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HTML

              
                <div class="page-container">
  <div class="header-container"><div class="save-button">Save</div></div>
  <div class="navigator-container">
  </div>
  <div class="form-container">
    <div class="form-section" data-title="Intervention Details" data-section="intervention details">
      <div class="header">Intervention Details</div>
      <div class="table-item">
        <table class="multiple-items">
          <tr>
            <td class="label">Caregiver</td>
            <td><select data-input-name="caregiver" data-input-type="select"></select></td>
          </tr>
          <tr>
            <td class="label">Client</td>
            <td><select data-input-name="client" data-input-type="select"></select></td>
          </tr>
          <tr>
            <td class="label">Date</td>
            <td><input type="text" data-input-name="date" data-input-type="text"/></td>
          </tr>
        </table>
      </div>
    </div>
    <div class="form-section" data-title="Endocrine" data-section="history">
      <div class="header">Endocrine (Check All That Apply)</div>
      <div class="check-item" data-form-item="iddm" data-display="IDDM"></div>
      <div class="check-item" data-form-item="niddm" data-display="NIDDM"></div>
      <div class="check-item" data-form-item="thyroid"></div>
      <div class="check-item" data-form-item="endocrine_other" data-display="Other"></div>
    </div>
    <div class="form-section" data-title="Skeletal" data-section="history">
      <div class="header">Skeletal (Check All That Apply)</div>
      <div class="check-item" data-form-item="fractures"></div>
      <div class="check-item" data-form-item="surgery"></div>
      <div class="check-item" data-form-item="osteoarthritis"></div>
      <div class="check-item" data-form-item="deformity"></div>
      <div class="check-item" data-form-item="osteoporosis"></div>
      <div class="check-item" data-form-item="skelatal_other" data-display="Other"></div>
    </div>
    <div class="form-section" data-title="Neurological" data-section="history">
      <div class="header">Neurological (Check All That Apply)</div>
      <div class="check-item" data-form-item="neuropathy"></div>
      <div class="check-item" data-form-item="cva" data-display="CVA"></div>
      <div class="check-item" data-form-item="ms" data-display="MS"></div>
      <div class="check-item" data-form-item="paralysis"></div>
      <div class="check-item" data-form-item="parkinsons" data-display="Parkinson\'s"></div>
      <div class="check-item" data-form-item="dementia"></div>
      <div class="check-item" data-form-item="neurological_other" data-display="Other"></div>
    </div>
    <div class="form-section" data-title="Cardiovascular" data-section="history">
      <div class="header">Cardiovascular (Check All That Apply)</div>
      <div class="check-item" data-form-item="angina"></div>
      <div class="check-item" data-form-item="mi" data-display="MI"></div>
      <div class="check-item" data-form-item="htn" data-display="HTN"></div>
      <div class="check-item" data-form-item="pvd" data-display="PVD"></div>
      <div class="check-item" data-form-item="pacemaker"></div>
      <div class="check-item" data-form-item="cardiovascular_other" data-display="Other"></div>
    </div>
    <div class="form-section" data-title="Respiratory" data-section="history">
      <div class="header">Respiratory (Check All That Apply)</div>
      <div class="check-item" data-form-item="asthma"></div>
      <div class="check-item" data-form-item="COPD" data-display="COPD"></div>
      <div class="check-item" data-form-item="cardiac_asthma" data-display="Cardiac Asthma"></div>
      <div class="check-item" data-form-item="emboli"></div>
      <div class="check-item" data-form-item="respiratory_other" data-display="Other"></div>
    </div>
    <div class="form-section" data-title="Sensory" data-section="history">
      <div class="header">Sensory (Check All That Apply)</div>
      <div class="check-item" data-form-item="poor_eyesight" data-display="Poor Eyesight"></div>
      <div class="check-item" data-form-item="hearing_loss" data-display="Hearing Loss"></div>
      <div class="check-item" data-form-item="sensory_other" data-display="Other"></div>
    </div>
    <div class="form-section" data-title="Communicable Diseases" data-section="history">
      <div class="header">Communicable Diseases (Check All That Apply)</div>
      <div class="check-item" data-form-item="hepatitis"></div>
      <div class="check-item" data-form-item="mrsa" data-display="MRSA"></div>
      <div class="check-item" data-form-item="vre" data-display="VRE"></div>
      <div class="check-item" data-form-item="communicable_diseases_other" data-display="Other"></div>
    </div>
    <div class="form-section" data-title="Mobility and Footwear" data-section="assessment">
      <div class="header">Mobility and Footwear</div>
      <div class="select-item" data-form-item="ambulatory_status">
        <span>Ambulatory Status</span>
