{
  "fieldia": "0.1",
  "id": "patient-intake",
  "title": "New patient form",
  "description": "Please fill this in before your first visit. Your answers stay between you and your care team.",
  "data": {
    "kind": "responses"
  },
  "maxWidth": "medium",
  "look": {
    "theme": "material"
  },
  "fields": {
    "full_name": {
      "type": "char",
      "label": "Full name",
      "required": true
    },
    "birth_date": {
      "type": "date",
      "label": "Date of birth",
      "required": true
    },
    "sex": {
      "type": "selection",
      "label": "Sex",
      "options": [
        {
          "value": "female",
          "label": "Female"
        },
        {
          "value": "male",
          "label": "Male"
        },
        {
          "value": "other",
          "label": "Prefer not to say"
        }
      ]
    },
    "phone": {
      "type": "char",
      "label": "Phone",
      "required": true
    },
    "email": {
      "type": "char",
      "label": "Email",
      "pattern": "^[^@\\s]+@[^@\\s]+\\.[^@\\s]+$"
    },
    "address": {
      "type": "text",
      "label": "Address",
      "size": 300
    },
    "has_allergies": {
      "type": "boolean",
      "label": "I have allergies"
    },
    "allergies": {
      "type": "text",
      "label": "Which allergies, and what happens?"
    },
    "medication": {
      "type": "text",
      "label": "Medicines you take now"
    },
    "conditions": {
      "type": "selection",
      "label": "Have you ever had any of these?",
      "multiple": true,
      "options": [
        {
          "value": "diabetes",
          "label": "Diabetes"
        },
        {
          "value": "info",
          "label": "Heart disease"
        },
        {
          "value": "blood_pressure",
          "label": "High blood pressure"
        },
        {
          "value": "asthma",
          "label": "Asthma"
        },
        {
          "value": "none",
          "label": "None of these"
        }
      ]
    },
    "smoker": {
      "type": "selection",
      "label": "Do you smoke?",
      "options": [
        {
          "value": "no",
          "label": "No"
        },
        {
          "value": "former",
          "label": "I used to"
        },
        {
          "value": "yes",
          "label": "Yes"
        }
      ]
    },
    "emergency_name": {
      "type": "char",
      "label": "Emergency contact",
      "required": true
    },
    "emergency_phone": {
      "type": "char",
      "label": "Their phone",
      "required": true
    },
    "consent": {
      "type": "boolean",
      "label": "I agree to be treated and to my records being kept as the clinic's privacy notice says"
    },
    "signature": {
      "type": "binary",
      "label": "Signature",
      "required": true
    }
  },
  "layout": {
    "type": "wizard",
    "id": "intake",
    "clickable": true,
    "finishLabel": "Send to the clinic",
    "children": [
      {
        "type": "step",
        "id": "step-patient",
        "label": "You",
        "icon": "user",
        "children": [
          {
            "type": "field",
            "id": "f-name",
            "field": "full_name"
          },
          {
            "type": "field",
            "id": "f-birth",
            "field": "birth_date"
          },
          {
            "type": "field",
            "id": "f-sex",
            "field": "sex",
            "widget": "radio"
          },
          {
            "type": "field",
            "id": "f-phone",
            "field": "phone",
            "widget": "phone"
          },
          {
            "type": "field",
            "id": "f-email",
            "field": "email",
            "widget": "email"
          },
          {
            "type": "field",
            "id": "f-address",
            "field": "address"
          }
        ]
      },
      {
        "type": "step",
        "id": "step-history",
        "label": "Your health",
        "icon": "info",
        "children": [
          {
            "type": "field",
            "id": "f-has-allergies",
            "field": "has_allergies",
            "widget": "toggle"
          },
          {
            "type": "field",
            "id": "f-allergies",
            "field": "allergies",
            "invisible": "not has_allergies",
            "required": "has_allergies"
          },
          {
            "type": "field",
            "id": "f-medication",
            "field": "medication"
          },
          {
            "type": "field",
            "id": "f-conditions",
            "field": "conditions",
            "widget": "checkboxes"
          },
          {
            "type": "field",
            "id": "f-smoker",
            "field": "smoker",
            "widget": "radio"
          }
        ]
      },
      {
        "type": "step",
        "id": "step-consent",
        "label": "Consent",
        "icon": "check",
        "children": [
          {
            "type": "field",
            "id": "f-emergency",
            "field": "emergency_name"
          },
          {
            "type": "field",
            "id": "f-emergency-phone",
            "field": "emergency_phone",
            "widget": "phone"
          },
          {
            "type": "field",
            "id": "f-consent",
            "field": "consent"
          },
          {
            "type": "field",
            "id": "f-signature",
            "field": "signature",
            "widget": "signature"
          }
        ]
      }
    ]
  }
}