<div class="card p-4">
    <div class="row">
        <div class="col-xl-6">
            <h4>Post-Diagnosis &ensp; &ensp; &ensp;&ensp; &ensp;<i class="ri-equalizer-line"></i></h4>
            <div class="row mt-2">
                <h5>Esophagus</h5>
                <div class="col-4">
                    <div class="form-check mb-2">
                        <input class="form-check-input" type="checkbox" id="formCheck29">
                        <label class="form-check-label ms-4" for="formCheck29">
                            Achalasia
                        </label>
                    </div>
                </div>
                <div class="col-4">
                    <div class="form-check mb-2">
                        <input class="form-check-input" type="checkbox" id="formCheck31">
                        <label class="form-check-label ms-4" for="formCheck31">
                            Corrosion of Esophagus
                        </label>
                    </div>
                </div>
                <div class="col-4">
                    <div class="form-check mb-2">
                        <input class="form-check-input" type="checkbox" id="formCheck32">
                        <label class="form-check-label ms-4" for="formCheck32">
                            Foreign body in esophagus
                        </label>
                    </div>
                </div>

                <div class="col-4">
                    <div class="form-check mb-2">
                        <input class="form-check-input" type="checkbox" id="formCheck33">
                        <label class="form-check-label ms-4" for="formCheck33">
                            Abdominal Pain
                        </label>
                    </div>
                </div>
                <div class="col-4">
                    <div class="form-check mb-2">
                        <input class="form-check-input" type="checkbox" id="formCheck34">
                        <label class="form-check-label ms-4" for="formCheck34">
                            Esophageal obstruction
                        </label>
                    </div>
                </div>
                <div class="col-4">
                    <div class="form-check mb-2">
                        <input class="form-check-input" type="checkbox" id="formCheck35">
                        <label class="form-check-label ms-4" for="formCheck35">
                            GERD without esophagitis
                        </label>
                    </div>
                </div>

                <div class="col-4">
                    <div class="form-check mb-2">
                        <input class="form-check-input" type="checkbox" id="formCheck36">
                        <label class="form-check-label ms-4" for="formCheck36">
                            GERD without esophagitis
                        </label>
                    </div>
                </div>
                <div class="col-4">
                    <div class="form-check mb-2">
                        <input class="form-check-input" type="checkbox" id="formCheck37">
                        <label class="form-check-label ms-4" for="formCheck37">
                            Foreign body in esophagus
                        </label>
                    </div>
                </div>
            </div>
            <div class="row mt-4">
                <h5>Stomach</h5>
                <div class="col-4">
                    <div class="form-check mb-2">
                        <input class="form-check-input" type="checkbox" id="formCheck38">
                        <label class="form-check-label ms-4" for="formCheck38">
                            Achalasia
                        </label>
                    </div>
                </div>
                <div class="col-4">
                    <div class="form-check mb-2">
                        <input class="form-check-input" type="checkbox" id="formCheck39">
                        <label class="form-check-label ms-4" for="formCheck39">
                            Corrosion of Esophagus
                        </label>
                    </div>
                </div>
                <div class="col-4">
                    <div class="form-check mb-2">
                        <input class="form-check-input" type="checkbox" id="formCheck40">
                        <label class="form-check-label ms-4" for="formCheck40">
                            Foreign body in esophagus
                        </label>
                    </div>
                </div>

                <div class="col-4">
                    <div class="form-check mb-2">
                        <input class="form-check-input" type="checkbox" id="formCheck41">
                        <label class="form-check-label ms-4" for="formCheck41">
                            Abdominal Pain
                        </label>
                    </div>
                </div>
                <div class="col-4">
                    <div class="form-check mb-2">
                        <input class="form-check-input" type="checkbox" id="formCheck42">
                        <label class="form-check-label ms-4" for="formCheck42">
                            Esophageal obstruction
                        </label>
                    </div>
                </div>
                <div class="col-4">
                    <div class="form-check mb-2">
                        <input class="form-check-input" type="checkbox" id="formCheck43">
                        <label class="form-check-label ms-4" for="formCheck43">
                            Foreign body in esophagus
                        </label>
                    </div>
                </div>

                <div class="col-4">
                    <div class="form-check mb-2">
                        <input class="form-check-input" type="checkbox" id="formCheck44">
                        <label class="form-check-label ms-4" for="formCheck44">
                            GERD without esophagitis
                        </label>
                    </div>
                </div>
                <div class="col-4">
                    <div class="form-check mb-2">
                        <input class="form-check-input" type="checkbox" id="formCheck45">
                        <label class="form-check-label ms-4" for="formCheck45">
                            GERD without esophagitis
                        </label>
                    </div>
                </div>
            </div>
            <div class="row mt-2">
                <h5>Duodenum</h5>
                <div class="col-4">
                    <div class="form-check mb-2">
                        <input class="form-check-input" type="checkbox" id="formCheck46">
                        <label class="form-check-label ms-4" for="formCheck46">
                            Achalasia
                        </label>
                    </div>
                </div>
                <div class="col-4">
                    <div class="form-check mb-2">
                        <input class="form-check-input" type="checkbox" id="formCheck47">
                        <label class="form-check-label ms-4" for="formCheck47">
                            Corrosion of Esophagus
                        </label>
                    </div>
                </div>
                <div class="col-4">
                    <div class="form-check mb-2">
                        <input class="form-check-input" type="checkbox" id="formCheck48">
                        <label class="form-check-label ms-4" for="formCheck48">
                            Foreign body in esophagus
                        </label>
                    </div>
                </div>