        <select data-input-name="ambulatory_status" data-input-type="select">
          <option value="">Select One</option>
          <option value="ambulatory">Ambulatory</option>
          <option value="non_ambulatory">Non-Ambulatory</option>
        </select>
      </div>
      <div class="check-item" data-form-item="leg_activity" data-display="Does the condition of the feet/legs limit activity?"></div>
      <div class="check-item" data-form-item="gait_disturbance" data-display="Observe gait with shoes on \'gait disturbance\'?"></div>
      <div class="check-item" data-form-item="mobility_and_footwear_other" data-display="Other"></div>
    </div>
    <div class="form-section" data-title="Current Footwear" data-section="assessment">
      <div class="header">Current Footwear (Check All That Apply)</div>
      <div class="check-item" data-form-item="wide_toe_box" data-display="Wide Toe Box"></div>
      <div class="check-item" data-form-item="good_depth" data-display="Good Depth"></div>
      <div class="check-item" data-form-item="good_arch_support" data-display="Good Arch Support"></div>
      <div class="check-item" data-form-item="no_rubbing" data-display="No Rubbing"></div>
      <div class="check-item" data-form-item="uneven_wear" data-display="Uneven wear on soles, heals, and/or inside of shoes"></div>
      <div class="check-item" data-form-item="current_footwear_other" data-display="Other"></div>
    </div>
    <div class="form-section" data-title="Dermatological Assessment & General Appearace" data-section="assessment">
      <div class="header">Dermatological Assessment & General Appearace</div>
      <div class="check-item" data-form-item="skin_intact" data-display="Skin is intact, clean, and hydrated"></div>
      <div class="form-item" data-form-item="general_skin">
        <span>General Skin</span>
        <div class="multi-select" data-input-name="general_skin" data-input-type="multi-select-radio" data-radio=true><span data-value="dry">Dry</span><span data-value="normal">Normal</span><span data-value="moist">Moist</span><span data-value="other">Other</span></div>
      </div>
      <div class="check-item" data-form-item="adequate_soft_tissue" data-display="Adequate Soft Tissue"></div>
      <div class="check-item" data-form-item="ulcer"></div>
      <div class="check-item" data-form-item="fissures" data-display="Fissures on heels"></div>
      <div class="check-item" data-form-item="excoriation" data-display="Excoriation on legs or feet"></div>
      <div class="check-item" data-form-item="corns"></div>
      <div class="check-item" data-form-item="planters_wart" data-display="Planters wart"></div>
      <div class="check-item" data-form-item="calluses"></div>
      <div class="check-item" data-form-item="dermatological_other" data-display="Other"></div>
      <div class="check-item" data-form-item="foot_sore_more" data-display="Ever had a foot sore that took more than 2 weeks to heal?"></div>
      <div class="sub-header">Toe Nails</div>
      <div class="check-item" data-form-item="nails_trimmed_correctly" data-display="Nails trimmed correctly"></div>
      <div class="left-right-item" data-form-item="nail_condition">
        <table>
          <tr>
            <td><div class="multi-select" data-input-name="ingrown_right" data-input-type="multi-select"><span data-value="R5">R5</span><span data-value="R4">R4</span><span data-value="R3">R3</span><span data-value="R2">R2</span><span data-value="R1">R1</span></div></td>
            <td>Ingrown</td>
            <td><div class="multi-select" data-input-name="ingrown_left" data-input-type="multi-select"><span data-value="L1">L1</span><span data-value="L2">L2</span><span data-value="L3">L3</span><span data-value="L4">L4</span><span data-value="L5">L5</span></div></td>
          </tr>
          <tr>
            <td><div class="multi-select" data-input-name="infection_right" data-input-type="multi-select"><span data-value="R5">R5</span><span data-value="R4">R4</span><span data-value="R3">R3</span><span data-value="R2">R2</span><span data-value="R1">R1</span></div></td>
            <td>Infection</td>
            <td><div class="multi-select" data-input-name="infection_left" data-input-type="multi-select"><span data-value="L1">L1</span><span data-value="L2">L2</span><span data-value="L3">L3</span><span data-value="L4">L4</span><span data-value="L5">L5</span></div></td>
          </tr>
          <tr>
            <td><div class="multi-select" data-input-name="overgrown_right" data-input-type="multi-select"><span data-value="R5">R5</span><span data-value="R4">R4</span><span data-value="R3">R3</span><span data-value="R2">R2</span><span data-value="R1">R1</span></div></td>
            <td>Overgrown</td>
            <td><div class="multi-select" data-input-name="overgrown_left" data-input-type="multi-select"><span data-value="L1">L1</span><span data-value="L2">L2</span><span data-value="L3">L3</span><span data-value="L4">L4</span><span data-value="L5">L5</span></div></td>
          </tr>
          <tr>
