https://hsl.co.in/build/assets/Form-CXhRWHSi.js

1import{r as p,G as N,j as e}from"./app-Mnt2IEGe.js";import{G as _}from"./GuestLayout-BYnLiqFZ.js";import{S as o}from"./sweetalert2.esm.all-CnnFETqF.js";import{S as v}from"./star-C1jGBhfp.js";import{U as w}from"./user-ad0RTXxq.js";import{H as C}from"./heart-BNUvMs6J.js";import{U as k}from"./users-TBz3OMTK.js";import{R as S}from"./refresh-cw-Bb8PiguS.js";import{C as A}from"./circle-check-big-DOBAhIbM.js";import"./ApplicationLogo-JvKRx6b1.js";import"./x-B1Pn9Kmg.js";import"./message-circle-D4MbkUVn.js";import"./phone-DSAsYLtt.js";import"./chevron-down-BlAiga6f.js";import"./package-CT4joqbC.js";import"./map-pin-BuVEKMGp.js";import"./truck-CpGakV_6.js";import"./shopping-cart-DokKNEt4.js";import"./search-BeXkNHdv.js";import"./clock-Dnho5FNh.js";import"./shield-Da3uiB5y.js";import"./mail-Ce-sk81h.js";function X(){const[n,g]=p.useState({num1:0,num2:0,answer:""}),[x,f]=p.useState("");p.useEffect(()=>{c()},[]);function c(){const r=Math.floor(Math.random()*50)+1,d=Math.floor(Math.random()*50)+1;g({num1:r,num2:d,answer:""}),f("")}const{data:s,setData:a,post:b,processing:u,errors:l}=N({name_identifier:"",name:"",gender:"",age:"",height_cm:"",weight_kg:"",city:"",mobile:"",email:"",occupation:"",general_nature:"",present_ailments:"",doctor_diagnosis:"",investigations:"",other_relevant:"",past_history:"",physical_generals:{weather:"",appetite:"",thirst:"",liking:"",urine:"",stool:"",perspiration:"",sleep:"",speed:"",sensitivity:""},female_history:{gynae:"",menstrual_history:"",age_of_menarche_menopause:"",abortions:""},family_history:"",additional_info:"",cigarettes_per_week:"",alcohol_units_per_week:"",exercise_sessions_per_week:"",security_code:""});function y(r){r.preventDefault();const d=n.num1+n.num2;if(parseInt(n.answer)!==d){o.fire({icon:"error",title:"Incorrect CAPTCHA",text:"The answer to the math problem is incorrect. Please try again.",confirmButtonColor:"#2e3192",backdrop:"rgba(0, 0, 0, 0.4)"}),c();return}const m=t=>{if(t===""||t===null||typeof t>"u")return null;const i=Number(t);return Number.isNaN(i)?null:Math.trunc(i)},j={...s,cigarettes_per_week:m(s.cigarettes_per_week),alcohol_units_per_week:m(s.alcohol_units_per_week),exercise_sessions_per_week:m(s.exercise_sessions_per_week)};o.fire({title:"Submitting your consultation...",text:"Please wait while we process your form.",icon:"info",allowOutsideClick:!1,allowEscapeKey:!1,didOpen:()=>{o.showLoading()},confirmButtonColor:"#2e3192"}),b(route("consultation.store"),{data:j,onSuccess:()=>{o.fire({icon:"success",title:"Consultation Submitted!",text:"Your consultation has been successfully submitted. Our doctors will review your case and respond within 2 working days.",confirmButtonColor:"#2e3192",backdrop:"rgba(0, 0, 0, 0.4)"}),a({name_identifier:"",name:"",gender:"",age:"",height_cm:"",weight_kg:"",city:"",mobile:"",email:"",occupation:"",general_nature:"",present_ailments:"",doctor_diagnosis:"",investigations:"",other_relevant:"",past_history:"",physical_generals:{weather:"",appetite:"",thirst:"",liking:"",urine:"",stool:"",perspiration:"",sleep:"",speed:"",sensitivity:""},female_history:{gynae:"",menstrual_history:"",age_of_menarche_menopause:"",abortions:""},family_history:"",additional_info:"",cigarettes_per_week:"",alcohol_units_per_week:"",exercise_sessions_per_week:"",security_code:""}),c()},onError:t=>{let i="There was an error submitting your consultation. Please check the form and try again.";if(t&&Object.keys(t).length>0){const h=Object.keys(t)[0];t[h]&&(i=t[h])}o.fire({icon:"error",title:"Submission Failed",text:i,confirmButtonColor:"#2e3192",backdrop:"rgba(0, 0, 0, 0.4)"})}})}return e.jsx(_,{children:e.jsxs("div",{className:"w-full bg-gradient-to-b from-primary-light via-white to-white",children:[e.jsxs("section",{className:"relative overflow-hidden bg-gradient-to-br from-primary via-primary to-indigo-800 py-20 sm:py-24 lg:py-28",children:[e.jsx("div",{className:"absolute inset-0 bg-black/10"}),e.jsx("div",{className:"relative max-w-7xl mx-auto px-6 sm:px-12 lg:px-20",children:e.jsxs("div",{className:"text-center",children:[e.jsxs("div",{className:"inline-flex items-center px-6 py-3 bg-white/20 backdrop-blur-sm rounded-full text-white text-lg font-bold shadow-lg mb-6 border border-white/30",children:[e.jsx(v,{className:"w-5 h-5 mr-3 text-yellow-300"}),"Online Consultation"]}),e.jsx("h1",{className:"text-4xl sm:text-5xl lg:text-6xl font-extrabold text-white mb-6 tracking-tight leading-tight",children:"Online Consultation"}),e.jsx("div",{className:"inline-block bg-gradient-to-r from-green-50 to-emerald-50 border-2 border-green-300 rounded-lg px-4 py-2 mb-4",children:e.jsx("p",{className:"text-sm sm:text-base font-bold text-green-700",children:"✨ First Time Free Consultation ✨"})}),e.jsx("p",{className:"text-lg sm:text-xl text-primary-light max-w-3xl mx-auto leading-relaxed mb-4",children:"Share your health details with our doctors. We respond within 2 working days."