46").prop('checked', true);
                        }
                        if (jsonResp[i]['campo47'] === '1') {
                            $("#encrm47").prop('checked', true);
                        }else if (jsonResp[i]['campo47'] === '2'){
                            $("#encrm48").prop('checked', true);
                        }
                        if (jsonResp[i]['campo49'] === '1') {
                            $("#encrm49").prop('checked', true);
                        }else if (jsonResp[i]['campo49'] === '2'){
                            $("#encrm50").prop('checked', true);
                        }
                        if (jsonResp[i]['campo51'] === '1') {
                            $("#encrm51").prop('checked', true);
                        }else if (jsonResp[i]['campo51'] === '2'){
                            $("#encrm52").prop('checked', true);
                        }
                        if (jsonResp[i]['campo53'] === '1') {
                            $("#encrm53").prop('checked', true);
                        }else if (jsonResp[i]['campo53'] === '2'){
                            $("#encrm54").prop('checked', true);
                        }
                        if (jsonResp[i]['campo55'] === '1') {
                            $("#encrm55").prop('checked', true);
                        }else if (jsonResp[i]['campo55'] === '2'){
                            $("#encrm56").prop('checked', true);
                        }
                        if (jsonResp[i]['campo57'] === '1') {
                            $("#encrm57").prop('checked', true);
                        }else if (jsonResp[i]['campo57'] === '2'){
                            $("#encrm58").prop('checked', true);
                        }
                        if (jsonResp[i]['campo59'] === '1') {
                            $("#encrm59").prop('checked', true);
                        }else if (jsonResp[i]['campo59'] === '2'){
                            $("#encrm60").prop('checked', true);
                        }
                        if (jsonResp[i]['campo61'] === '1') {
                            $("#encrm61").prop('checked', true);
                        }else if (jsonResp[i]['campo61'] === '2'){
                            $("#encrm62").prop('checked', true);
                        }
                        if (jsonResp[i]['campo63'] === '1') {
                            $("#encrm63").prop('checked', true);
                        }else if (jsonResp[i]['campo63'] === '2') {
                            $("#encrm64").prop('checked', true);
                        }
                        if (jsonResp[i]['campo65'] === '1') {
                            $("#encrm65").prop('checked', true);
                        }else if (jsonResp[i]['campo65'] === '2'){
                            $("#encrm66").prop('checked', true);
                        }
                        if (jsonResp[i]['campo67'] === '1') {
                            $("#encrm67").prop('checked', true);
                        }else if (jsonResp[i]['campo67'] === '2'){
                            $("#encrm68").prop('checked', true);
                        }
                        if (jsonResp[i]['campo69'] === '1') {
                            $("#encrm69").prop('checked', true);
                        }else if (jsonResp[i]['campo69'] === '2'){
                            $("#encrm70").prop('checked', true);
                        }
                        if (jsonResp[i]['campo71'] === '1') {
                            $("#encrm71").prop('checked', true);
                        }else if (jsonResp[i]['campo71'] === '2'){
                            $("#encrm72").prop('checked', true);
                        }
                        if (jsonResp[i]['campo73'] === '1') {
                            $("#encrm73").prop('checked', true);
                        }else if (jsonResp[i]['campo73'] === '2'){
                            $("#encrm74").prop('checked', true);
                        }
                        if (jsonResp[i]['campo75'] === '1') {
                            $("#encrm75").prop('checked', true);
                        }else if (jsonResp[i]['campo75'] === '2'){
                            $("#encrm76").prop('checked', true);
                        }
                        if (jsonResp[i]['campo77'] === '1') {
                            $("#encrm77").prop('checked', true);
                        }else if (jsonResp[i]['campo77'] === '2'){
                            $("#encrm78").prop('checked', true);
                        }
                        if (jsonResp[i]['campo79'] === '1') {
                            $("#encrm79").prop('checked', true);
                        }else if (jsonResp[i]['campo79'] === '2'){
