import gradio as gr

def submit_form(
    patient_name, dob, ssn, goal_met, goal_reason,
    discharge_date, wound1_location, wound1_status, wound1_measure_date, wound1_length, wound1_width, wound1_depth,
    wound2_location, wound2_status, wound2_measure_date, wound2_length, wound2_width, wound2_depth,
    provider_name, provider_phone, info_date
):
    result = f"""
    Patient Information:
    Name: {patient_name}
    DOB: {dob}
    SSN: {ssn}
    
    Physician's Goal Met: {'Yes' if goal_met else 'No'}
    Reason (if no): {goal_reason}
    
    Discharge Date: {discharge_date}
    
    Wound #1:
    Location: {wound1_location}
    Status: {', '.join(wound1_status)}
    Measurement Date: {wound1_measure_date}
    Length: {wound1_length} cm, Width: {wound1_width} cm, Depth: {wound1_depth} cm
    
    Wound #2:
    Location: {wound2_location}
    Status: {', '.join(wound2_status)}
    Measurement Date: {wound2_measure_date}
    Length: {wound2_length} cm, Width: {wound2_width} cm, Depth: {wound2_depth} cm
    
    Provider Information:
    Name: {provider_name}
    Phone: {provider_phone}
    Information Date: {info_date}
    """
    return result

with gr.Blocks() as app:
    gr.Markdown("### Discharge Form")
    with gr.Row():
        patient_name = gr.Textbox(label="Patient's Name (Last, First, MI)")
        dob = gr.Textbox(label="Date of Birth (MM/DD/YYYY)")
        ssn = gr.Textbox(label="Social Security Number (XXX-XX-XXXX)")
    
    goal_met = gr.Checkbox(label="Was the Physician’s Goal Met?")
    goal_reason = gr.Textbox(label="If No, Explain Why")
    discharge_date = gr.Textbox(label="Therapy Discharge Date (MM/DD/YYYY)")
    
    gr.Markdown("### Wound #1")
    with gr.Row():
        wound1_location = gr.Textbox(label="Wound Location")
    wound1_status = gr.CheckboxGroup(["Adequate granulation", "Patient in hospital", "Wound unresponsive", "Pain", "Wound healed", "Delayed primary closure", "Patient non-compliant", "Patient expired", "Wound sutured closed", "Tunnel dimensions decreased or closed", "Undermining improved or resolved", "4 months of treatment completed", "Other"], label="Wound Status")
    wound1_measure_date = gr.Textbox(label="Final Measurement Date (MM/DD/YYYY)")
    with gr.Row():
        wound1_length = gr.Number(label="Length (cm)")
        wound1_width = gr.Number(label="Width (cm)")
        wound1_depth = gr.Number(label="Depth (cm)")
    
    gr.Markdown("### Wound #2 (if applicable)")
    with gr.Row():
        wound2_location = gr.Textbox(label="Wound Location")
    wound2_status = gr.CheckboxGroup(["Adequate granulation", "Patient in hospital", "Wound unresponsive", "Pain", "Wound healed", "Delayed primary closure", "Patient non-compliant", "Patient expired", "Wound sutured closed", "Tunnel dimensions decreased or closed", "Undermining improved or resolved", "4 months of treatment completed", "Other"], label="Wound Status")
    wound2_measure_date = gr.Textbox(label="Final Measurement Date (MM/DD/YYYY)")
    with gr.Row():
        wound2_length = gr.Number(label="Length (cm)")
        wound2_width = gr.Number(label="Width (cm)")
        wound2_depth = gr.Number(label="Depth (cm)")
    
    gr.Markdown("### Provider Information")
    provider_name = gr.Textbox(label="Print Name, Title, Employer")
    provider_phone = gr.Textbox(label="Phone Number")
    info_date = gr.Textbox(label="Information Date (MM/DD/YYYY)")
    
    submit = gr.Button("Submit")
    output = gr.Textbox(label="Form Output", interactive=False)
    submit.click(submit_form, inputs=[
        patient_name, dob, ssn, goal_met, goal_reason,
        discharge_date, wound1_location, wound1_status, wound1_measure_date, wound1_length, wound1_width, wound1_depth,
        wound2_location, wound2_status, wound2_measure_date, wound2_length, wound2_width, wound2_depth,
        provider_name, provider_phone, info_date
    ], outputs=output)
    
app.launch()