            <td><div class="multi-select" data-input-name="thickened_right" data-input-type="multi-select"><span data-value="R5">R5</span><span data-value="R4">R4</span><span data-value="R3">R3</span><span data-value="R2">R2</span><span data-value="R1">R1</span></div></td>
            <td>Thickened</td>
            <td><div class="multi-select" data-input-name="thickened_left" data-input-type="multi-select"><span data-value="L1">L1</span><span data-value="L2">L2</span><span data-value="L3">L3</span><span data-value="L4">L4</span><span data-value="L5">L5</span></div></td>
          </tr>
          <tr>
            <td><div class="multi-select" data-input-name="discoloured_right" data-input-type="multi-select"><span data-value="R5">R5</span><span data-value="R4">R4</span><span data-value="R3">R3</span><span data-value="R2">R2</span><span data-value="R1">R1</span></div></td>
            <td>Discoloured</td>
            <td><div class="multi-select" data-input-name="discolured_left" data-input-type="multi-select"><span data-value="L1">L1</span><span data-value="L2">L2</span><span data-value="L3">L3</span><span data-value="L4">L4</span><span data-value="L5">L5</span></div></td>
          </tr>
          <tr>
            <td><div class="multi-select" data-input-name="involuted_right" data-input-type="multi-select"><span data-value="R5">R5</span><span data-value="R4">R4</span><span data-value="R3">R3</span><span data-value="R2">R2</span><span data-value="R1">R1</span></div></td>
            <td>Involuted</td>
            <td><div class="multi-select" data-input-name="involuted_left" data-input-type="multi-select"><span data-value="L1">L1</span><span data-value="L2">L2</span><span data-value="L3">L3</span><span data-value="L4">L4</span><span data-value="L5">L5</span></div></td>
          </tr>
          <tr>
            <td><div class="multi-select" data-input-name="rams_horn_right" data-input-type="multi-select"><span data-value="R5">R5</span><span data-value="R4">R4</span><span data-value="R3">R3</span><span data-value="R2">R2</span><span data-value="R1">R1</span></div></td>
            <td>Rams Horn</td>
            <td><div class="multi-select" data-input-name="rams_horn_left" data-input-type="multi-select"><span data-value="L1">L1</span><span data-value="L2">L2</span><span data-value="L3">L3</span><span data-value="L4">L4</span><span data-value="L5">L5</span></div></td>
          </tr>
        </table>
      </div>
      <div class="sub-header">Structure Deformities</div>
      <div class="check-item" data-form-item="boney_prominances" data-display="Boney prominances"></div>
      <div class="check-item" data-form-item="hallus_vulgus" data-display="Hallus vulgus (bunion)"></div>
      <div class="check-item" data-form-item="hammer_toes" data-display="Hammer toes"></div>
      <div class="check-item" data-form-item="overlapping_digits" data-display="Overlapping digits"></div>
      <div class="check-item" data-form-item="tailor_bunionette" data-display="Tailor bunionette"></div>
    </div>
    <div class="form-section" data-title="Circulatory Status of Feet and Legs" data-section="assessment">
      <div class="header">Circulatory Status of Feet and Legs</div>
      <div class="form-item" data-form-item="capillary_refill">
        <table>
          <tr>
            <td></td>
            <td class="text-bold">Capillary Refill</td>
          </tr>
          <tr>
            <td class="text-right">Right Foot</td>
            <td><div class="multi-select" data-input-name="capillary_refill_right" data-input-type="multi-select-radio" data-radio=true><span data-value="-3">-3 sec</span><span data-value="3">+3 sec</span></div></td>
          </tr>
          <tr>
            <td class="text-right">Left Foot</td>
            <td><div class="multi-select" data-input-name="capillary_refill_left" data-input-type="multi-select-radio" data-radio=true><span data-value="-3">-3 sec</span><span data-value="3">+3 sec</span></div></td>
          </tr>
        </table>
      </div>
      <div class="form-item" data-form-item="pedul_pulses">
        <table>
          <tr>
            <td></td>
            <td colspan=2 class="text-bold text-center">Pedul Pulses</td>
          </tr>
          <tr>
            <td></td>
            <td>Right Foot</td>
            <td>Left Foot</td>
          </tr>
          <tr>
            <td class="text-right">Dorsalis pedis pulse</td>
            <td class="text-center"><input type="checkbox" data-input-name="dorsalis_pedis_right" data-input-type="checkbox" /></td>
            <td class="text-center"><input type="checkbox" data-input-name="dorsalis_pedis_left" data-input-type="checkbox" /></td>
          </tr>
          <tr>
            <td class="text-right">Posterior tibial pulse</td>
            <td class="text-center"><input type="checkbox" data-input-name="posterior_tibial_right" data-input-type="checkbox" /></td>
            <td class="text-center"><input type="checkbox" data-input-name="posterior_tibial_left" data-input-type="checkbox" /></td>
          </tr>
        </table>
      </div>
