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initial.html
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<!DOCTYPE html>
<html>
<head>
<meta charset="utf-8" />
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<title>Page Title</title>
<meta name="viewport" content="width=device-width, initial-scale=1">
<link rel="stylesheet" type="text/css" media="screen" href="../css/common.css" />
<!--<script src="main.js"></script>-->
<script>
function toggleDisabledState(clickedElement, specificRadio, specificTarget){
if(specificRadio){
clickedElement = document.querySelector(specificRadio);
}
let el = clickedElement.parentElement;
if(!specificTarget){
//console.log('toggling state', clickedElement);
while(el.nextElementSibling) {
el = el.nextElementSibling;
//console.log(el, el.children[0]);
el.children[0].disabled = !clickedElement.checked;
//console.log('toggled disavbled on element with id', el.children[0].id);
}
} else {
if(Array.isArray(specificTarget)) {
for(target of specificTarget) {
document.querySelector(target).disabled = !clickedElement.checked;
}
} else {
document.querySelector(specificTarget).disabled = !clickedElement.checked;
}
}
};
</script>
</head>
<body>
<h1 class="">This is a previous version and will be removed, please start viewing mockups from <a href="index.html">here</a> in the future!</h1>
<form autocomplete="off">
<fieldset id="header">
<label for="province-select">Province
<select name="province-select" id="province-select" autocomplete="off">
<option value="">--Not Selected--</option>
<option value="other">Other</option>
</select>
</label>
<label for="transfer-or-consult-date">Date of Consulation/Transfer
<input type="date" id="transfer-or-consult-date">
</label>
<label for="district-select">District
<select name="district-select" id="district-select">
<option value="">--Not Selected--</option>
<option value="other">Other</option>
</select>
</label>
<label for="medical-institution">Institution
<input type="text" id="medical-institution" name="medical-institution">
</label>
<label for="NID">NID
<input type="text" id="NID" name="NID" autocomplete="off">
</label>
</fieldset>
<fieldset id="patient-details">
<legend>Patient/Companion Details</legend>
<div>
<label for="patient-name">Name
<input type="text" name="patient-name" id="patient-name" autocomplete="off">
</label>
<fieldset>
<legend>Gender</legend>
<label for="gender-m" aria-label="Gender Male">Male
<input name="gender" id="gender-m" value="m" type="radio">
</label>
<label for="gender-f" aria-label="Gender Female">Female
<input name="gender" id="gender-f" value="f" type="radio">
</label>
</fieldset>
<label>Age
<input type="number" name="age" id="age" min="0">
</label>
<label for="dob">Date of Birth
<input type="date" name="dob" id="dob">
</label>
<label for="bario">Bario
<input type="text" name="bario" id="bario">
</label>
<label for="nearby-landmark">Nearby Landmark
<input type="text" name="nearby-landmark" id="nearby-landmark">
</label>
</div>
<label for="patient-telephone-number">Patient Telephone Number
<input name="patient-telephone-number" id="patient-telephone-number" type="tel" pattern="[0-9]{2-3}-[0-9]{3}-[0-9]{3}-[0-9]{4}">
</label>
<label for="homeless-status" aria-label="homelessness status">
<fieldset>
<legend>Homeless</legend>
<label for="homeless-yes" aria-label="homeless">Yes
<input type="radio" name="homeless" value="homeless-yes" id="homeless-yes">
</label>
<label for="homeless-no" aria-label="has home">No
<input type="radio" name="homeless" value="homeless-no" id="homeless-no">
</label>
</fieldset>
</label>
<label for="martial-status" aria-label="marital status">
<fieldset id="marital-status">
<legend>Marital Status</legend>
<label for="marital-status-single">Single
<input type="radio" name="marital-status" value="single" id="marital-status-single">
</label>
<label for="marital-status-married">Married
<input type="radio" name="marital-status" value="married" id="marital-status-married">
</label>
<label for="martial-status-union-de-facto">Union de Facto
<input type="radio" name="marital-status" value="union-de-facto" id="martial-status-union-de-facto">