                            $("#encrm80").prop('checked', true);
                        }
                        if (jsonResp[i]['campo81'] === '1') {
                            $("#encrm81").prop('checked', true);
                        }else if (jsonResp[i]['campo81'] === '2'){
                            $("#encrm82").prop('checked', true);
                        }
                        if (jsonResp[i]['campo83'] === '1') {
                            $("#encrm83").prop('checked', true);
                        }else if (jsonResp[i]['campo83'] === '2'){
                            $("#encrm84").prop('checked', true);
                        }
                        if (jsonResp[i]['campo85'] === '1') {
                            $("#encrm85").prop('checked', true);
                        }else if(jsonResp[i]['campo85'] === '2') {
                            $("#encrm86").prop('checked', true);
                        }else if (jsonResp[i]['campo85'] === '3'){
                            $("#encrm87").prop('checked', true);
                        }
                        $("#encrm88").val(jsonResp[i]['campo88']);
                        if (jsonResp[i]['campo89'] === '1') {
                            $("#encrm89").prop('checked', true);
                        }else if (jsonResp[i]['campo89'] === '2'){
                            $("#encrm90").prop('checked', true);
                        }
                        $("#encrm91").val(jsonResp[i]['campo91']);
                        $("#encrm92").val(jsonResp[i]['campo92']);
                        $("#encrm93").val(jsonResp[i]['campo93']);
                        $("#encrm94").val(jsonResp[i]['campo94']);
                        $("#encrm96").val(jsonResp[i]['campo96']);
                        $("#encrm83").val(jsonResp[i]['campo83']);

                        if (jsonResp[i]['campo97'] == '1') {
                            $("#encrm97").prop('checked', true);
                            $("#encrm8").prop('disabled', false);
                            $("#encrm95").prop('disabled', false);
                            $("#encrm101").prop('disabled', false);
                            $("#encrm95").val(jsonResp[i]['campo95']);
                            $("#encrm8").val(jsonResp[i]['campo8']);
                            $("#encrm101").val(jsonResp[i]['campo99']);
                        }else if (jsonResp[i]['campo97'] == '2'){
                            $("#encrm97").prop('checked', false);
                            $("#encrm98").prop('checked', true);
                            $("#encrm8").prop('disabled', true);
                            $("#encrm95").prop('disabled', true);
                            $("#encrm101").prop('disabled', true);
                        }

                        if (jsonResp[i]['campo98'] == '1') {
                            $("#encrm99").prop('checked', true);
                            $("#encrm9").prop('disabled', false);
                            $("#encrm96").prop('disabled', false);
                            $("#encrm102").prop('disabled', false);
                            $("#encrm102").val(jsonResp[i]['campo100']);
                            $("#encrm96").val(jsonResp[i]['campo96']);
                            $("#encrm9").val(jsonResp[i]['campo9']);
                        }else if (jsonResp[i]['campo98'] == '2'){
                            $("#encrm99").prop('checked', false);
                            $("#encrm100").prop('checked', true);
                            $("#encrm9").prop('disabled', true);
                            $("#encrm96").prop('disabled', true);
                            $("#encrm102").prop('disabled', true);
                        }
                        $("#encrm103").val(jsonResp[i]['campo103']);
                    }
                },
                error: function (jqXHR, textStatus, errorThrown){
                    $.blockUI({
                        css: {
                            border: 'none',
                            padding: '15px',
                            '-webkit-border-radius': '10px',
                            '-moz-border-radius': '10px',
                            'border-radius': '10px',
                            color: '#fff'
                        },
                        message: '<div class="alert alert-danger" role="alert" style="font-size:25px; margin:0; padding:0;" >' +
                        ' <span class="glyphicon glyphicon-alert" aria-hidden="true"></span> <span class="sr-only">Error:</span> '+errorAjax+'</div>'
                    });
                    setTimeout($.unblockUI, 1000);
                }
            })
            {% endif %}
        })
    </script>

