import { Form } from "@samplehc/ui/components";
import { useScreenFunctions } from "@samplehc/ui/contexts";
import { Card, CardHeader, CardTitle, CardContent } from "@/components/ui/card";
function PatientIntakeForm() {
const { handleComplete } = useScreenFunctions();
const formElements = [
{
type: "text",
key: "patientName",
label: "Patient Full Name",
description: "As it appears on insurance card"
},
{
type: "text",
key: "dateOfBirth",
label: "Date of Birth",
description: "MM/DD/YYYY format"
},
{
type: "text",
key: "copayAmount",
label: "Copay Amount",
format: "currency",
description: "Patient's copay for this visit"
},
{
type: "document",
key: "insuranceCard",
label: "Insurance Card",
description: "Upload front and back of insurance card",
allowMultiple: true
},
{
type: "document",
key: "medicalRecords",
label: "Previous Medical Records",
description: "Upload any relevant medical history (PDFs or ZIP files)",
allowMultiple: true
},
{
type: "csv",
key: "labResults",
label: "Lab Results (CSV)",
description: "Upload lab results in CSV format if available"
},
{
type: "text",
key: "notes",
label: "Additional Notes",
description: "Any additional information about the patient"
}
];
return (
<Card className="max-w-4xl mx-auto">
<CardHeader>
<CardTitle>Patient Intake Form</CardTitle>
</CardHeader>
<CardContent>
<Form
elements={formElements}
onSubmit={(results) => {
handleComplete({ result: results });
}}
/>
</CardContent>
</Card>
);
}