      <div class="check-item" data-form-item="calf_pain" data-display="Do you have pain in the calf when walking or exertion that is relieved by rest within minutes?">
        <span>Assess for intermittent claudication</span>
      </div>
      <div class="check-item" data-form-item="pain_relief_bed" data-display="Do you have pain when you go to bed at night relieved by putting your foot over the side of the bed?"></div>
      <div class="left-right-item" data-form-item="toe_pain">
        <span>Do you have toe pain?</span>
        <table>
          <tr>
            <td><div class="multi-select" data-input-name="toe_pain_right" data-input-type="multi-select"><span data-value="R5">R5</span><span data-value="R4">R4</span><span data-value="R3">R3</span><span data-value="R2">R2</span><span data-value="R1">R1</span></div></td>
            <td>Rate the pain</td>
            <td><div class="multi-select" data-input-name="toe_pain_left" data-input-type="multi-select"><span data-value="L1">L1</span><span data-value="L2">L2</span><span data-value="L3">L3</span><span data-value="L4">L4</span><span data-value="L5">L5</span></div></td>
          </tr>
        </table>
      </div>
      <div class="form-item" data-form-item="anticoagulant">
        <span>Do you use an anticoagulant?</span>
        <table class="anticoagulant">
          <tbody>
            <tr>
              <td class="text-bold text-center">Name of drug</td>
              <td class="text-bold text-center">Dosage</td>
            </tr>
            <!--<tr>
              <td><input type="text" name="name" value="test" /></td>
              <td><input type="text" name="dosage" /></td>
              <td class="vert-middle"><div class="delete-anticoagulant">x</div></td>
            </tr>-->
          </tbody>
        </table>
      </div>
      <div class="check-item" data-form-item="edema"></div>
      <div class="check-item" data-form-item="varocities"></div>
      <div class="check-item" data-form-item="spider_veins" data-display="Spider Veins"></div>
      <div class="check-item" data-form-item="feet_temperature" data-display="Are feet the same temperature?"></div>
      <div class="check-item" data-form-item="leg_temperature" data-display="Are legs the same temperature?"></div>
      <div class="form-item" data-form-item="hair_growth">
        <span>Hair growth (foot/toes)</span>
        <table>
          <tr>
            <td class="text-center">Right Foot</td>
            <td class="text-center">Left Foot</td>
          </tr>
          <tr>
            <td><div class="multi-select" data-input-name="hair_growth_right" data-input-type="multi-select-radio" data-radio=true><span data-value="normal">Normal</span><span data-value="sparce">Sparce</span><span data-value="absent">Absent</span></div></td>
            <td><div class="multi-select" data-input-name="hair_growth_left" data-input-type="multi-select-radio" data-radio=true><span data-value="normal">Normal</span><span data-value="sparce">Sparce</span><span data-value="absent">Absent</span></div></td>
          </tr>
        </table>
      </div>
      <div class="form-item" data-form-item="foot_colour">
        <table>
          <tr>
            <td></td>
            <td class="text-bold text-center" colspan=2>Colour</td>
          </tr>
          <tr>
            <td></td>
            <td>Right Foot</td>
            <td>Left Foot</td>
          </tr>
          <tr>
            <td class="text-right">Hyperpigmentation</td>
            <td class="text-center"><input type="checkbox" data-input-name="foot_colour_hyperpigmentation_right" data-input-type="checkbox"/></td>
            <td class="text-center"><input type="checkbox" data-input-name="foot_colour_hyperpigmentation_left" data-input-type="checkbox"/></td>
          </tr>
          <tr>
            <td class="text-right">Red</td>
            <td class="text-center"><input type="checkbox" data-input-name="foot_colour_red_right" data-input-type="checkbox"/></td>
            <td class="text-center"><input type="checkbox" data-input-name="foot_colour_red_left" data-input-type="checkbox"/></td>
          </tr>
          <tr>
            <td class="text-right">Red-Blue on dependency</td>
            <td class="text-center"><input type="checkbox" data-input-name="foot_colour_red_blue_right" data-input-type="checkbox"/></td>
            <td class="text-center"><input type="checkbox" data-input-name="foot_colour_red_blue_left" data-input-type="checkbox"/></td>
          </tr>
          <tr>
            <td class="text-right">Blue</td>
            <td class="text-center"><input type="checkbox" data-input-name="foot_colour_blue_right" data-input-type="checkbox"/></td>
            <td class="text-center"><input type="checkbox" data-input-name="foot_colour_blue_left" data-input-type="checkbox"/></td>
          </tr>
        </table>
      </div>
    </div>
    <div class="form-section" data-title="Neurological Assessment" data-section="assessment">
      <div class="header">Neurological Assessment</div>
      <div class="check-item" data-form-item="leg_sensation" data-display="Any changes to sensation of legs and feet?"></div>