{% endblock %}
{% block content %}
    {% block stylesheets %}
        <link rel="stylesheet" href="{{ asset('bundles/main/css/bootstrap.css') }}"/>
        <link rel="stylesheet" href="{{ asset('bundles/shedule/'~ hrk_skin ~'/dataTableCustom.css') }}"/>
        <link rel="stylesheet" href="{{ asset('bundles/reading/css/notificationsLight.css') }}"/>
        <link href="{{ asset('bundles/utilities/css/font-awesome.css') }}" rel="stylesheet">
    {% endblock %}
    {% if disabled is defined %}
        <fieldset disabled>
    {% endif %}
    <div class="row">
        <div class="table-responsive encuesta-mammo">
            <div class="col-md-6">
                <table class="table table-condensed table-bordered table-mammo" style="width:100%;font-size:12px;">
                    {#<thead>
                        <tr>
                            <th style="text-align: center;">{{ 'labels.antecedentes'|trans([],'LocalizationBundle') }}</th>
                            <th style="text-align: center;">{{ 'labels.right'|trans([],'LocalizationBundle') }}</th>
                            <th style="text-align: center;">{{ 'labels.left'|trans([],'LocalizationBundle') }}</th>
                        </tr>
                    </thead>#}
                    <tbody>
                    <tr>
                        <th colspan="4" style="text-align: center;">
                            Encuesta para estudios de resonancia magnetica:
                        </th>
                    </tr>
                    <tr>
                        <td>
                            Cr:<input id="encrm1" name="encrm1" type="text" class="form-control">
                        </td>
                        <td>
                            Depuración:<input id="encrm2" name="encrm2" type="text" class="form-control">
                        </td>
                        <td>
                            PA:<input id="encrm3" name="encrm3" type="text" class="form-control">
                        </td>
                    </tr>
                    <tr>
                        <th colspan="3" style="text-align: center;">Antecedentes:</th>
                    </tr>
                    <tr>
                        <td>Patológicos:</td>
                        <td colspan="2" style="text-align: center;"><input id="encrm4" name="encrm4" class="form-control" type="text"></td>
                    </tr>
                    <tr>
                        <td>Disautonomia:</td>
                        <td colspan="2" style="text-align: center;">
                            {{ 'labels.yes'|trans([],'LocalizationBundle') }}:&nbsp;&nbsp;<input id="encrm5" name="encrm_dis" value="1" type="radio">&nbsp;&nbsp;
                            {{ 'labels.no'|trans([],'LocalizationBundle') }}:&nbsp;&nbsp;<input id="encrm6" name="encrm_dis" value="2" type="radio" checked="true"  >
                        </td>
                    </tr>
                    <tr>
                        <td>Cáncer (ubicación):</td>
                        <td colspan="2" style="text-align: center;"><input id="encrm7" name="encrm7" class="form-control" type="text"></td>
                    </tr>
                    <tr>
                        <td>
                            Quimio:
                            {{ 'labels.yes'|trans([],'LocalizationBundle') }}:&nbsp;&nbsp;<input id="encrm97" name="encrm_quimio" value="1" type="radio">&nbsp;&nbsp;
                            {{ 'labels.no'|trans([],'LocalizationBundle') }}:&nbsp;&nbsp;<input id="encrm98" name="encrm_quimio" value="2" type="radio" checked="true"  >
                        </td>
                        <td>Fecha:<input id="encrm8" name="encrm8" class="form-control" type="text" placeholder="__/__/____ " disabled="true"></td>
                        <td>N° sesiones:<input id="encrm95" name="encrm95" class="form-control" type="text" placeholder="#" disabled="true"></td>
                    </tr>
                    <tr>
                        <td>Descripción Quimio:</td>
                        <td colspan="2">
                            <textarea rows="3" id="encrm101" name="encrm101" class="form-control" type="text" disabled="true"></textarea>
                        </td>
                    </tr>
                    <tr>
                        <td>
                            Radio:
                            {{ 'labels.yes'|trans([],'LocalizationBundle') }}:&nbsp;&nbsp;<input id="encrm99" name="encrm_radio" value="1" type="radio">&nbsp;&nbsp;
                            {{ 'labels.no'|trans([],'LocalizationBundle') }}:&nbsp;&nbsp;<input id="encrm100" name="encrm_radio" value="2" type="radio" checked="true" >
                        </td>