</label>
<label for="marital-status-divorced">Divorced
<input type="radio" name="marital-status" value="divorced" id="marital-status-divorced">
</label>
<label for="marital-status-widowed">Widowed
<input type="radio" name="marital-status" value="widowed" id="marital-status-widowed">
</label>
<label for="marital-status-separated">Separated
<input type="radio" name="marital-status" value="separated" id="marital-status-separated">
</label>
</fieldset>
</label>
<label for="number-of-children">Number of Children
<input type="number" id="number-of-children" name="number-of-children" min="0">
</label>
<label for="community-agreement" aria-label="agrees with community suggestion">
<fieldset id="community-agreement">
<legend>Agrees with community process</legend>
<label for="community-agreement-yes" aria-label="community agreement yes">Yes
<input type="radio" name="community-agreement" id="community-agreement-yes" value="y">
</label>
<label for="community-agreement-no" aria-label="community agreement no">No
<input type="radio" name="community-agreement" id="community-agreement-no" value="n">
</label>
</fieldset>
</label>
<fieldset id="companion-information">
<legend>Companion Information</legend>
<label for="companion-name">Name
<input type="text" name="" id="companion-name" autocomplete="off">
</label>
<label for="companion-telephone-number">Telephone
<input type="tel" name="companion-telephone-number" id="companion-telephone-number" pattern="[0-9]{2-3}-[0-9]{3}-[0-9]{3}-[0-9]{4}" autocomplete="off">
</label>
<label for="companion-relationship">Relationship to Patient
<input type="text" id="companion-relationship" name="companion-relationship">
</label>
</fieldset>
</fieldset>
<fieldset id="anamnesis">
<legend>Medical History (Anamnesis)</legend>
<fieldset>
<legend>Principal Complaint</legend>
<textarea name="anamnesis-principal-complaint" id="anamnesis-principal-complaint" cols="30" rows="10"></textarea>
</fieldset>
<!--<label for="anamnesis-principal-complaint">Principal Complaint
<textarea name="anamnesis-principal-complaint" id="anamnesis-principal-complaint" cols="30" rows="10"></textarea>
</label>-->
<fieldset>
<legend>Principal Complaint</legend>
<textarea name="anamnesis-reason-for-consult" id="anamnesis-reason-for-consult" cols="30" rows="10"></textarea>
</fieldset>
<!--<label for="anamnesis-reason-for-consult">Reason for Consultation
<textarea name="anamnesis-reason-for-consult" id="anamnesis-reason-for-consult" cols="30" rows="10"></textarea>
</label>-->
<fieldset>
<legend>History of Disease</legend>
<textarea name="anamnesis-disease-history" id="anamnesis-disease-history" cols="30" rows="10"></textarea>
</fieldset>
<!--<label for="anamnesis-disease-history">History of Disease
<textarea name="anamnesis-disease-history" id="anamnesis-disease-history" cols="30" rows="10"></textarea>
</label>-->
</fieldset>
<fieldset id="family-history">
<!--div>(fieldset>legend+(label>input)*3+label>input:text+(label>input:date)*2)*6 -->
<legend>Family History</legend>
<fieldset>
<legend>Epilepsy</legend>
<label for="">Yes
<input type="radio" name="epilepsy" id="family-history-epilepsy-yes" value="y">
</label>
<label for="">No
<input type="radio" name="epilepsy" id="family-history-epilepsy-no">
</label>
<label for="">Unknown
<input type="radio" name="epilepsy" id="family-history-epilepsy-unknown">
</label>
</fieldset>
<fieldset id="family-history-mental-disease" onChange="toggleDisabledState(this, 'fieldset[id=family-history-mental-disease] input[id=family-history-mental-disease-yes]', 'fieldset[id=family-history-mental-disease] input[id=family-history-mental-disease-specific]');">
<legend>Mental Disease</legend>
<label for="">Yes
<input type="radio" name="family-history-mental-disease" id="family-history-mental-disease-yes" value="y">
</label>
<label for="">No
<input type="radio" name="family-history-mental-disease" id="family-history-mental-disease-no" value="n">
</label>
<label for="">Unknown
<input type="radio" name="family-history-mental-disease" id="family-history-mental-disease-unknown" value="u">
</label>
<label for="">If yes, specify
