<div class="card p-2">
    <div class="card-body">
        <div class="row" id="icd10s">
            <div class="col-lg-12">
                <div class="row">
                    <div class="col-12">
                        <h5 class="text-decoration-underline">POST-PROCEDURE  (Diagnosis)</h5>
                    </div>
                    <div class="col-auto">
                        <b>Post-DIAGNOSTIC (ICD-10) </b>
                    </div>
                    <div class="col-auto">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck1">
                            <label class="form-check-label" for="formCheck1">
                                Normal
                            </label>
                        </div>
                    </div>
                </div>
            </div>
            <div class="col-lg-7">
                <div class="row border-light border-bottom">
                    <div class="col-12">
                        1.Cecum
                    </div>
                    <div class="col-4">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck1">
                            <label class="form-check-label" for="formCheck1">
                                CA Cecum
                            </label>
                        </div>
                    </div>
                </div>
                <div class="row border-light border-bottom mt-4 pb-4">
                    <div class="col-12">2.Colon</div>
                    <div class="col-4">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck1">
                            <label class="form-check-label" for="formCheck1">
                                Angiodysplasia of Colon
                            </label>
                        </div>
                    </div>
                    <div class="col-4">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck1">
                            <label class="form-check-label" for="formCheck1">
                                Diverticulitis/Diverticulosis/Diverticulum
                            </label>
                        </div>
                    </div>
                    <div class="col-4">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck1">
                            <label class="form-check-label" for="formCheck1">
                                CA colon
                            </label>
                        </div>
                    </div>
                    <div class="col-4">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck1">
                            <label class="form-check-label" for="formCheck1">
                                Colitis
                            </label>
                        </div>
                    </div>
                    <div class="col-4">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck1">
                            <label class="form-check-label" for="formCheck1">
                                Colonic polyp
                            </label>
                        </div>
                    </div>
                    <div class="col-4">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck1">
                            <label class="form-check-label" for="formCheck1">
                                Colonic polyp
                            </label>
                        </div>
                    </div>
                </div>
                <div class="row border-light border-bottom mt-4 pb-4">
                    <div class="col-12">3.Rectum</div>
                    <div class="col-4">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck1">
                            <label class="form-check-label" for="formCheck1">
                                Anal polyp
                            </label>
                        </div>
                    </div>
                    <div class="col-4">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck1">
                            <label class="form-check-label" for="formCheck1">
                                Internal hemorrhoids without complication
                            </label>
                        </div>
                    </div>
                    <div class="col-4">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck1">
                            <label class="form-check-label" for="formCheck1">
                                External hemorrhoids without complication
                            </label>
                        </div>
                    </div>
                    <div class="col-4">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck1">
                            <label class="form-check-label" for="formCheck1">
                                External hemorrhoids with complications
                            </label>
                        </div>
                    </div>
                    <div class="col-4">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck1">
                            <label class="form-check-label" for="formCheck1">
                                Foreign body in anus
                            </label>
                        </div>
                    </div>
                </div>
            </div>
            <div class="col-lg-5">
                <div class="row">
                    <div class="col-4">Primary Diagnostic</div>
                    <div class="col-8"><input type="text" class="form-control"></div>
                </div>
                <div class="row mt-2">
                    <div class="col-4">Secondary Diagnostic</div>
                    <div class="col-8"><input type="text" class="form-control"></div>
                </div>
                <div class="row mt-2">
                    <div class="col-4">Add Diagnostic</div>
                    <div class="col-8"><input type="text" class="form-control"></div>
                </div>
                <div class="row mt-2">
                    <div class="col-4">Add Diagnostic</div>
                    <div class="col-8"><input type="text" class="form-control"></div>
                </div>
                <div class="row mt-2">
                    <div class="col-4">Add Diagnostic</div>
                    <div class="col-8"><input type="text" class="form-control"></div>
                </div>
                <div class="row mt-2">
                    <div class="col-4">Add Diagnostic</div>
                    <div class="col-8"><input type="text" class="form-control"></div>
                </div>
                <div class="row mt-2">
                    <div class="col-4">Add Diagnostic</div>
                    <div class="col-8"><input type="text" class="form-control"></div>
                </div>
                <div class="row mt-2">
                    <div class="col-4">ICD-10 Diagnostic</div>
                    <div class="col-8"><input type="text" class="form-control"></div>
                </div>
            </div>
            <div class="col-lg-12">
                <textarea name="" id="" rows="6" class="form-control" placeholder="Free text"></textarea>
            </div>
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