                        <td>Fecha:<input id="encrm9" name="encrm9" class="form-control" type="text" placeholder="__/__/____ " disabled="true"></td>
                        <td>N° sesiones:<input id="encrm96" name="encrm96" class="form-control" type="text" placeholder="#" disabled="true"></td>
                    </tr>
                    <tr>
                        <td>Descripción Radio:</td>
                        <td colspan="2">
                            <textarea rows="3" id="encrm102" name="encrm102" class="form-control" type="text" disabled="true"></textarea>
                        </td>
                    </tr>
                    <tr>
                        <td>Quirúrgico (adicionar fechas):</td>
                        <td colspan="2" style="text-align: center;"><textarea rows="2" id="encrm10" name="encrm10" class="form-control" type="text"></textarea></td>
                    </tr>
                    <tr>
                        <td>Alérgicos:</td>
                        <td colspan="2" style="text-align: center;"><input id="encrm11" name="encrm11" class="form-control" type="text"></td>
                    </tr>
                    <tr>
                        <td>Insuficiencia renal:
                            <input id="encrm12" class="encrm12_1" value="1" name="encrm_2" type="checkbox"></td>
                        <td>Transplante:
                            <input id="encrm13" class="encrm12_2" value="1" name="encrm_3" type="checkbox"></td>
                        <td>Monorenal:
                            <input id="encrm14" class="encrm12_3" value="1" name="encrm_4" type="checkbox"></td>
                    </tr>
                    <tr>
                        <td>Terapia dialítica:</td>
                        <td colspan="2" style="text-align: center;"><input id="encrm15" name="encrm15" class="form-control" type="text"></td>
                    </tr>
                    <tr>
                        <th colspan="4" style="text-align: center;">Inyección previa de medios de contraste:</th>
                    </tr>
                    <tr>
                        <td>
                            {{ 'labels.yes'|trans([],'LocalizationBundle') }}:<input id="encrm16" name="encrm_iny" value="1" type="radio">
                            {{ 'labels.no'|trans([],'LocalizationBundle') }}:<input id="encrm17" name="encrm_iny" value="2" type="radio" checked="true"  >
                            Cual:<input id="encrm18" name="encrm18" class="form-control" type="text" disabled="true">
                        </td>
                        <td>Fecha:<input id="encrm19" name="encrm19" class="form-control" type="text" disabled="true"></td>
                        <td>HR:<input id="encrm20" name="encrm20" class="form-control" type="text" disabled="true"></td>
                    </tr>
                    <tr>
                        <td>Medicamentos actuales</td>
                        <td colspan="2" style="text-align: center;"><input id="encrm21" name="encrm21" class="form-control" type="text"></td>
                    </tr>
                    <tr>
                        <td>Estudios previos</td>
                        <td colspan="2" style="text-align: center;"> <textarea rows="3" id="encrm22" name="encrm22" class="form-control" type="text"></textarea>
                    </tr>
                    <tr>
                        <th colspan="3" style="text-align: center;">Evaluación de riesgos y/o contraindicaciones para estudios de resonancia magnética:</th>
                    </tr>
                    <tr>
                        <td>Profesión o trabajo:</td>
                        <td colspan="2" style="text-align: center;"><input id="encrm23" name="encrm23" class="form-control" type="text"></td>
                    </tr>
                    <tr>
                        <td>¿Ha tenido accidentes en sus ojos con elementos metálicos?</td>
                        <td colspan="2">
                            {{ 'labels.yes'|trans([],'LocalizationBundle') }}:&nbsp;&nbsp;<input id="encrm24" name="encrm_elem" value="1" type="radio">&nbsp;&nbsp;
                            {{ 'labels.no'|trans([],'LocalizationBundle') }}:&nbsp;&nbsp;<input id="encrm25" name="encrm_elem" value="2" type="radio" checked="true" >
                        </td>
                    </tr>
                    <tr>
                        <td>¿Estado de gestación?&nbsp;&nbsp;
                            {{ 'labels.yes'|trans([],'LocalizationBundle') }}:&nbsp;&nbsp;<input id="encrm26" name="encrm_gest" value="1" type="radio">&nbsp;&nbsp;
                            {{ 'labels.no'|trans([],'LocalizationBundle') }}:&nbsp;&nbsp;<input id="encrm27" name="encrm_gest" value="2" type="radio" checked="true" >
                        </td>
                        <td>¿Cuántas semanas?