<input type="text" name="family-history-mental-disease-specific" id="family-history-mental-disease-specific" disabled="true">
</label>
</fieldset>
<fieldset>
<legend>Suicide</legend>
<label for="">Yes
<input type="radio" name="suicide" id="y">
</label>
<label for="">No
<input type="radio" name="suicide" id="n">
</label>
<label for="">Unknown
<input type="radio" name="suicide" id="u">
</label>
</fieldset>
<fieldset>
<legend>Alcoholism</legend>
<label for="">Yes
<input type="radio" name="alcoholism" id="y">
</label>
<label for="">No
<input type="radio" name="alcoholism" id="n">
</label>
<label for="">Unknown
<input type="radio" name="alcoholism" id="u">
</label>
</fieldset>
<fieldset id="family-history-other-substances" onChange="toggleDisabledState(this, 'fieldset[id=family-history-other-substances] input[id=family-history-other-substances-yes]', 'fieldset[id=family-history-other-substances] input[id=family-history-other-substances-specific]');">
<legend>Other Substances</legend>
<label for="">Yes
<input type="radio" name="family-history-other-substances" id="family-history-other-substances-yes" value="y">
</label>
<label for="">No
<input type="radio" name="family-history-other-substances" id="family-history-other-substances-no" value="n">
</label>
<label for="">Unknown
<input type="radio" name="family-history-other-substances" id="family-history-other-substances-unknown" value="u">
</label>
<label for="family-history-other-substances-specific">If yes, specify
<input type="text" name="family-history-other-substances-specific" id="family-history-other-substances-specific" disabled="true">
</label>
</fieldset>
</fieldset>
<fieldset id="patient-history">
<legend>Patient History</legend>
<fieldset id="patient-history-other-chronic-diseases" onChange="toggleDisabledState(this, 'fieldset[id=patient-history-other-chronic-diseases] input[id=patient-history-other-chronic-diseases-yes]', 'fieldset[id=patient-history-other-chronic-diseases] input[id=patient-history-other-chronic-diseases-specific]');">
<legend>Other Chronic Diseases (Comorbid)</legend>
<label for="other-chronic-diseases-yes">Yes
<input type="radio" name="other-chronic-diseases" id="patient-history-other-chronic-diseases-yes" value="y">
</label>
<label for="other-chronic-diseases-no">No
<input type="radio" name="other-chronic-diseases" id="patient-history-other-chronic-diseases-no" value="n">
</label>
<label for="other-chronic-diseases-unknown">Unknown
<input type="radio" name="other-chronic-diseases" id="patient-history-other-chronic-diseases-unknown" value="u">
</label>
<label for="patient-history-other-chronic-diseases-specific">If yes, specify
<input type="text" name="patient-history-other-chronic-diseases-specific" id="patient-history-other-chronic-diseases-specific" disabled="true">
</label>
</fieldset>
<fieldset id="patient-history-tuberculosis" onChange="toggleDisabledState(this, 'fieldset[id=patient-history-tuberculosis] input[id=patient-history-tuberculosis-yes]', 'fieldset[id=patient-history-tuberculosis] input[id=patient-history-tuberculosis-diagnosis-date]');">
<legend>Tuberculosis</legend>
<label for="patient-history-tuberculosis-yes">Yes
<input type="radio" name="patient-history-tuberculosis" id="patient-history-tuberculosis-yes" value="y">
</label>
<label for="patient-history-tuberculosis-no">No
<input type="radio" name="patient-history-tuberculosis" id="patient-history-tuberculosis-no" value="n">
</label>
<label for="patient-history-tuberculosis-untested">Untested
<input type="radio" name="patient-history-tuberculosis" id="patient-history-tuberculosis-untested" value="u">
</label>
<label for="patient-history-tuberculosis-diagnosis-date">If yes, date diagnosed
<input type="date" name="patient-history-tuberculosis-diagnosis-date" id="patient-history-tuberculosis-diagnosis-date" disabled="true">
</label>
</fieldset>
<fieldset id="patient-history-hiv" onChange="toggleDisabledState(this, 'fieldset[id=patient-history-hiv] input[id=patient-history-hiv-yes]', ['fieldset[id=patient-history-hiv] input[id=patient-history-hiv-diagnosis-date]', 'fieldset[id=patient-history-hiv] input[id=patient-history-hiv-tarv-started-date]']);">