      <div class="form-item" data-form-item="semmes">
        <div class="semmes">
          <div class="title">Assess using the Semmes-Weinstein 10g Monofilament</div>      
          <div class="point-container">
            <img src="/img/footcare/semmes-feet.png"/>
            <div class="test-point" data-input-name="semmes_point_right_1" data-input-type="semmes-point" data-point-number=1><span></span></div>
            <div class="test-point" data-input-name="semmes_point_right_2" data-input-type="semmes-point" data-point-number=2><span></span></div>
            <div class="test-point" data-input-name="semmes_point_right_3" data-input-type="semmes-point" data-point-number=3><span></span></div>
            <div class="test-point" data-input-name="semmes_point_right_4" data-input-type="semmes-point" data-point-number=4><span></span></div>
            <div class="test-point" data-input-name="semmes_point_right_5" data-input-type="semmes-point" data-point-number=5><span></span></div>
            <div class="test-point" data-input-name="semmes_point_right_6" data-input-type="semmes-point" data-point-number=6><span></span></div>
            <div class="test-point" data-input-name="semmes_point_right_7" data-input-type="semmes-point" data-point-number=7><span></span></div>
            <div class="test-point" data-input-name="semmes_point_right_8" data-input-type="semmes-point" data-point-number=8><span></span></div>
            <div class="test-point" data-input-name="semmes_point_right_9" data-input-type="semmes-point" data-point-number=9><span></span></div>
            <div class="test-point" data-input-name="semmes_point_right_10" data-input-type="semmes-point" data-point-number=10><span></span></div>
            <div class="test-point" data-input-name="semmes_point_left_1" data-input-type="semmes-point" data-point-number=11><span></span></div>
            <div class="test-point" data-input-name="semmes_point_left_2" data-input-type="semmes-point" data-point-number=12><span></span></div>
            <div class="test-point" data-input-name="semmes_point_left_3" data-input-type="semmes-point" data-point-number=13><span></span></div>
            <div class="test-point" data-input-name="semmes_point_left_4" data-input-type="semmes-point" data-point-number=14><span></span></div>
            <div class="test-point" data-input-name="semmes_point_left_5" data-input-type="semmes-point" data-point-number=15><span></span></div>
            <div class="test-point" data-input-name="semmes_point_left_6" data-input-type="semmes-point" data-point-number=16><span></span></div>
            <div class="test-point" data-input-name="semmes_point_left_7" data-input-type="semmes-point" data-point-number=17><span></span></div>
            <div class="test-point" data-input-name="semmes_point_left_8" data-input-type="semmes-point" data-point-number=18><span></span></div>
            <div class="test-point" data-input-name="semmes_point_left_9" data-input-type="semmes-point" data-point-number=19><span></span></div>
            <div class="test-point" data-input-name="semmes_point_left_10" data-input-type="semmes-point" data-point-number=20><span></span></div>
          </div>
          <div class="clear"></div>
        </div>
      </div>
      <div class="form-item" data-form-item="foot_sensation">
        <table>
          <tr>
            <td></td>
            <td>Right Foot</td>
            <td>Left Foot</td>
          </tr>
          <tr>
            <td>Do your feet ever numb?</td>
            <td class="text-center"><input type="checkbox" data-input-name="foot_sensation_numb_right" data-input-type="checkbox"/></td>
            <td class="text-center"><input type="checkbox" data-input-name="foot_sensation_numb_left" data-input-type="checkbox"/></td>
          </tr>
          <tr>
            <td>Do your feet ever tingle?</td>
            <td class="text-center"><input type="checkbox" data-input-name="foot_sensation_tingle_right" data-input-type="checkbox"/></td>
            <td class="text-center"><input type="checkbox" data-input-name="foot_sensation_tingle_left" data-input-type="checkbox"/></td>
          </tr>
          <tr>
            <td>Do your feet ever burn?</td>
            <td class="text-center"><input type="checkbox" data-input-name="foot_sensation_burn_right" data-input-type="checkbox"/></td>
            <td class="text-center"><input type="checkbox" data-input-name="foot_sensation_burn_left" data-input-type="checkbox"/></td>
          </tr>
          <tr>
            <td>Feel like insects crawling on them?</td>
            <td class="text-center"><input type="checkbox" data-input-name="foot_sensation_insects_right" data-input-type="checkbox"/></td>
            <td class="text-center"><input type="checkbox" data-input-name="foot_sensation_insects_left" data-input-type="checkbox"/></td>
          </tr>
        </table>
      </div>
    </div>
    <div class="form-section" data-title="Diagram" data-section="diagram and notes">
      <div class="header">Diagram</div>
      <div class="form-item">