                            <input id="encrm28" name="encrm28" class="form-control" type="text" disabled="true">
                        </td>
                        <td>
                            ¿Está lactando?
                            {{ 'labels.yes'|trans([],'LocalizationBundle') }}:&nbsp;&nbsp;<input id="encrm29" name="encrm_lact" value="1" type="radio">&nbsp;&nbsp;
                            {{ 'labels.no'|trans([],'LocalizationBundle') }}:&nbsp;&nbsp;<input id="encrm30" name="encrm_lact" value="2" type="radio"  checked="true" >
                        </td>
                    </tr>
                    <tr>
                        <td>¿Fecha de ultima menstruación?
                            <input id="encrm31" name="encrm31" class="form-control" type="text">
                        </td>
                        <td>¿Padece de claustrofobia?
                            {{ 'labels.yes'|trans([],'LocalizationBundle') }}:&nbsp;&nbsp;<input id="encrm32" name="encrm_claus" value="1" type="radio">&nbsp;&nbsp;
                            {{ 'labels.no'|trans([],'LocalizationBundle') }}:&nbsp;&nbsp;<input id="encrm33" name="encrm_claus" value="2" type="radio" checked="true">
                        </td>
                        <td>Ayuno:
                            {{ 'labels.yes'|trans([],'LocalizationBundle') }}:&nbsp;&nbsp;<input id="encrm34" name="encrm_ayu" value="1" type="radio">&nbsp;&nbsp;
                            {{ 'labels.no'|trans([],'LocalizationBundle') }}:&nbsp;&nbsp;<input id="encrm35" name="encrm_ayu" value="2" type="radio" checked="true">
                            ¿Cuántas horas?
                            <input id="encrm36" name="encrm36" class="form-control" type="text" disabled="true">
                        </td>
                    </tr>

                    </tbody>
                </table>
            </div>
            <div class="col-md-6">
                <table class="table table-condensed table-bordered table-mammo" style="width:100%;font-size:12px;">
                    {#<thead>
                        <tr>
                            <td colspan="2" style="text-align: center;"></td>
                            <td style="text-align: center;">{{ 'labels.yes'|trans([],'LocalizationBundle') }}</td>
                            <td style="text-align: center;">{{ 'labels.no'|trans([],'LocalizationBundle') }}</td>
                        </tr>
                    </thead>#}
                    <tbody>
                    <tr style="text-align: center;">
                        <td>Descripción</td>
                        <td>{{ 'labels.yes'|trans([],'LocalizationBundle') }}&nbsp;&nbsp;{{ 'labels.no'|trans([],'LocalizationBundle') }}</td>
                        <td>Descripción</td>
                        <td>{{ 'labels.yes'|trans([],'LocalizationBundle') }}&nbsp;&nbsp;{{ 'labels.no'|trans([],'LocalizationBundle') }}</td>
                    </tr>
                    <tr style="text-align: center;">
                        <td>Marcapasos cardíaco</td>
                        <td><input id="encrm37" name="encrm_marc" value="1" type="radio">&nbsp;&nbsp;
                            <input id="encrm38" name="encrm_marc" value="2" type="radio" checked="true">
                        </td>
                        <td>Prótesis valvular aórtica</td>
                        <td><input id="encrm39" name="encrm_pro" value="1" type="radio">&nbsp;&nbsp;
                            <input id="encrm40" name="encrm_pro" value="2" type="radio" checked="true">
                        </td>
                    </tr>
                    <tr style="text-align: center;">
                        <td>Grapas o válvulas cardiacas</td>
                        <td><input id="encrm41" name="encrm_graps" value="1" type="radio">&nbsp;&nbsp;
                            <input id="encrm42" name="encrm_graps" value="2" type="radio" checked="true">
                        </td>
                        <td>Stent coronario</td>
                        <td><input id="encrm43" name="encrm_stent" value="1" type="radio">&nbsp;&nbsp;
                            <input id="encrm44" name="encrm_stent" value="2" type="radio" checked="true">
                        </td>
                    </tr>
                    <tr style="text-align: center;">
                        <td>Gancho de aneurisma</td>
                        <td><input id="encrm45" name="encrm_ane" value="1" type="radio">&nbsp;&nbsp;
                            <input id="encrm46" name="encrm_ane" value="2" type="radio" checked="true">
                        </td>

                        <td>Filtro de vena cava</td>