                <div class="col-4">
                    <div class="form-check mb-2">
                        <input class="form-check-input" type="checkbox" id="formCheck49">
                        <label class="form-check-label ms-4" for="formCheck49">
                            Abdominal Pain
                        </label>
                    </div>
                </div>
                <div class="col-4">
                    <div class="form-check mb-2">
                        <input class="form-check-input" type="checkbox" id="formCheck50">
                        <label class="form-check-label ms-4" for="formCheck50">
                            Esophageal obstruction
                        </label>
                    </div>
                </div>
                <div class="col-4">
                    <div class="form-check mb-2">
                        <input class="form-check-input" type="checkbox" id="formCheck51">
                        <label class="form-check-label ms-4" for="formCheck51">
                            GERD without esophagitis
                        </label>
                    </div>
                </div>

                <div class="col-4">
                    <div class="form-check mb-2">
                        <input class="form-check-input" type="checkbox" id="formCheck52">
                        <label class="form-check-label ms-4" for="formCheck52">
                            GERD without esophagitis
                        </label>
                    </div>
                </div>
            </div>
            <div class="col-12 mt-3">
                <textarea name="" id="" cols="30" rows="3" class="form-control"
                    placeholder="Free text"></textarea>
            </div>
        </div>
        <div class="col-xl-6 mt-5">
            <button type="button" class="btn btn-checkbox  waves-effect waves-light btn-sm fs-14"
                id="btn_prediagnostic">
                <i class="mdi mdi-checkbox-outline   align-middle  me-2 text-light fs-16"></i>
                Normal EGD
            </button>
            <div class="row">
                <div class="col-12">
                    <div class="input-group mb-3">
                        <input type="text" class="form-control" placeholder="Primary Diagnosis"
                            aria-label="Recipient's username" aria-describedby="basic-addon2">
                        <span class="input-group-text" id="basic-addon2">ICD-10</span>
                    </div>
                </div>
                <div class="col-12">
                    <div class="input-group mb-3">
                        <input type="text" class="form-control" placeholder="Secondary Diagnosis"
                            aria-label="Recipient's username" aria-describedby="basic-addon2">
                        <span class="input-group-text" id="basic-addon2">ICD-10</span>
                    </div>
                </div>
                <div class="col-12">
                    <div class="input-group mb-3">
                        <input type="text" class="form-control" placeholder="Other Diagnosis"
                            aria-label="Recipient's username" aria-describedby="basic-addon2">
                        <span class="input-group-text" id="basic-addon2">ICD-10</span>
                    </div>
                </div>
                <div class="col-12">
                    <div class="input-group mb-3">
                        <input type="text" class="form-control" placeholder="Other Diagnosis"
                            aria-label="Recipient's username" aria-describedby="basic-addon2">
                        <span class="input-group-text" id="basic-addon2">ICD-10</span>
                    </div>
                </div>
                <div class="col-12">
                    <div class="input-group mb-3">
                        <input type="text" class="form-control" placeholder="Other Diagnosis"
                            aria-label="Recipient's username" aria-describedby="basic-addon2">
                        <span class="input-group-text" id="basic-addon2">ICD-10</span>
                    </div>
                </div>
            </div>
        </div>
        <div class="row mt-4">
            <div class="col-3"></div>
            <div class="col-6">
                <hr>
            </div>
            <div class="col-3"></div>
        </div>
        <div class="row">
            <div class="col-xl-6">
                <div class="col-auto">
                    <h4>Procedure &ensp; &ensp; &ensp;&ensp; &ensp;<i class="ri-equalizer-line"></i></h4>
                </div>
                <div class="row">
                    <div class="col-6">
                        <div class="row">
                            <div class="col-auto">
                                <div class="form-check mb-2">
                                    <input class="form-check-input" type="checkbox" id="formCheck53">
                                    <label class="form-check-label ms-4" for="formCheck53">
                                        Adrenalin injection
                                    </label>
                                </div>
                            </div>
                            <div class="col-3">
                                <input type="text" class="form-control form-control-sm ">
                            </div>
                            <div class="col-auto">
                                ml.
                            </div>
                        </div>
                    </div>
                    <div class="col-6">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck54">
                            <label class="form-check-label ms-4" for="formCheck54">
                                Heater probe/Gold probe
                            </label>
                        </div>
                    </div>
                </div>
                <div class="row mt-2">
                    <div class="col-6">
                        <div class="row">
                            <div class="col-auto">
                                <div class="form-check mb-2">
                                    <input class="form-check-input" type="checkbox" id="formCheck55">
                                    <label class="form-check-label ms-4" for="formCheck55">
                                        Hemoclip
                                    </label>
                                </div>
                            </div>
                            <div class="col-3">
                                <input type="text" class="form-control form-control-sm ">
                            </div>
                            <div class="col-auto">
                                Pcs.
                            </div>
                        </div>
                    </div>
                    <div class="col-6">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck56">
                            <label class="form-check-label ms-4" for="formCheck56">
                                Esophageal obstruction
                            </label>
