<!-- BEGIN hmrn/data/staging.tt -->
    [% sites = hmrn_data.params.staging; # PROCESS dumper.tt dump = sites %]
    
    [% BLOCK build_checkbox %]
        <tr>
            <td class="label" align="right">
                <span title="[% span %]" class="[% span ? 'acronym' : 'normal' %]">
                    [% IF NOT label; field | ucfirst; ELSE; label; END %]</span>:
            </td>
            <td class="normal" align="center">
                [% IF cols == 2;
                    field_left = field _ '_left'; field_right = field _ '_right'
                %]
                    <input type="checkbox" name="[% field_left %]" value="1"
                        [% 'checked' IF sites.${field_left} %] />
                    <input type="checkbox" name="[% field_right %]" value="1"
                        [% 'checked' IF sites.${field_right} %] />
                [% ELSE %]
                    <input type="checkbox" name="[% field %]" value="1"
                        [% 'checked' IF sites.${field} %] />
                [% END %]
            </td>
        </tr>    
    [% END %]
    
  <div class="indent">    
    <form method="post" name="involvement" id="involvement"
		action="[% app_url %]/hmrn_data/staging/[% data.id %]/[% patient.id %]">
        
    <table class="indent">
        <tr>
            <td style="border: none; vertical-align: top">
                <h4>Nodal involvement:</h4>

                <table class="yhhn indent">
                    <tr>
                        <th>Site</th>
                        <th>L | R</th>
                    </tr>
                    
                    [% INCLUDE build_checkbox
                        label = "Waldeyer's ring"
                        field = 'waldeyer'
                        span  = 'tonsillar, adenoidal, pharangeal'
                    %]
                    [% INCLUDE build_checkbox
                        field = 'neck'
                        cols  = 2
                        span  = 'cervical, supraclavicular, occipital, preauricular'
                    %]       
                    [% INCLUDE build_checkbox
                        field = 'infraclavicular'
                        cols  = 2
                    %]       
                    [% INCLUDE build_checkbox
                        label = 'Axillary/Pectoral'
                        field = 'axillary'
                        cols  = 2
                    %]       
                    [% INCLUDE build_checkbox
                        field = 'arm'
                        cols  = 2
                        span  = 'epitrochlear & brachial'
                    %]       
                    [% INCLUDE build_checkbox
                        field = 'thymus'
                    %]       
                    [% INCLUDE build_checkbox
                        field = 'hilar'
                        cols  = 2
                    %]       
                    [% INCLUDE build_checkbox
                        field = 'mediastinal'
                    %]       
                    <tr><td id="diaphragm" colspan="2"></tr>
                    [% INCLUDE build_checkbox
                        label = 'Para-aortic'
                        field = 'para_aortic'
                    %]       
                    [% INCLUDE build_checkbox
                        label = 'Spleen (palpable)'
                        field = 'spleen'
                    %]       
                    [% INCLUDE build_checkbox
                        field = 'mesenteric'
                    %]       
                    [% INCLUDE build_checkbox
                        field = 'iliac'
                        cols  = 2
                    %]       
                    [% INCLUDE build_checkbox
                        label = 'Inguinal/Femoral'
                        field = 'inguinal'
                        cols  = 2
                    %]       
                    [% INCLUDE build_checkbox
                        field = 'popliteal'
                        cols  = 2
                    %]       
                    <tr><td colspan="2" class="borderless">&nbsp;</td></tr>        
                    [% INCLUDE build_checkbox
                        label = 'Bulky disease'
                        field = 'bulky'
                    %]       
                    [% INCLUDE build_checkbox
                        label = 'Check CT scan'
                        field = 'check_ct'
                    %]       
                </table>
            </td>
            <td class="borderless">&nbsp;</td>
            <td style="border: none; vertical-align: top">
                <h4>Extranodal involvement:</h4>

                <table class="yhhn indent">
                    <tr>
                        <th>Site</th>
                        <th>L | R</th>
                    </tr>
                    
                    [% INCLUDE build_checkbox
                        field = 'blood'
                    %]
                    [% INCLUDE build_checkbox
                        field = 'bone'
                    %]
                    [% INCLUDE build_checkbox
                        label = 'CNS'
                        field = 'cns'
                    %]
                    [% INCLUDE build_checkbox
                        label = 'GIT'
                        field = 'git'
                        span  = 'gastro-intestinal tract'
                    %]
                    [% INCLUDE build_checkbox
                        label = 'GU'
                        field = 'gu'
                        span  = 'genito-urinary tract'
                    %]
                    [% INCLUDE build_checkbox
                        field = 'liver'
                    %]
                    [% INCLUDE build_checkbox
                        field = 'marrow'
                    %]
                    [% INCLUDE build_checkbox
                        field = 'muscle'
                    %]
                    [% INCLUDE build_checkbox
                        field = 'orbit'
                        cols  = 2
                    %]
                    [% INCLUDE build_checkbox
                        field = 'pericardium'
                    %]
                    [% INCLUDE build_checkbox
                        field = 'pulmonary'
                        cols  = 2
                    %]
                    [% INCLUDE build_checkbox
                        label = 'Salivary gland'
                        field = 'salivary_gland'
                        cols  = 2
                    %]
                    [% INCLUDE build_checkbox
                        field = 'skin'
                    %]
                    [% INCLUDE build_checkbox
                        field = 'thyroid'
                    %]
                    <tr>
                        <td class="right" colspan="2">
                            <span style="vertical-align: top">Other:</span>
                            <textarea rows="2" cols="15"
                                name="details">[% sites.details %]</textarea>
                        </td>
                    </tr>        
                    [% INCLUDE build_checkbox
                        field = 'extensive'
                        span  = 'extensive organ involvement'
                    %]
                </table>
            </td>
        </tr>
        [% IF user_can_enter_data %]
        <tr class="borderless" align="center">
            <td colspan="2">[% site.html.submit %] [% site.html.reset %]</td>
        </tr>
        [% END %]
    </table>
    </form>
  </div>
	
    

<!-- END hmrn/data/staging.tt -->