<legend>HIV</legend>
<label for="patient-history-hiv-yes">Yes
<input type="radio" name="patient-history-hiv" id="patient-history-hiv-yes" value="y">
</label>
<label for="patient-history-hiv-no">No
<input type="radio" name="patient-history-hiv" id="patient-history-hiv-no" value="n">
</label>
<label for="patient-history-hiv-untested">Untested
<input type="radio" name="patient-history-hiv" id="patient-history-hiv-untested" value="u">
</label>
<label for="patient-history-hiv-diagnosis-date">Date Diagnosed
<input type="date" name="patient-history-hiv-diagnosis-date" id="patient-history-hiv-diagnosis-date" disabled="true">
</label>
<label for="patient-history-hiv-tarv-started-date">Date TARV started
<input type="date" name="patient-history-hiv-tarv-started-date" id="patient-history-hiv-tarv-started-date" disabled="true">
</label>
</fieldset>
<fieldset id="patient-history-alcohol-use" onChange="toggleDisabledState(this, 'fieldset[id=patient-history-alcohol-use] input[id=patient-history-alcohol-use-current]', 'fieldset[id=patient-history-alcohol-use] input[id=patient-history-alcohol-use-specific]');">
<legend>Alcohol Use</legend>
<label for="patient-history-alcohol-use-current">Current
<input type="radio" name="patient-history-alcohol-use" id="patient-history-alcohol-use-current" value="c">
</label>
<label for="patient-history-alcohol-use-past">Past
<input type="radio" name="patient-history-alcohol-use" id="patient-history-alcohol-use-past" value="p">
</label>
<label for="patient-history-alcohol-use-never">Never
<input type="radio" name="patient-history-alcohol-use" id="patient-history-alcohol-use-never" value="n">
</label>
<label for="patient-history-alcohol-use-specific">If yes, type and description
<input type="text" name="patient-history-alcohol-use-specific" id="patient-history-alcohol-use-specific" disabled="true" autocomplete="off">
</label>
</fieldset>
<fieldset id="patient-history-other-drug-use" onChange="toggleDisabledState(this, 'fieldset[id=patient-history-other-drug-use] input[id=patient-history-other-drug-use-current]', 'fieldset[id=patient-history-other-drug-use] input[id=patient-history-other-drug-use-specific]');">
<legend>Other Drug Use</legend>
<label for="patient-history-other-drug-use-current">Current
<input type="radio" name="patient-history-other-drug-use" id="patient-history-other-drug-use-current" value="c">
</label>
<label for="patient-history-other-drug-use-past">Past
<input type="radio" name="patient-history-other-drug-use" id="patient-history-other-drug-use-past" value="p">
</label>
<label for="patient-history-other-drug-use-never">Never
<input type="radio" name="patient-history-other-drug-use" id="patient-history-other-drug-use-never" value="n">
</label>
<label for="patient-history-other-drug-use-specific">If yes, type and description
<input type="text" name="patient-history-other-drug-use-specific" id="patient-history-other-drug-use-specific" disabled="true" autocomplete="off">
</label>
</fieldset>
<fieldset id="patient-history-traditional-medicine-use" onChange="toggleDisabledState(this, 'fieldset[id=patient-history-traditional-medicine-use] input[id=patient-history-traditional-medicine-use-current]', 'fieldset[id=patient-history-traditional-medicine-use] input[id=patient-history-traditional-medicine-use-specific]');">
<legend>Traditional Medicine Use</legend>
<label for="traditional-medicine-use-current">Current
<input type="radio" name="traditional-medicine-use" id="traditional-medicine-use-current" value="c">
</label>
<label for="traditional-medicine-use-past">Past
<input type="radio" name="traditional-medicine-use" id="traditional-medicine-use-past" value="p">
</label>
<label for="traditional-medicine-use-never">Never
<input type="radio" name="traditional-medicine-use" id="traditional-medicine-use-never" value="n">
</label>
<label for="traditional-medicine-use-specific">If yes, type and description
<input type="text" name="traditional-medicine-use-specific" id="traditional-medicine-use-specific" disabled="true" autocomplete="off">
</label>