        <div class="feet-diagram-container" data-type="top_view">
          <div class="feet-diagram">
            <div class="title">Top</div>
            <div class="diagram-container"><img src="/img/footcare/feet-top.png"/></div>
          </div>
          <table class="foot-diagram-notes">
            <!--<tbody class="hidden">
              <tr>
                <td class="text-center vert-middle"><div class="feet-diagram-point">1</div></td>
                <td><div class="add-picture">Add a picture</div></td>
                <td class="diagram-note-input"><div contenteditable data-ph="Notes...">notes</div></td>
                <td class="text-center vert-middle"><div class="delete-foot-point">x</div></td>
              </tr>
            </tbody>-->
          </table>
        </div>
        <div class="feet-diagram-container" data-type="bottom_view">
          <div class="feet-diagram">
            <div class="title">Bottom</div>
            <div class="diagram-container"><img src="/img/footcare/feet-bottom.png"/></div>
          </div>
          <table class="foot-diagram-notes"></table>
        </div>
        <div class="feet-diagram-container" data-type="insole_view">
          <div class="feet-diagram wide">
            <div class="title">Insole</div>
            <div class="diagram-container"><img src="/img/footcare/feet-insole.png"/></div>
          </div>
          <table class="foot-diagram-notes"></table>
        </div>
        <div class="feet-diagram-container" data-type="outsole_view">
          <div class="feet-diagram wide">
            <div class="title">Outsole</div>
            <div class="diagram-container"><img src="/img/footcare/feet-outsole.png"/></div>
          </div>
          <table class="foot-diagram-notes"></table>
        </div>
      </div>
    </div>
    <div class="form-section" data-title="Notes" data-section="diagram and notes">
      <div class="header">Notes</div>
      <div class="final-notes" data-input-name="final_notes" data-input-type="contenteditable" contenteditable data-ph="Notes..."></div>
    </div>
    <div class="form-section" data-title="Transaction" data-section="transaction">
      <div class="header">Transaction</div>
      <div class="form-item">
        <div class="product-wrap">
          <input type="hidden" data-input-name="payment_id" data-input-type="text" />
          <table class="products">
            <thead>
              <tr>
                <td>Item</td>
                <td>Qty</td>
                <td>Service/Product</td>
                <td class="text-right">Price</td>
                <td class="text-right">Extended</td>
                <td></td>
              </tr>
            </thead>
            <tbody>
              <!--<tr class="product-item">
                <td class="text-center vert-middle" data-field="index" data-input-type="contenteditable"></td>
                <td><input data-field="quantity" data-input-type="text" type="text"/></td>
                <td><select data-field="product" data-input-type="select"></select></td>
                <td class="text-right" data-field="price" data-input-type="contenteditable"></td>
                <td class="text-right text-bold" data-field="extended" data-input-type="contenteditable"></td>
                <td><div class="delete-product">x</div></td>
              </tr>-->
            </tbody>
          </table>
          <table class="product-totals">
            <tr>
              <td class="text-right">Subtotal</td><td data-input-name="subtotal" data-input-type="contenteditable" data-format="currency" class="amount"></td>
            </tr>
            <tr>
              <td class="text-right">HST @ 13%</td><td data-input-name="tax" data-input-type="contenteditable" data-format="currency" class="amount"></td>
            </tr>
            <tr>
              <td class="text-right">Total</td><td data-input-name="total" data-input-type="contenteditable" data-format="currency" class="amount"></td>
            </tr>
          </table>
          <div class="clear"></div>
        </div>
      </div>
      <div class="form-item text-center">
        <span>Payment Method</span>
        <div class="multi-select" data-input-name="payment_method" data-input-type="multi-select-radio" data-radio=true><span data-value="Cash/Cheque">Cash/Cheque</span><span data-value="Credit">Credit</span><span data-value="COA">COA</span><span data-value="Bill to Family">Bill to Family</span><span data-value="DVA">DVA</span></div>
      </div>
      <div class="form-item text-center">
        <span>Air Miles</span>
        <span><input class="text-center" data-input-name="air_miles" data-input-type="text" type="text" /></span>
      </div>
    </div>
    <div class="form-section" data-title="Book Next Appointment">
      <div class="header">Book Next Appointment</div>
      <div class="form-item text-center">
        <span>Would you like to book another appointment?</span>
        <div class="multi-select"><span>Book</span><span>Directions</span></div>
      </div>
    </div>
  </div>
</div>
              