}),e.jsx("div",{className:"inline-block bg-blue-50 border-2 border-blue-200 rounded-lg px-4 py-2",children:e.jsxs("p",{className:"text-sm text-blue-900",children:[e.jsx("span",{className:"font-semibold",children:"Consultation Timings:"})," ","Monday to Saturday | 11:30 AM to 5:30 PM"]})})]})})]}),e.jsx("div",{className:"max-w-7xl mx-auto px-6 sm:px-12 lg:px-20 py-10",children:e.jsxs("form",{onSubmit:y,className:"bg-white rounded-xl shadow-lg p-6 sm:p-8 space-y-8 max-w-4xl mx-auto",children:[e.jsxs("div",{className:"border-b-2 border-primary-light pb-6",children:[e.jsxs("div",{className:"flex items-center gap-3 mb-6",children:[e.jsx("div",{className:"bg-primary/10 p-2 rounded-lg",children:e.jsx(w,{className:"w-5 h-5 text-primary"})}),e.jsx("h2",{className:"text-2xl font-bold text-gray-900",children:"Personal Information"})]}),e.jsxs("div",{className:"grid grid-cols-1 md:grid-cols-2 gap-4",children:[e.jsxs("label",{className:"flex flex-col",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Patient ID (Optional)"}

1),e.jsx("input",{value:s.name_identifier,onChange:r=>a("name_identifier",r.target.value),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"If you have visited before"}),l.name_identifier&&e.jsx("div",{className:"text-sm text-red-600",children:l.name_identifier})]}),e.jsxs("label",{className:"flex flex-col",children:[e.jsxs("span",{className:"font-semibold text-gray-700 mb-2",children:["Full Name"," ",e.jsx("span",{className:"text-red-500",children:"*"})]}),e.jsx("input",{value:s.name,onChange:r=>a("name",r.target.value),required:!0,className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"Your full name"}),l.name&&e.jsx("div",{className:"text-sm text-red-600",children:l.name})]})]}),e.jsxs("div",{className:"grid grid-cols-1 md:grid-cols-3 gap-4 mt-4",children:[e.jsxs("label",{className:"flex flex-col",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Gender"}),e.jsxs("select",{value:s.gender,onChange:r=>a("gender",r.target.value),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent bg-white",children:[e.jsx("option",{value:"",children:"Select"}),e.jsx("option",{value:"male",children:"Male"}),e.jsx("option",{value:"female",children:"Female"}),e.jsx("option",{value:"other",children:"Other"})]}),l.gender&&e.jsx("div",{className:"text-sm text-red-600",children:l.gender})]}),e.jsxs("label",{className:"flex flex-col",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Age"}),e.jsx("input",{type:"number",value:s.age,onChange:r=>a("age",r.target.value),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"Years"}),l.age&&e.jsx("div",{className:"text-sm text-red-600",children:l.age})]}),e.jsxs("label",{className:"flex flex-col",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Height (Cm)"}),e.jsx("input",{type:"number",value:s.height_cm,onChange:r=>a("height_cm",r.target.value),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"cm"}),l.height_cm&&e.jsx("div",{className:"text-sm text-red-600",children:l.height_cm})]})]}),e.jsxs("div",{className:"grid grid-cols-1 md:grid-cols-3 gap-4 mt-4",children:[e.jsxs("label",{className:"flex flex-col",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Weight (Kg)"}),e.jsx("input",{type:"number",value:s.weight_kg,onChange:r=>a("weight_kg",r.target.value),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"kg"}),l.weight_kg&&e.jsx("div",{className:"text-sm text-red-600",children:l.weight_kg})]}),e.jsxs("label",{className:"flex flex-col",children:[e.jsxs("span",{className:"font-semibold text-gray-700 mb-2",children:["City",e.jsx("span",{className:"text-red-500",children:"*"})]}),e.jsx("input",{value:s.city,onChange:r=>a("city",r.target.value),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"Your