                        <td><input id="encrm47" name="encrm_venac" value="1" type="radio">&nbsp;&nbsp;
                            <input id="encrm48" name="encrm_venac" value="2" type="radio" checked="true">
                        </td>
                    </tr>
                    <tr style="text-align: center;">
                        <td>Espiral de embolización</td>
                        <td><input id="encrm49" name="encrm_embol" value="1" type="radio">&nbsp;&nbsp;
                            <input id="encrm50" name="encrm_embol" value="2" type="radio" checked="true">
                        </td>
                        <td>Implante de oído medio</td>
                        <td><input id="encrm51" name="encrm_oido" value="1" type="radio">&nbsp;&nbsp;
                            <input id="encrm52" name="encrm_oido" value="2" type="radio" checked="true">
                        </td>
                    </tr>
                    <tr style="text-align: center;">
                        <td>Hemoclip, gancho vascular</td>
                        <td><input id="encrm53" name="encrm_hem" value="1" type="radio">&nbsp;&nbsp;
                            <input id="encrm54" name="encrm_hem" value="2" type="radio" checked="true">
                        </td>
                        <td>Implante coclear</td>
                        <td><input id="encrm55" name="encrm_Imp" value="1" type="radio">&nbsp;&nbsp;
                            <input id="encrm56" name="encrm_Imp" value="2" type="radio" checked="true">
                        </td>
                    </tr>
                    <tr style="text-align: center;">
                        <td>Desfibrilador implantado</td>
                        <td><input id="encrm57" name="encrm_desf" value="1" type="radio">&nbsp;&nbsp;
                            <input id="encrm58" name="encrm_desf" value="2" type="radio" checked="true">
                        </td>
                        <td>Audífonos</td>
                        <td><input id="encrm59" name="encrm_audif" value="1" type="radio">&nbsp;&nbsp;
                            <input id="encrm60" name="encrm_audif" value="2" type="radio" checked="true">
                        </td>
                    </tr>
                    <tr style="text-align: center;">
                        <td>Prótesis ortopedica</td>
                        <td><input id="encrm61" name="encrm_proOrt" value="1" type="radio">&nbsp;&nbsp;
                            <input id="encrm62" name="encrm_proOrt" value="2" type="radio" checked="true">
                        </td>
                        <td>Parche para Parkinson</td>
                        <td><input id="encrm63" name="encrm_parche" value="1" type="radio">&nbsp;&nbsp;
                            <input id="encrm64" name="encrm_parche" value="2" type="radio" checked="true">
                        </td>
                    </tr>
                    <tr style="text-align: center;">
                        <td>Grapas QX</td>
                        <td><input id="encrm65" name="encrm_grapsOk" value="1" type="radio">&nbsp;&nbsp;
                            <input id="encrm66" name="encrm_grapsOk" value="2" type="radio" checked="true">
                        </td>
                        <td>Bomba de insulina</td>
                        <td><input id="encrm67" name="encrm_bombIns" value="1" type="radio">&nbsp;&nbsp;
                            <input id="encrm68" name="encrm_bombIns" value="2" type="radio" checked="true">
                        </td>
                    </tr>
                    <tr style="text-align: center;">
                        <td>Prótesis dental</td>
                        <td><input id="encrm69" name="encrm_protDent" value="1" type="radio">&nbsp;&nbsp;
                            <input id="encrm70" name="encrm_protDent" value="2" type="radio" checked="true">
                        </td>
                        <td>Cosméticos o tatuajes</td>
                        <td><input id="encrm71" name="encrm_cosm" value="1" type="radio">&nbsp;&nbsp;
                            <input id="encrm72" name="encrm_cosm" value="2" type="radio" checked="true">
                        </td>
                    </tr>
                    <tr style="text-align: center;">
                        <td>Estimulador</td>
                        <td><input id="encrm73" name="encrm_estim" value="1" type="radio">&nbsp;&nbsp;
                            <input id="encrm74" name="encrm_estim" value="2" type="radio" checked="true">
                        </td>
                        <td>Derivación ventricular</td>
                        <td><input id="encrm75" name="encrm_derVen" value="1" type="radio">&nbsp;&nbsp;
