<div class="card p-4">
    <div class="row">
        <div class="col-xl-6">
            <h4>Other</h4>
            <div class="row">
                <div class="col-3 d-flex align-items-center">
                    Gastric Content
                </div>
                <div class="col-auto">
                <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>
                    Clear
                </button>
                </div>
                <div class="row">
                    <div class="col-6">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck63">
                            <label class="form-check-label ms-4" for="formCheck63">
                                Food Content
                            </label>
                        </div>
                    </div>
                    <div class="col-6">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck64">
                            <label class="form-check-label ms-4" for="formCheck64">
                                Coffee ground
                            </label>
                        </div>
                    </div>
                </div>
                <div class="row">
                    <div class="col-6">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck65">
                            <label class="form-check-label ms-4" for="formCheck65">
                                Blood
                            </label>
                        </div>
                    </div>
                    <div class="col-6">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck66">
                            <label class="form-check-label ms-4" for="formCheck66">
                                Bile
                            </label>
                        </div>
                    </div>
                    <div class="col-12">
                        <input type="text" class="form-control" placeholder="Free text">
                    </div>
                </div>
            </div>
            <div class="row mt-2">
                <div class="col-3 d-flex align-items-center">
                    Complication
                </div>
                <div class="col-auto">
                <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 Immediately Complication
                </button>
                </div>
                <div class="row">
                    <div class="col-6">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck67">
                            <label class="form-check-label ms-4" for="formCheck67">
                                Perforation
                            </label>
                        </div>
                    </div>
                    <div class="col-6">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck68">
                            <label class="form-check-label ms-4" for="formCheck68">
                                Hypoxia
                            </label>
                        </div>
                    </div>
                </div>
                <div class="row">
                    <div class="col-6">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck69">
                            <label class="form-check-label ms-4" for="formCheck69">
                                Bleeding
                            </label>
                        </div>
                    </div>
                    <div class="col-6">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="checkbox" id="formCheck70">
                            <label class="form-check-label ms-4" for="formCheck70">
                                Cardiovascular instability
                            </label>
                        </div>
                    </div>
                    <div class="col-12">
                        <input type="text" class="form-control" placeholder="Free text">
                    </div>
                </div>
            </div>
            <div class="row mt-2">
                <div class="col-3 d-flex align-items-center">
                    Rapid Urease Test
                </div>
                <div class="col-auto">
                <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>
                    Not done
                </button>
                </div>

                <div class="row">
                    <div class="col-12">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="radio" name="flexRadioDefault" id="flexRadioDefault1">
                            <label class="form-check-label" for="flexRadioDefault1">
                                &ensp;  &ensp;   Positive (+)
                            </label>
                        </div>
                    </div>
                    <div class="col-12">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="radio" name="flexRadioDefault" id="flexRadioDefault2">
                            <label class="form-check-label" for="flexRadioDefault2">
                                &ensp;  &ensp;   Negative (-)
                            </label>
                        </div>
                    </div>
                    <div class="col-12">
                        <div class="form-check mb-2">
                            <input class="form-check-input" type="radio" name="flexRadioDefault" id="flexRadioDefault3">
                            <label class="form-check-label" for="flexRadioDefault3">
                                &ensp;  &ensp;   Pending
                            </label>
                        </div>
                    </div>
                    <div class="col-12">
                        <input type="text" class="form-control" placeholder="Free text">
                    </div>
                </div>
            </div>
        </div>
        <div class="col-xl-6 mt-5 ">
            <div class="row">
                <div class="col-6">
                    <span>Estimate Blood Loss</span>
                </div>
                <div class="col-3">
                    <input type="text" class="form-control">
                </div>
                <div class="col-2">
                    ml.
                </div>
            </div>
            <div class="row mt-2">
                <div class="col-6">
                    <span>Blood Transfusion</span>
                </div>
                <div class="col-3">
                    <input type="text" class="form-control">
                </div>
                <div class="col-2 an">
                    ml.
                </div>
            </div>
            <div class="row mt-2">
                <div class="col-6">
                    <span>Specimen</span>
                </div>
                <div class="col-3">
                    <input type="text" class="form-control">
                </div>
                <div class="col-2 an">
                    Bottle
                </div>
            </div>
            <div class="row mt-2">
                <div class="col-6">
                    <span>Follow Up</span>
                </div>
                <div class="col-3">
                    <input type="text" class="form-control">
                </div>
                <div class="col-2 an">
                    ml.
                </div>
            </div>
            <div class="other-pos">
                <div class="col-auto">
                    Comment
                </div>
                <div class="col-12 mt-2">
                    <textarea name="" id="" cols="30" rows="3" class="form-control" placeholder="Free text"></textarea>
                </div>
            </div>
        </div>

    </div>
</div>