city"}),l.city&&e.jsx("div",{className:"text-sm text-red-600",children:l.city})]}),e.jsxs("label",{className:"flex flex-col",children:[e.jsxs("span",{className:"font-semibold text-gray-700 mb-2",children:["Mobile"," ",e.jsx("span",{className:"text-red-500",children:"*"})]}),e.jsx("input",{value:s.mobile,onChange:r=>a("mobile",r.target.value),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"10-digit mobile"}),l.mobile&&e.jsx("div",{className:"text-sm text-red-600",children:l.mobile})]})]}),e.jsxs("div",{className:"grid grid-cols-1 md:grid-cols-2 gap-4 mt-4",children:[e.jsxs("label",{className:"flex flex-col",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Email"}),e.jsx("input",{value:s.email,onChange:r=>a("email",r.target.value),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"[email protected]"}),l.email&&e.jsx("div",{className:"text-sm text-red-600",children:l.email})]}),e.jsxs("label",{className:"flex flex-col",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Occupation"}),e.jsx("input",{value:s.occupation,onChange:r=>a("occupation",r.target.value),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"Your occupation"}),l.occupation&&e.jsx("div",{className:"text-sm text-red-600",children:l.occupation}),e.jsx("small",{className:"text-sm text-gray-500",children:"(Often relevant to your health)"})]})]})]}),e.jsxs("div",{className:"border-b-2 border-primary-light pb-6",children:[e.jsxs("div",{className:"flex items-center gap-3 mb-6",children:[e.jsx("div",{className:"bg-primary/10 p-2 rounded-lg",children:e.jsx(C,{className:"w-5 h-5 text-primary"})}),e.jsx("h2",{className:"text-2xl font-bold text-gray-900",children:"Health Information"})]}),e.jsxs("label",{className:"flex flex-col",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Your General Nature"}),e.jsx("textarea",{value:s.general_nature,onChange:r=>a("general_nature",r.target.value),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent h-24",placeholder:"E.g., Anger, extrovert/introvert, emotional, etc."}),e.jsx("small",{className:"text-sm text-gray-500",children:"(Anger, extrovert or introvert, emotional, decision making quality, childhood nature, how you take criticism etc.)"}),l.general_nature&&e.jsx("div",{className:"text-sm text-red-600",children:l.general_nature})]}),e.jsxs("label",{className:"flex flex-col mt-4",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Present Disease/Ailments"}),e.jsx("textarea",{value:s.present_ailments,onChange:r=>a("present_ailments",r.target.value),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent h-28",placeholder:"List in order of appearance with duration..."}),e.jsx("small",{className:"text-sm text-gray-500",children:"(List in order of appearance with duration)"}),l.present_ailments&&e.jsx("div",{className:"text-sm text-red-600",children:l.present_ailments})]}),e.jsxs("label",{className:"flex flex-col mt-4",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Doctor's Diagnosis (if any)"}),e.jsx("textarea",{value:s.doctor_diagnosis,onChange:r=>a("doctor_diagnosis",r.target.value),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent h-20",placeholder:"Previous diagnosis from doctors..."}),l.doctor_diagnosis&&e.jsx("div",{className:"text-sm text-red-600",children:l.doctor_diagnosis})]}),e.jsxs("label",{className:"flex flex-col mt-4",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Tests & Investigations"}),e.jsx("textarea",{value:s.investigations,onChange:r=>a("investigations",r.target.value),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent h-20",placeholder:"Reports, treatment history, etc."}),l.investigations&&e.jsx("div",{className:"text-sm text-red-600",children:l.investigations})]}),e.jsxs("label",{className:"flex flex-col mt-4",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Additional Information"}),e.jsx("textarea",{value:s.other_relevant,onChange:r=>a("other_relevant",r.target.value),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent h-20",placeholder:"Allergies, family illnesses, lifestyle details..."}),l.other_relevant&&e.jsx("div",{className:"text-sm text-red-600",children:l.other_relevant})]}),e.jsxs("label",{className:"flex flex-col mt-4",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Past Medical History"}),e.jsx("textarea",{value:s.past_history,onChange:r=>a("past_history",r.target.value),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent h-20",placeholder:"Previous diseases, symptoms & treatment..."