                            <input id="encrm76" name="encrm_derVen" value="2" type="radio" checked="true">
                        </td>
                    </tr>
                    <tr style="text-align: center;">
                        <td>Balas o fragmentos</td>
                        <td><input id="encrm77" name="encrm_frag" value="1" type="radio">&nbsp;&nbsp;
                            <input id="encrm78" name="encrm_frag" value="2" type="radio" checked="true">
                        </td>
                        <td>Prótesis orbitaria</td>
                        <td><input id="encrm79" name="encrm_protOrb" value="1" type="radio">&nbsp;&nbsp;
                            <input id="encrm80" name="encrm_protOrb" value="2" type="radio" checked="true">
                        </td>
                    </tr>
                    <tr style="text-align: center;">
                        <td>Ortodoncia</td>
                        <td><input id="encrm81" name="encrm_ortod" value="1" type="radio">&nbsp;&nbsp;
                            <input id="encrm82" name="encrm_ortod" value="2" type="radio" checked="true">
                        </td>
                        {#<td>Otro</td>#}
                        <td colspan="2">Otro:<input  id="encrm83" name="encrm_otro"  class="form-control">&nbsp;&nbsp;
                        </td>
                    </tr>
                    <tr>
                        <th colspan="4" style="text-align: center;">Requerimientos durante todo el procedimiento:</th>
                    </tr>
                    <tr>
                        <th colspan="4" style="text-align: center;">RM-1</th>
                    </tr>
                    <tr>
                        <td>
                            Sedación&nbsp;&nbsp;<input id="encrm85" name="encrm_rm1" value="1" type="radio">
                        </td>
                        <td>
                            BAG&nbsp;&nbsp;<input id="encrm86" name="encrm_rm1" value="2" type="radio">
                        </td>
                        <td>
                            Ninguno&nbsp;&nbsp;<input id="encrm87" name="encrm_rm1" value="3" type="radio" checked="true">
                        </td>
                        <td>
                            Contraste<input id="encrm88" name="encrm88" class="form-control" type="text">
                        </td>
                    </tr>
                    <tr>
                        <td colspan="2">Reacciones adversas</td>
                        <td>
                            {{ 'labels.yes'|trans([],'LocalizationBundle') }}:&nbsp;&nbsp;<input id="encrm89" name="encrm_reac" value="1" type="radio">&nbsp;&nbsp;
                            {{ 'labels.no'|trans([],'LocalizationBundle') }}:&nbsp;&nbsp;<input id="encrm90" name="encrm_reac" value="2" type="radio" checked="true">
                        </td>
                        <td>
                            Conducta médica<input id="encrm91" name="encrm91" class="form-control" type="text" disabled="true">
                        </td>
                    </tr>
                    <tr>
                        <td colspan="2">Registro enfermería</td>
                        <td colspan="2">
                            <textarea rows="4" id="encrm92" name="encrm92" class="form-control" type="text"></textarea>
                        </td>
                    </tr>
                    <tr>
                        <td colspan="2">Nombre de quien brinda la información:</td>
                        <td colspan="2">
                            <input id="encrm93" name="encrm93" class="form-control" type="text">
                        </td>
                    </tr>
                    <tr>
                        <td colspan="2">Parentesco:</td>
                        <td colspan="2">
                            <input id="encrm94" name="encrm94" class="form-control" type="text">
                        </td>
                    </tr>
                    </tbody>
                </table>
                <table class="table table-condensed table-bordered table-mammo" style="width:100%;font-size:12px;">
                    <tbody>
                    <tr>
                        <td colspan="3"><b> Realizado por:</b></td>
                        <td colspan="2">
                            <input id="encrm103" name="encrm103" class="form-control" type="text">
                        </td>
                    </tr>
                    </tbody>
                </table>
            </div>
        </div>
    </div>
    </fieldset>
    <div class="clearfix"></div>

{% endblock %}