</fieldset>
</fieldset>
<fieldset id="symptom-assessment">
<legend>Symptom Assessment</legend>
<label for="symptom-assessment-phq-9">PHQ-9 (Depression)
<input type="number" name="symptom-assessment-phq-9" id="symptom-assessment-phq-9" min="0">
</label>
<label for="symptom-assessment-gad-7">GAD-7 (Anxiety)
<input type="number" name="symptom-assessment-gad-7" id="symptom-assessment-gad-7" min="0">
</label>
<label for="symptom-assessment-audit">AUDIT (Alcohol)
<input type="number" name="symptom-assessment-audit" id="symptom-assessment-audit" min="0">
</label>
<label for="symptom-assessment-whodas">WHODAS (Disability)
<input type="number" name="symptom-assessment-whodas" id="symptom-assessment-whodas" min="0">
</label>
</fieldset>
<fieldset id="patient-overview">
<legend>Patient Overview</legend>
<label for="appearance-and-posture">Appearance and Posture
<input type="text" name="appearance-and-posture" id="appearance-and-posture" autocomplete="off">
</label>
<label for="synthesis-functions">Synthesis Functions
<input type="text" name="synthesis-functions" id="synthesis-functions" autocomplete="off">
</label>
<label for="perceptual-sense">Sense of Perception
<input type="text" name="perceptual-sense" id="perceptual-sense" autocomplete="off">
</label>
<label for="critical-thinking-judgement">Critical Thinking/Judgement
<input type="text" name="critical-thinking-judgement" id="critical-thinking-judgement" autocomplete="off">
</label>
<label for="humor">Humor
<input type="text" name="humor" id="humor" autocomplete="off">
</label>
<label for="conduct">Conduct
<input type="text" name="conduct" id="conduct" autocomplete="off">
</label>
<label for="relational-functions">Relational Functions
<input type="text" name="relational-functions" id="relational-functions" autocomplete="off">
</label>
</fieldset>
<!--
fieldset>legend+(fieldset>legend+((label>input:checkbox)*8+input:text)+label>input:date)*21
-->
<fieldset id="mental-health-disorders">
<legend>Mental Health Disorders</legend>
<fieldset>
<legend>Depressive Disorder</legend>
<label for="depressive-disorder" aria-label="depressive disorder">
<input type="checkbox" name="depressive-disorder" id="depressive-disorder" value="y" onClick="toggleDisabledState(this);">
</label>
<label for="depressive-disorder-diagnosis-date">Date
<input type="date" name="depressive-disorder-diagnosis-date" id="depressive-disorder-diagnosis-date" disabled="true">
</label>
</fieldset>
<fieldset>
<legend>Anxiety Disorder</legend>
<label for="anxiety-disorder" aria-label="anxiety disorder">
<input type="checkbox" name="anxiety-disorder" id="anxiety-disorder" value="y" onClick="toggleDisabledState(this);">
</label>
<div>
<fieldset disabled="true">
<label for="anxiety-disorder-ptsd" aria-label="ptsd">PTSD
<input type="radio" name="anxiety-disorder-type" id="anxiety-disorder-ptsd" value="ptsd">
</label>
<label for="anxiety-disorder-panic" aria-label="panic">Panic
<input type="radio" name="anxiety-disorder-type" id="anxiety-disorder-panic" value="panic">
</label>
<label for="anxiety-disorder-gad" aria-label="generalized anxiety disorder G A D">Generalized (GAD)
<input type="radio" name="anxiety-disorder-type" id="anxiety-disorder-gad" value="gad">
</label>
</fieldset>
</div>
<label for="anxiety-disorder-diagnosis-date" aria-label="anxiety disorder diagnosis date">Date
<input type="date" name="anxiety-disorder-diagnosis-date" id="anxiety-disorder-diagnosis-date" disabled="true">
</label>
</fieldset>
<fieldset>
<legend>Adjustment Disorder Comorbidity</legend>
<label for="adjustment-disorder-comorbidity">
<input type="checkbox" name="adjustment-disorder" id="adjustment-disorder-comorbidity" value="y" onClick="toggleDisabledState(this);">
</label>
<div>
<fieldset disabled="true">
<label for="adjustment-disorder-comorbid-anxiety">Anxiety
<input type="radio" name="adjustment-disorder-comorbid-type" id="adjustment-disorder-comorbid-anxiety" value="anxiety">
</label>
<label for="adjustment-disorder-comorbid-depression">Depression
<input type="radio" name="adjustment-disorder-comorbid-type" id="adjustment-disorder-comorbid-depression" value="depression">
