[% META title = 'Admin » Edit Diagnosis Change Option' -%]
[% # PROCESS dumper.tt dump = c.stash.errs %]
[% diagnosis_change_dfv_js %]
[% # PROCESS admin/request_nav.tt page = 'diagnostic-categories' %]
<h2 align="center">Edit Diagnosis Change Option</h2>
[% IF dfv_errors %]
<dl>
<dt class="error">[% c.cfg('msg').dfv_errors %]</dt>
[% IF error_description %]
<dd>Option name [% error_option_name %]</dd>[% END %]
[% IF error_description %]
<dd>Description [% error_description %]</dd>[% END %]
</dl>
[% END %]
<form method="post" action="[% app_url %]/config/diagnosis-change-options/update/[% data.id %]"
[% diagnosis_change_onsubmit %] name="diagnosis-change" id="diagnosis-change">
<table>
<tr>
<th [% IF error_option_name %]class="error"[% END %]>Option name</th>
<th [% IF error_description %]class="error"[% END %]>Description</th>
<th [% IF error_active %]class="error"[% END %]>Active</th>
</tr>
<tr>
<td>
<input type="text" name="option_name" size="20"
value="[% data.option_name | html %]" />
</td>
<td>
<input type="text" name="description" size="40"
value="[% data.description | html %]" />
</td>
<td>
<select name="is_active">
[% FOREACH option IN ['yes', 'no'] %]
<option value="[% option %]" [% 'selected' IF option == data.is_active %]>
[% option %]
</option>
[% END %]
</select>
</td>
<td>
[% site.html.submit %]
</td>
</tr>
</table>
</form>
<p>[% site.html.back_button %]</p>