            
!

CSS

              
                @import url(https://fonts.googleapis.com/css?family=Lato:400,700);

body {
  font-family: Lato;
  position: absolute;
  top: 0px;
  bottom: 0px;
  right: 0px;
  left: 0px;
}

.clear {
  clear: both;
}
.left {
  float: left;
}
.right {
  float: right;
}

.text-left { text-align: left; }
.text-center { text-align: center; }
.text-right { text-align: right; }
.text-bold { font-weight: bold; }
.vert-middle { vertical-align: middle; }

.page-container {
  position: absolute;
  top: 0px;
  bottom: 0px;
  right: 0px;
  left: 0px;
}

.header-container {
  height: 45px;
  border-bottom: 1px solid #999;
}

.navigator-container {
  position: absolute;
  left: 0;
  width: 225px;
  top: 46px;
  bottom: 0;
  overflow: auto;
  -webkit-overflow-scrolling: touch;
}

.form-container {
  position: absolute;
  border-left: 1px solid #888;
  left: 225px;
  right: 0px;
  top: 46px;
  bottom: 0px;
  overflow: auto;
  -webkit-overflow-scrolling: touch;
}

.save-button {
  cursor: pointer;
  float: right;
  line-height: 45px;
  color: hsl(10,80%,50%);
  padding: 0 10px;
  font-size: 1.1em;
}

.navigator-container .form-item {
  position: relative;
  cursor: pointer;
  width: 100%;
  box-sizing: border-box;
  white-space: nowrap;
  overflow: hidden;
  text-overflow: ellipsis;
}
.navigator-container .form-item:hover,
.navigator-container .form-item.selected {
  background-color: #eee;
}

.navigator-container .header {
  background-color: #bbb;
  border-color: #aaa;
  text-transform: capitalize;
}