                        </div>
                    </div>
                </div>
                <div class="row mt-2">
                    <div class="col-6">
                        <div class="row">
                            <div class="col-auto">
                                <div class="form-check mb-2">
                                    <input class="form-check-input" type="checkbox" id="formCheck57">
                                    <label class="form-check-label ms-4" for="formCheck57">
                                        Polypectomy
                                    </label>
                                </div>
                            </div>
                        </div>
                    </div>
                    <div class="col-6">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck58">
                            <label class="form-check-label ms-4" for="formCheck58">
                                Foreign body in esophagus
                            </label>
                        </div>
                    </div>
                </div>
                <div class="row mt-1">
                    <div class="col-6">
                        <div class="row ms-4">
                            <div class="col-auto">
                                <div class="form-check mb-2">
                                    <input class="form-check-input" type="checkbox" id="formCheck59">
                                    <label class="form-check-label ms-3" for="formCheck59">
                                        Polypectomy (Esophagus)
                                    </label>
                                </div>
                            </div>
                        </div>
                    </div>
                    <div class="col-6">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck60">
                            <label class="form-check-label ms-4" for="formCheck60">
                                Foreign body in esophagus
                            </label>
                        </div>
                    </div>
                </div>
                <div class="row mt-1">
                    <div class="col-6">
                        <div class="row ms-4">
                            <div class="col-auto">
                                <div class="form-check mb-2">
                                    <input class="form-check-input" type="checkbox" id="formCheck61">
                                    <label class="form-check-label ms-3" for="formCheck61">
                                        Polypectomy (Stomach)
                                    </label>
                                </div>
                            </div>
                        </div>
                    </div>
                    <div class="col-6"></div>
                </div>
                <div class="row mt-1">
                    <div class="col-6">
                        <div class="row ms-4">
                            <div class="col-auto">
                                <div class="form-check mb-2">
                                    <input class="form-check-input" type="checkbox" id="formCheck62">
                                    <label class="form-check-label ms-3" for="formCheck62">
                                        Polypectomy (Duodenum)
                                    </label>
                                </div>
                            </div>
                        </div>
                    </div>
                    <div class="col-6"></div>
                </div>
                <div class="row mt-1">
                    <div class="col-6">
                        <div class="row ">
                            <div class="col-auto">
                                <div class="form-check mb-2">
                                    <input class="form-check-input" type="checkbox" id="formCheck1">
                                    <label class="form-check-label ms-3" for="formCheck1">
                                        GERD without esophagitis
                                    </label>
                                </div>
                            </div>
                        </div>
                    </div>
                </div>
                <div class="col-12">
                    <textarea name="" id="" cols="30" rows="3" class="form-control"
                        placeholder="Free text"></textarea>
                </div>
            </div>
            <div class="col-xl-6 mt-4">
                <button type="button" class="btn btn-checkbox  waves-effect waves-light btn-sm fs-14"
                    id="btn_prediagnostic">
                    <i class="mdi mdi-checkbox-outline   align-middle  me-2 text-light fs-16"></i>
                    None other Procedure
                </button>
                <div class="row">
                    <div class="col-12">
                        <div class="input-group mb-3">
                            <input type="text" class="form-control" placeholder="Primary Diagnosis"
                                aria-label="Recipient's username" aria-describedby="basic-addon2">
                            <span class="input-group-text" id="basic-addon2">ICD-9</span>
                        </div>
                    </div>
                    <div class="col-12">
                        <div class="input-group mb-3">
                            <input type="text" class="form-control" placeholder="Secondary Diagnosis"
                                aria-label="Recipient's username" aria-describedby="basic-addon2">
                            <span class="input-group-text" id="basic-addon2">ICD-9</span>
                        </div>
                    </div>
                    <div class="col-12">
                        <div class="input-group mb-3">
                            <input type="text" class="form-control" placeholder="Other Diagnosis"
                                aria-label="Recipient's username" aria-describedby="basic-addon2">
                            <span class="input-group-text" id="basic-addon2">ICD-9</span>
                        </div>
                    </div>
                    <div class="col-12">
                        <div class="input-group mb-3">
                            <input type="text" class="form-control" placeholder="Other Diagnosis"
                                aria-label="Recipient's username" aria-describedby="basic-addon2">
                            <span class="input-group-text" id="basic-addon2">ICD-9</span>
                        </div>
                    </div>
                    <div class="col-12">
                        <div class="input-group mb-3">
                            <input type="text" class="form-control" placeholder="Other Diagnosis"
                                aria-label="Recipient's username" aria-describedby="basic-addon2">
                            <span class="input-group-text" id="basic-addon2">ICD-9</span>
                        </div>
                    </div>
                </div>
            </div>
        </div>
    </div>
</div>
