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<!-- BEGIN [% component.name %] -->
    [% cml_dates = vars.cml_data.dates; # INCLUDE dumper.tt dump = cml_dates  %]

    <script src="[% request.uri_base %]/javascripts/jquery-ui.js"></script>
    <script type="text/javascript">
      $(function() {
        $('.datepicker').datepicker({
          changeMonth: true,
          changeYear: true,
          dateFormat: 'dd/mm/yy',
        });
      });
    </script>

    <input type="hidden" name="bcr_abl_req" value="1" />
    <div class="form-group">
      <label class="col-md-3 control-label text-danger" for="diagnosis_date">
        Date of diagnosis
      </label>
      <div class="col-md-4">
        [% IF errs.diagnosis_date; errs.diagnosis_date;
            ELSIF cml_dates.diagnosis_date %]
          <div class="dfv-err">** check this is correct **</div>
        [% END %]
        <input id="diagnosis_date" name="diagnosis_date" placeholder="dd/mm/yyyy"
          class="form-control input-md datepicker" required="" type="text"
          value="[% cml_dates.diagnosis_date.strftime('%d/%m/%Y')
              || params.diagnosis_date %]" />
      </div>
    </div>

    <div class="form-group">
      <label class="col-md-3 control-label text-danger" for="phase">
        Phase of disease
      </label>
      <div class="col-md-4">
        [% errs.phase %]
        <select name="phase" class="form-control">
            <option value="">-- select --</option>
            [% phases = ['chronic phase' 'acute phase' 'blast crisis'];
                FOREACH entry IN phases %]
                <option value="[% entry %]"[% 'selected' IF
                    entry == params.phase %]>[% entry %]</option>
            [% END %]
        </select>
      </div>
    </div>

    <div class="form-group">
      <label class="col-md-3 control-label text-danger" for="treatment">
        Current TKI treatment
      </label>
      <div class="col-md-4">
        [% errs.treatment %]
        <select name="treatment" class="form-control">
            <option value="">-- select --</option>
            [% treatments = [ 'imatinib' 'dasatinib' 'nilotinib'
                'ponatinib' 'bosutinib' ];
                FOREACH entry IN treatments %]
                <option value="[% entry %]"[% ' selected' IF
                    entry == params.treatment %]>[% entry %]</option>
            [% END %]
        </select>
      </div>
    </div>

    <div class="form-group">
      <label class="col-md-3 control-label text-danger" for="first_line_date">
        Date 1st line treatment commenced
      </label>
      <div class="col-md-4">
        [% IF errs.first_line_date; errs.first_line_date;
            ELSIF cml_dates.first_line_date %]
          <div class="dfv-err">** check this is correct **</div>
        [% END %]
        <input id="first_line_date" name="first_line_date" placeholder="dd/mm/yyyy"
          class="form-control input-md datepicker" required="" type="text"
          value="[% cml_dates.first_line_date.strftime('%d/%m/%Y')
              || params.first_line_date %]" />
      </div>
    </div>

    <div class="form-group">
      <label class="col-md-3 control-label text-danger" for="line_num">
        Treatment line number
      </label>
      <div class="col-md-4">
        [% errs.line_num %]
        <select name="line_num" class="form-control">
            <option value="">-- select --</option>
            [% line_opts = [ '1st line' '2nd line' '> 2nd line' ];
                FOREACH entry IN line_opts %]
              <option value="[% entry %]"[% ' selected' IF
                entry == params.line_num %]>[% entry %]</option>
            [% END %]
        </select>
      </div>
    </div>

    <div class="form-group">
      <label class="col-md-3 control-label text-danger" for="treatment_date">
        Date TKI treatment commenced<br />(if NOT 1st-line)
      </label>
      <div class="col-md-4">
        [% errs.treatment_date %]
      <input id="treatment_date" name="treatment_date" placeholder="dd/mm/yyyy"
        class="form-control input-md datepicker" type="text"
        value="[% params.treatment_date %]" />
      </div>
    </div>

    <div class="form-group">
      <label class="col-md-3 control-label text-danger" for="other_tx">
        Any other treatment
      </label>
      <div class="col-md-4">
        [% errs.other_tx %]
        <select name="other_tx" class="form-control">
            <option value="">-- select --</option>
            [% others = [ 'interferon' ];
                FOREACH entry IN others %]
               <option value="[% entry %]"[% ' selected' IF
                entry == params.other_tx %]>[% entry %]</option>
            [% END %]
        </select>
      </div>
    </div>
<!-- END [% component.name %] -->