</label>
<label for="adjustment-disorder-comorbid-agitation">Agitation
<input type="radio" name="adjustment-disorder-comorbid-type" id="adjustment-disorder-comorbid-agitation" value="agitation">
</label>
</fieldset>
</div>
<label for="adjustment-disorder-diagnosis-date">Date
<input type="date" name="adjustment-disorder-diagnosis-date" id="adjustment-disorder-diagnosis-date" disabled="true">
</label>
</fieldset>
<fieldset>
<legend>Bipolar Affective Disorder</legend>
<label for="bipolar-affective-disorder">
<input type="checkbox" name="bipolar-affective-disorder" id="bipolar-affective-disorder" value="y" onClick="toggleDisabledState(this);">
</label>
<label for="bipolar-affective-disorder-diagnosis-date">Date
<input type="date" name="bipolar-affective-disorder-diagnosis-date" id="bipolar-affective-disorder-diagnosis-date" disabled="true">
</label>
</fieldset>
<fieldset>
<legend>Transient Acute Psychotic Disorder</legend>
<label for="transient-acute-psychotic-disorder">
<input type="checkbox" name="transient-acute-psychotic-disorder" id="transient-acute-psychotic-disorder" value="y" onClick="toggleDisabledState(this);">
</label>
<label for="transient-acute-psychotic-disorder-diagnosis-date">Date
<input type="date" name="transient-acute-psychotic-disorder-diagnosis-date" id="transient-acute-psychotic-disorder-diagnosis-date" disabled="true">
</label>
</fieldset>
<fieldset>
<legend>Schizophreniform Disorder</legend>
<label for="schizophreniform-disorder">
<input type="checkbox" name="schizophreniform-disorder" id="schizophreniform-disorder" value="y" onClick="toggleDisabledState(this);">
</label>
<label for="schizophreniform-disorder-diagnosis-date">Date
<input type="date" name="schizophreniform-disorder-diagnosis-date" id="schizophreniform-disorder-diagnosis-date" disabled="true">
</label>
</fieldset>
<fieldset>
<legend>Persistent Delusional Disorder</legend>
<label for="persistent-delusional-disorder">
<input type="checkbox" name="persistent-delusional-disorder" id="persistent-delusional-disorder" value="y" onClick="toggleDisabledState(this);">
</label>
<label for="persistent-delusional-disorder-diagnosis-date">Date
<input type="date" name="persistent-delusional-disorder-diagnosis-date" id="persistent-delusional-disorder-diagnosis-date" disabled="true">
</label>
</fieldset>
<fieldset>
<legend>Personality Disorder</legend>
<label for="personality-disorder">
<input type="checkbox" name="personality-disorder" id="personality-disorder" value="y" onClick="toggleDisabledState(this);">
</label>
<label for="personality-disorder-diagnosis-date">Date
<input type="date" name="personality-disorder-diagnosis-date" id="personality-disorder-diagnosis-date" disabled="true">
</label>
</fieldset>
<fieldset>
<legend>Schizophrenia</legend>
<label for="schizophrenia">
<input type="checkbox" name="schizophrenia" id="schizophrenia" value="y" onClick="toggleDisabledState(this);">
</label>
<label for="schizophrenia-diagnosis-date">Date
<input type="date" name="schizophrenia-diagnosis-date" id="schizophrenia-diagnosis-date" disabled="true">
</label>
</fieldset>
<fieldset>
<legend>Postpartum Psychosis (Puerperal Psychosis)</legend>
<label for="puerperal-psychosis">
<input type="checkbox" name="puerperal-psychosis" id="puerperal-psychosis" value="y" onClick="toggleDisabledState(this);">
</label>
<label for="puerperal-psychosis-date">Date
<input type="date" name="puerperal-psychosis-date" id="puerperal-psychosis-date" disabled="true">
</label>
</fieldset>
<fieldset>
<legend>Non-organic Psychosis (SOE)</legend>
<label for="nonorganic-psychosis">
<input type="checkbox" name="nonorganic-psychosis" id="nonorganic-psychosis" value="y" onClick="toggleDisabledState(this);">
</label>
<label for="nonorganic-psychosis-diagnosis-date">Date
<input type="date" name="nonorganic-psychosis-diagnosis-date" id="nonorganic-psychosis-diagnosis-date" disabled="true">
</label>
</fieldset>
<fieldset>
<legend>Epilepsy</legend>
<label for="epilepsy">
<input type="checkbox" name="epilepsy" id="epilepsy" value="y" onClick="toggleDisabledState(this);">
</label>
<div>