}),l.past_history&&e.jsx("div",{className:"text-sm text-red-600",children:l.past_history})]})]}),e.jsxs("div",{className:"border-b-2 border-primary-light pb-6",children:[e.jsx("h3",{className:"text-2xl font-bold text-gray-900 mb-6",children:"Physical Characteristics"}),e.jsxs("div",{className:"grid grid-cols-1 md:grid-cols-2 gap-4",children:[e.jsxs("label",{className:"flex flex-col",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Preferred Weather"}),e.jsx("input",{value:s.physical_generals.weather,onChange:r=>a("physical_generals",{...s.physical_generals,weather:r.target.value}),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"Which weather you prefer most"})]}),e.jsxs("label",{className:"flex flex-col",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Appetite"}),e.jsx("input",{value:s.physical_generals.appetite,onChange:r=>a("physical_generals",{...s.physical_generals,appetite:r.target.value}),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"Appetite"})]}),e.jsxs("label",{className:"flex flex-col",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Thirst"}),e.jsx("input",{value:s.physical_generals.thirst,onChange:r=>a("physical_generals",{...s.physical_generals,thirst:r.target.value}),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"Thirst"})]}),e.jsxs("label",{className:"flex flex-col",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Liking for specific taste/food"}),e.jsx("input",{value:s.physical_generals.liking,onChange:r=>a("physical_generals",{...s.physical_generals,liking:r.target.value}),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"Liking for specific taste/food"})]}),e.jsxs("label",{className:"flex flex-col",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Urine"}),e.jsx("input",{value:s.physical_generals.urine,onChange:r=>a("physical_generals",{...s.physical_generals,urine:r.target.value}),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"Urine"})]}),e.jsxs("label",{className:"flex flex-col",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Stool"}

1),e.jsx("input",{value:s.physical_generals.stool,onChange:r=>a("physical_generals",{...s.physical_generals,stool:r.target.value}),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"Stool"})]}),e.jsxs("label",{className:"flex flex-col",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Perspiration"}),e.jsx("input",{value:s.physical_generals.perspiration,onChange:r=>a("physical_generals",{...s.physical_generals,perspiration:r.target.value}),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"Perspiration"})]}),e.jsxs("label",{className:"flex flex-col",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Sleep pattern, position during sleep"}),e.jsx("input",{value:s.physical_generals.sleep,onChange:r=>a("physical_generals",{...s.physical_generals,sleep:r.target.value}),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"Sleep pattern, position during sleep"})]}),e.jsxs("label",{className:"flex flex-col",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Speed (walking, eating, working)"}),e.jsx("input",{value:s.physical_generals.speed,onChange:r=>a("physical_generals",{...s.physical_generals,speed:r.target.value}),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"Speed"})]}),e.jsxs("label",{className:"flex flex-col",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Sensitivity"}),e.jsx("input",{value:s.physical_generals.sensitivity,onChange:r=>a("physical_generals",{...s.physical_generals,sensitivity:r.target.value}),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"Sensitivity"})]})]})]}),e.jsxs("div",{className:"border-b-2 border-primary-light pb-6 bg-pink-50 p-6 rounded-lg",children:[e.jsxs("div",{className:"flex items-center gap-3 mb-6",children:[e.jsx("div",{className:"bg-pink-200 p-2 rounded-lg",children:e.jsx(k,{className:"w-5 h-5 text-pink-600"})}),e.jsx("h3",{className:"text-2xl font-bold text-gray-900",children:"Female Health History (if applicable)"})]}),e.jsxs("label",{className:"flex flex-col",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Gynaecological & Obstetric History"}),e.jsx("textarea",{value:s.female_history.gynae,onChange:r=>a("female_history",{...s.female_history,gynae:r.target.value}),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent h-20",placeholder:"Gynaecological history..."