import gradio as gr

def display_form(
    first_name, last_name, middle_initial, dob, age, sex, address, city, state, zip_code,
    doctor_first_name, doctor_last_name, doctor_middle_initial, hospital_name, doctor_address,
    doctor_city, doctor_state, doctor_zip,
    admission_date, referral_source, admission_method, discharge_date, discharge_reason, date_of_death,
    diagnosis, procedures, medications, preparer_name, preparer_job_title
):
    form = f"""
    **Patient Discharge Form**
    
    **Patient Details:**
    - Name: {first_name} {middle_initial} {last_name}
    - Date of Birth: {dob}, Age: {age}, Sex: {sex}
    - Address: {address}, {city}, {state}, {zip_code}
    
    **Primary Healthcare Professional Details:**
    - Name: {doctor_first_name} {doctor_middle_initial} {doctor_last_name}
    - Hospital/Clinic: {hospital_name}
    - Address: {doctor_address}, {doctor_city}, {doctor_state}, {doctor_zip}
    
    **Admission and Discharge Details:**
    - Date of Admission: {admission_date}
    - Source of Referral: {referral_source}
    - Method of Admission: {admission_method}
    - Date of Discharge: {discharge_date}
    - Discharge Reason: {discharge_reason}
    - Date of Death (if applicable): {date_of_death}
    
    **Diagnosis & Procedures:**
    - Diagnosis: {diagnosis}
    - Procedures: {procedures}
    
    **Medication Details:**
    - Medications on Discharge: {medications}
    
    **Prepared By:**
    - Name: {preparer_name}, Job Title: {preparer_job_title}
    """
    return form

with gr.Blocks() as demo:
    gr.Markdown("# Patient Discharge Form")
    
    with gr.Row():
        first_name = gr.Textbox(label="First Name")
        last_name = gr.Textbox(label="Last Name")
        middle_initial = gr.Textbox(label="Middle Initial")
    
    with gr.Row():
        dob = gr.Textbox(label="Date of Birth")
        age = gr.Textbox(label="Age")
        sex = gr.Textbox(label="Sex")
    
    address = gr.Textbox(label="Address")
    
    with gr.Row():
        city = gr.Textbox(label="City")
        state = gr.Textbox(label="State")
        zip_code = gr.Textbox(label="Zip Code")
    
    gr.Markdown("## Primary Healthcare Professional Details")
    
    with gr.Row():
        doctor_first_name = gr.Textbox(label="Doctor's First Name")
        doctor_last_name = gr.Textbox(label="Doctor's Last Name")
        doctor_middle_initial = gr.Textbox(label="Middle Initial")
    
    hospital_name = gr.Textbox(label="Hospital/Clinic Name")
    doctor_address = gr.Textbox(label="Address")
    
    with gr.Row():
        doctor_city = gr.Textbox(label="City")
        doctor_state = gr.Textbox(label="State")
        doctor_zip = gr.Textbox(label="Zip Code")
    
    gr.Markdown("## Admission and Discharge Details")
    
    with gr.Row():
        admission_date = gr.Textbox(label="Date of Admission")
        referral_source = gr.Textbox(label="Source of Referral")
    
    admission_method = gr.Textbox(label="Method of Admission")
    
    with gr.Row():
        discharge_date = gr.Textbox(label="Date of Discharge")
        discharge_reason = gr.Radio(["Treated", "Transferred", "Discharge Against Advice", "Patient Died"], label="Discharge Reason")
    
    date_of_death = gr.Textbox(label="Date of Death (if applicable)")
    
    gr.Markdown("## Diagnosis & Procedures")
    diagnosis = gr.Textbox(label="Diagnosis")
    procedures = gr.Textbox(label="Operation & Procedures")
    
    gr.Markdown("## Medication Details")
    medications = gr.Textbox(label="Medication on Discharge")
    
    gr.Markdown("## Prepared By")
    
    with gr.Row():
        preparer_name = gr.Textbox(label="Name")
        preparer_job_title = gr.Textbox(label="Job Title")
    
    submit = gr.Button("Generate Form")
    output = gr.Markdown()
    
    submit.click(
        display_form,
        inputs=[
            first_name, last_name, middle_initial, dob, age, sex, address, city, state, zip_code,
            doctor_first_name, doctor_last_name, doctor_middle_initial, hospital_name, doctor_address,
            doctor_city, doctor_state, doctor_zip,
            admission_date, referral_source, admission_method, discharge_date, discharge_reason, date_of_death,
            diagnosis, procedures, medications, preparer_name, preparer_job_title
        ],
        outputs=output
    )

demo.launch()