<fieldset disabled="true">
<label for="epilepsy-focal">Focal (Partial)
<input type="radio" name="epilepsy-type" id="epilepsy-type-focal" value="focal">
</label>
<label for="">Generalized
<input type="radio" name="epilepsy-type" id="epilepsy-type-generalized" value="generalized">
</label>
<label for="">Absence (Petit mal)
<input type="radio" name="epilepsy-type" id="epilepsy-type-absense" value="absence">
</label>
<label for="">Myoclonic
<input type="radio" name="epilepsy-type" id="epilepsy-type-myoclonic" value="myoclonic">
</label>
</fieldset>
</div>
<label for="epilepsy-diagnosis-date">Date
<input type="date" name="epilepsy-diagnosis-date" id="epilepsy-diagnosis-date" disabled="true">
</label>
</fieldset>
<fieldset>
<legend>Acute Organic Psychosis</legend>
<label for="acute-organic-psychosis">
<input type="checkbox" name="acute-organic-psychosis" id="acute-organic-psychosis" value="y" onClick="toggleDisabledState(this);">
</label>
<div>
<fieldset disabled="true">
<label for="acute-organic-psychosis-type-malaria">Malaria
<input type="radio" name="acute-organic-psychosis-type" id="acute-organic-psychosis-type-malaria" value="malaria">
</label>
<label for="acute-organic-psychosis-type-hiv-aids">HIV/AIDS
<input type="radio" name="acute-organic-psychosis-type" id="acute-organic-psychosis-type-hiv-aids" value="hiv-aids">
</label>
<label for="acute-organic-psychosis-type-hta">HTA
<input type="radio" name="acute-organic-psychosis-type" id="acute-organic-psychosis-type-hta" value="hta">
</label>
<label for="acute-organic-psychosis-type-tce">TCE
<input type="radio" name="acute-organic-psychosis-type" id="acute-organic-psychosis-type-tce" value="tce">
</label>
</fieldset>
</div>
<label for="acute-organic-psychosis-diagnosis-date">Date
<input type="date" name="acute-organic-psychosis-diagnosis-date" id="acute-organic-psychosis-diagnosis-date">
</label>
</fieldset>
<fieldset>
<legend>Drug Use</legend>
<label for="drug-use">
<input type="checkbox" name="drug-use" id="drug-use" value="y" onClick="toggleDisabledState(this);">
</label>
<div>
<fieldset id="drug-use-type-fieldset" onChange="toggleDisabledState(this, 'fieldset[id=drug-use-type-fieldset] input[id=drug-use-other-drug]');" disabled="true">
<label for="drug-use-alcohol">Alcohol
<input type="radio" name="drug-use-type" id="drug-use-alcohol" value="alcohol">
</label>
<label for="drug-use-intoxication">Intoxication
<input type="radio" name="drug-use-type" id="drug-use-intoxication" value="intoxication">
</label>
<label for="drug-use-abuse">Abuse
<input type="radio" name="drug-use-type" id="drug-use-abuse" value="abuse">
</label>
<label for="drug-use-abstinence">Abstinence
<input type="radio" name="drug-use-type" id="drug-use-abstinence" value="abstinence">
</label>
<label for="drug-use-dependence">Dependence
<input type="radio" name="drug-use-type" id="drug-use-dependence" value="dependence">
</label>
<label for="drug-use-other-drug">Other Drug
<input type="radio" name="drug-use-type" id="drug-use-other-drug" value="other-drug">
</label>
<label for="drug-use-other-drug-specific">If other drug, specify
<input type="text" name="drug-use-other-drug-specific" id="drug-use-other-drug-specific" disabled="true" autocomplete="off">
</label>
</fieldset>
</div>
<label for="drug-use-diagnosis-date">Date
<input type="date" name="drug-use-diagnosis-date" id="drug-use-diagnosis-date" disabled="true">
</label>
</fieldset>
<fieldset>
<legend>Multiple Drug Use</legend>
<label for="multiple-drug-use">
<input type="checkbox" name="multiple-drug-use" id="multiple-drug-use" value="y" onClick="toggleDisabledState(this);">
</label>
<div>
<fieldset id="multiple-drug-use-type-fieldset" onChange="toggleDisabledState(this, 'fieldset[id=multiple-drug-use-type-fieldset] input[id=multiple-drug-use-other-drug]');" disabled="true">
<label for="multiple-drug-use-alcohol">Alcohol
<input type="radio" name="multiple-drug-use-type" id="multiple-drug-use-alcohol" value="alcohol">
</label>
<label for="multiple-drug-use-intoxication">Intoxication
<input type="radio" name="multiple-drug-use-type" id="multiple-drug-use-intoxication" value="intoxication">
