
	<form name="formM0230" id="formM0230" action="#">
		<div style="margin:0 15px;">
			<h4>Diagnosis Select</h4>
			<input type="hidden" name="M0230DiagnosisID" id="M0230DiagnosisID"/>
			<input type="hidden" name="M0230DiagnosisID1" id="M0230DiagnosisID1"/>
			<input type="hidden" name="vcodesdiag" id="vcodesdiag" value=""/>
			<input type="hidden" name="vcodesicd" id="vcodesicd" value=""/>
			<!---<cfparam name="form.M0230_Primary" default="primary">
			<cfparam name="form.M0230_Secondary" default="Secondary">
			<cfparam name="form.M0230_Onset" default="Onset">
			<cfparam name="form.M0230_Severity" default="Severity">
--->
			
			<div class="form-group">
				<label>Diagnosis</label>
				<label id="DiagnosisA"></label>
			</div>
            <div class="row">
                <div class="col-md-4">
                	<div class="form-group">
                        <div class="label-stable">
                            <label>Primary?</label>
                            <div id="M0230Primaryd" class="radio-list">
                                <label>
                                <input type="radio" id="M0230Primary" name="M0230Primary" value="1" >Yes</label>
                                <label>
                                <input type="radio" id="M0230Primary" name="M0230Primary" value="0" >No</label>
                            </div>
                        </div>
					</div>
                </div>
                <div class="col-md-4">
                	<div class="form-group">
                        <div class="label-stable">
                            <label>Secondary?</label>
                            <div id="M0230Secondaryd" class="radio-list">
                                <label>
                                <input type="radio" id="M0230Secondary" name="M0230Secondary" value="1" >Yes</label>
                                <label>
                                <input type="radio" id="M0230Secondary" name="M0230Secondary" value="0" >No</label>
                            </div>
                        </div>
                    </div>
                </div>
                <div class="col-md-4">
                	<div class="form-group">
                        <div class="label-stable">
                            <label>Onset or Exacerbation</label>
                            <div id="M0230Onsetd" class="radio-list">
                                <label>
                                <input type="radio" id="M0230Onset" name="M0230Onset" value="(O)" >(O)</label>
                                <label>
                                <input type="radio" id="M0230Onset" name="M0230Onset" value="(E)" >(E)</label>
                            </div>
                        </div>
                    </div>
                </div>
            </div>

            <div class="row">
                <div class="col-md-6">
                	<div class="form-group">
                        <label>*SEVERITY KEY</label>
                        <p style="font-size:13px;">0 - Asymptomatic, no treatment needed</p>
                        <p style="font-size:13px;">1 - Symptoms well controlled</p>
                        <p style="font-size:13px;">2 - Symptoms controlled with difficulty</p>
                        <p style="font-size:13px;">3 - Symptoms poorly controlled</p>
                        <p style="font-size:13px;">4 - history of rehospitalizations</p>
                    </div>
                </div>

                <div class="col-md-6">
                	<div class="form-group">
                        <div class="label-stable">
                            <label>Severity level?</label>
                            <div id="M0230Severityd" class="radio-list">
                                <label>
                                <input type="radio" id="M0230Severity" name="M0230Severity" value="0" >0</label>
                                <label>
                                <input type="radio" id="M0230Severity" name="M0230Severity" value="1" >1</label>
                                <label>
                                <input type="radio" id="M0230Severity" name="M0230Severity" value="2" >2</label>
                                <label>
                                <input type="radio" id="M0230Severity" name="M0230Severity" value="3" >3</label>
                                <label>
                                <input type="radio" id="M0230Severity" name="M0230Severity" value="4" >4</label>
                            </div>
                        </div>
                    </div>
                </div>
            </div>

			<div class="form-group">
				<label>Add Case Mix For ICD10 Z-Code <img src="../../images/icon_add.png" style="cursor:pointer" onclick="vcodeprocess();"/></label>
				<label id="DiagnosisB1"></label>
			</div>
			<div id="DivM0230SubPage1" class="well" style="display:none;">
				<div class="form-group">
					<label>Diagnosis Search</label>
					<textarea name="M1020Manifestsearch1" type="text" value="" class="form-control"></textarea>
				</div>
				<input class="btn btn-sm blue" name="btnM1020" type="button" value="Show All Results" onclick="SearchClickM0230M1();"/>
				<input class="btn btn-sm default" name="btnM0230cancel1" id="btnM0230cancel1" type="button" value="Cancel" />
			</div>
			<div class="form-group">
				<label>Add Manifestation For ICD10 Z-Code <img id="ImgM0230Add" name="ImgM1020Add" src="../../images/icon_add.png" style="cursor:pointer" /></label>
				<label id="DiagnosisB"></label>
			</div>
			<div id="DivM0230SubPage" class="well" style="display:none;">
				<div class="form-group">
					<label>Manifestation Diagnosis Search</label>
					<textarea name="M1020Manifestsearch" type="text" value="" class="form-control"></textarea>
				</div>
				<input class="btn btn-sm blue" name="btnM1020" type="button" value="Show All Results" onclick="SearchClickM0230M();"/>
				<input class="btn btn-sm default" name="btnM0230cancel" id="btnM0230cancel" type="button" value="Cancel" />
			</div>
			<div class="form-group">
				<label>If this is a ICD10 Z-Code, and you want to add a case mix diagnosis, click "add case mix..."now to include that data. Click "add manifestation" to add a manifestation code.</label>
			</div>
			<div class="form-group">
				<input class="btn blue" type="button" name="btndone" value="Done" onClick="UpdateSoc('M0230search');"/>
				<input class="btn btn-default" type="button" name="btnCancel" value="Cancel" onclick="ColdFusion.Window.hide('searchFormM0230SubWindow'); $('#StartOfCare4').show();"/>
			</div>
		</div>
	</form>

	<cfinclude template="startofcarewizard_script.cfm" />