})]}),e.jsxs("label",{className:"flex flex-col mt-4",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Menstrual History"}),e.jsx("textarea",{value:s.female_history.menstrual_history,onChange:r=>a("female_history",{...s.female_history,menstrual_history:r.target.value}),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent h-20",placeholder:"Menstrual cycle details..."})]}),e.jsxs("label",{className:"flex flex-col mt-4",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Age of Menarche/Menopause"}),e.jsx("input",{value:s.female_history.age_of_menarche_menopause,onChange:r=>a("female_history",{...s.female_history,age_of_menarche_menopause:r.target.value}),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"Age of menarche/menopause"})]}),e.jsxs("label",{className:"flex flex-col mt-4",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Abortions"}),e.jsx("input",{value:s.female_history.abortions,onChange:r=>a("female_history",{...s.female_history,abortions:r.target.value}),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"Number of abortions"})]})]}),e.jsxs("div",{className:"border-b-2 border-primary-light pb-6",children:[e.jsx("h3",{className:"text-2xl font-bold text-gray-900 mb-6",children:"Lifestyle"}),e.jsxs("div",{className:"grid grid-cols-1 md:grid-cols-3 gap-4",children:[e.jsxs("label",{className:"flex flex-col",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Cigarettes per week"}),e.jsx("input",{type:"number",value:s.cigarettes_per_week,onChange:r=>a("cigarettes_per_week",r.target.value),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"0"})]}),e.jsxs("label",{className:"flex flex-col",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Alcohol units per week"}),e.jsx("input",{type:"number",value:s.alcohol_units_per_week,onChange:r=>a("alcohol_units_per_week",r.target.value),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"0"})]}),e.jsxs("label",{className:"flex flex-col",children:[e.jsx("span",{className:"font-semibold text-gray-700 mb-2",children:"Exercise sessions per week"}),e.jsx("input",{type:"number",value:s.exercise_sessions_per_week,onChange:r=>a("exercise_sessions_per_week",r.target.value),className:"w-full px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"0"})]})]})]}),e.jsxs("div",{className:"border-t-2 border-primary-light pt-6",children:[e.jsxs("div",{className:"flex items-center gap-3 mb-6",children:[e.jsx("div",{className:"bg-yellow-100 p-2 rounded-lg",children:e.jsx(S,{className:"w-5 h-5 text-yellow-600"})}),e.jsx("h3",{className:"text-xl font-bold text-gray-900",children:"Security Check"})]}),e.jsxs("div",{className:"bg-gray-50 p-6 rounded-lg",children:[e.jsxs("div",{className:"text-center mb-6",children:[e.jsxs("p",{className:"text-xl font-bold text-gray-800 mb

1-2",children:[n.num1," + ",n.num2," = ?"]}),e.jsx("button",{type:"button",onClick:c,className:"text-sm text-primary hover:underline underline-offset-2 mb-4",children:"Refresh CAPTCHA"})]}),e.jsxs("div",{className:"flex gap-3",children:[e.jsx("input",{type:"number",value:n.answer,onChange:r=>g({...n,answer:r.target.value}),className:"flex-1 px-4 py-2 border border-gray-300 rounded-lg focus:ring-2 focus:ring-primary focus:border-transparent",placeholder:"Enter answer"}),x&&e.jsx("div",{className:"text-sm text-red-600 bg-red-50 px-4 py-2 rounded-lg border border-red-200",children:x})]})]})]}),e.jsx("div",{className:"flex flex-col sm:flex-row items-center justify-center gap-4 pt-8",children:e.jsx("button",{type:"submit",disabled:u,className:"w-full sm:w-auto bg-gradient-to-r from-primary to-indigo-600 hover:from-primary hover:to-indigo-700 text-white font-semibold py-4 px-12 rounded-xl transition-all duration-300 flex items-center justify-center gap-3 disabled:opacity-50 disabled:cursor-not-allowed shadow-xl hover:shadow-2xl hover:-translate-y-1 text-lg",children:u?e.jsxs(e.Fragment,{children:[e.jsx("div",{className:"animate-spin h-5 w-5 border-2 border-white border-t-transparent rounded-full"}),"Submitting..."]}):e.jsxs(e.Fragment,{children:[e.jsx(A,{className:"w-5 h-5"}),"Submit Consultation"]})})})]})})]})})}export{X as default};