</label>
<label for="multiple-drug-use-abuse">Abuse
<input type="radio" name="multiple-drug-use-type" id="multiple-drug-use-abuse" value="abuse">
</label>
<label for="multiple-drug-use-abstinence">Abstinence
<input type="radio" name="multiple-drug-use-type" id="multiple-drug-use-abstinence" value="abstinence">
</label>
<label for="multiple-drug-use-dependence">Dependence
<input type="radio" name="multiple-drug-use-type" id="multiple-drug-use-dependence" value="dependence">
</label>
<label for="multiple-drug-use-other-drug">Other Drug
<input type="radio" name="multiple-drug-use-type" id="multiple-drug-use-other-drug" value="other-drug">
</label>
<label for="multiple-drug-use-other-drug-specific">If other drug, specify
<input type="text" name="multiple-drug-use-other-drug-specific" id="multiple-drug-use-other-drug-specific" disabled="true" autocomplete="off">
</label>
</fieldset>
</div>
<label for="multiple-drug-use-diagnosis-date">Date
<input type="date" name="multiple-drug-use-diagnosis-date" id="multiple-drug-use-diagnosis-date" disabled="true">
</label>
</fieldset>
<fieldset>
<legend>Dementia</legend>
<label for="dementia">
<input type="checkbox" name="dementia" id="dementia" value="y" onClick="toggleDisabledState(this);">
</label>
<label for="demntia-diagnosis-date">Date
<input type="date" name="demntia-diagnosis-date" id="demntia-diagnosis-date" disabled="true">
</label>
</fieldset>
<fieldset>
<legend>Mental Retardation</legend>
<label for="mental-retardation">
<input type="checkbox" name="mental-retardation" id="mental-retardation" value="y" onClick="toggleDisabledState(this);">
</label>
<label for="mental-retardation-diagnosis-date">Date
<input type="date" name="mental-retardation-diagnosis-date" id="mental-retardation-diagnosis-date" disabled="true">
</label>
</fieldset>
<fieldset>
<legend>Conduct Disorder</legend>
<label for="conduct-disorder">
<input type="checkbox" name="conduct-disorder" id="conduct-disorder" value="y" onClick="toggleDisabledState(this);">
</label>
<label for="conduct-disorder-diagnosis-date">Date
<input type="date" name="conduct-disorder-diagnosis-date" id="conduct-disorder-diagnosis-date" disabled="true">
</label>
</fieldset>
<fieldset>
<legend>Attention Deficit/Hyperactivity Disorder</legend>
<label for="attention-deficity-hyperactity-disorder">
<input type="checkbox" name="attention-deficity-hyperactity-disorder" id="attention-deficity-hyperactity-disorder" value="y" onClick="toggleDisabledState(this);">
</label>
<label for="attention-deficity-hyperactity-disorder-diagnosis-date">Date
<input type="date" name="attention-deficity-hyperactity-disorder-diagnosis-date" id="attention-deficity-hyperactity-disorder-diagnosis-date" disabled="true">
</label>
</fieldset>
<fieldset>
<legend>Nocturnal enuresis</legend>
<label for="nocturnal-enuresis">
<input type="checkbox" name="nocturnal-enuresis" id="nocturnal-enuresis" value="y" onClick="toggleDisabledState(this);">
</label>
<label for="nocturnal-enuresis-diagnosis-date">Date
<input type="date" name="nocturnal-enuresis-diagnosis-date" id="nocturnal-enuresis-diagnosis-date" disabled="true">
</label>
</fieldset>
<!--<fieldset>
<legend></legend>
<label for="">
<input type="checkbox" name="" id="" value="y" onClick="toggleDisabledState(this);">
</label>
<label for="">
<input type="checkbox" name="" id="" value="y">
</label>
<label for="">
<input type="checkbox" name="" id="" value="y">
</label>
<label for="">
<input type="checkbox" name="" id="" value="y">
</label>
<label for="">
<input type="checkbox" name="" id="" value="y">
</label>
<label for="">
<input type="checkbox" name="" id="" value="y">
</label>
<label for="">
<input type="checkbox" name="" id="" value="y">
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<label for="">
<input type="checkbox" name="" id="" value="y">
</label>
<label for="">
<input type="text" name="" id="">
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<label for="">
<input type="date" name="" id="">
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</fieldset>
</form>
<button mat-button>click</button>
</body>
</html>