[contenteditable]:empty:not(:focus):before {
  content:attr(data-ph);
  color: #d0d0d0;
}
.diagram-note-input [contenteditable]:empty:not(:focus):before,
.final-notes:empty:not(:focus):before {
  color: hsl(45,90%,45%);
}

.image-flip {
  -moz-transform: scaleX(-1);
  -o-transform: scaleX(-1);
  -webkit-transform: scaleX(-1);
  transform: scaleX(-1);
  filter: FlipH;
  -ms-filter: "FlipH";
}

.hidden {
  display: none;
}

.header {
  background-color: hsl(200,80%,50%);
  border: 1px solid hsl(200,60%,50%);
  border-left: none;
  border-right: none;
  color: white;
  font-size: 0.9em;
  padding: 3px 3px 3px 10px;
}

.check-item,
.select-item,
.radio-item,
.left-right-item,
.sub-header {
  position: relative;
  margin-left: 10px;
  font-size: 1.2em;
  line-height: 1.2em;
  padding: 12px 50px 12px 0;
  border-bottom: 1px solid #ccc;
}
.check-item:last-child,
.select-item:last-child,
.radio-item:last-child,
.left-right-item:last-child {
  border-bottom: none;
}

.form-item {
  position: relative;
  border-bottom: none;
  margin: 0;
  padding: 12px;
  padding-right: 0px;
  font-size: 1.2em;
}
.form-item:after {
  position: absolute;
  content: " ";
  bottom: 0px;
  left: 10px;
  right: 0px;
  height: 1px;
  background-color: #ccc;
}
.form-item:last-child:after {
  display: none;
}

.check-item {
  position: relative;
}
.check-item input[type="checkbox"] {
  margin-right: 10px;
}
.check-item label {
  cursor: pointer;
}

input[type="checkbox"] {
  cursor: pointer;
  position: relative;
  -webkit-appearance: none;
  appearance: none;
  box-sizing: content-box;
  outline: none;
  content: " ";
  width: 28px;
  height: 18px;
  background-color: #fff;
  border: 1px solid #ddd;
  border-radius: 14px;
  left: 0;
  top: 1px;
  /* margin-top: -9px; */
  transition: 0.3s;
  vertical-align: text-bottom;
}

input[type="checkbox"]:checked {
  background-color: hsl(120,65%,55%);
  border: 1px solid hsl(120,56%,55%);
}

input[type="checkbox"]:after {
  position: absolute;
  content: " ";
  width: 16px;
  height: 16px;
  background-color: white;
  border: 1px solid #d2d2d2;
  border-radius: 16px;
  box-shadow: 0px 1px 2px rgba(120,120,120,0.3);
  left: 0;
  top: 50%;
  margin-top: -9px;
  transition: 0.3s;
}

input[type="checkbox"]:checked:after {
  left: 11px;
}

.sub-header {
  font-family: helvetica;
  text-align: center;
  font-weight: bold;
}

.form-container select {
  margin-top: -2px;
  font-size: 1.0em;
  color: #222;
  font-family: Lato;
  border: 1px solid #ccc;
  border-radius: 5px;
  padding: 5px;
}

.radio-item table {
  margin-top: 10px;
  width: 100%;
  text-align: center;
}

.left-right-item table {
  text-align: center;
}
.left-right-item > span,
.check-item > span,
.form-item > span {
  display: block;
  margin-bottom: 10px;
}

.table-item {
  font-size: 1.2em;
  padding-left: 12px;
}
.table-item .label {
  text-align: right;
  width: 1px;
}
.table-item table.multiple-items {
  width: 100%;
}
.table-item table.multiple-items tr {
  border-bottom: 1px solid #ccc;
}
.table-item table.multiple-items tr:last-child {
  border-bottom: none;
}
.table-item table.multiple-items td {
  padding: 12px;
}
.table-item select,
.table-item input {
  box-sizing: border-box;
  width: 100%;
}

.multi-select {
  display: inline-block;
  border: 1px solid hsl(10,80%,50%);
  border-radius: 5px;
  color: hsl(10,80%,50%);
  font-size: 0.8em;
  white-space: nowrap;
}
.multi-select span {
  cursor: pointer;
  display: inline-block;
  padding: 6px 12px;
  border-right: 1px solid hsl(10,80%,50%);
  transition: 0.3s;
}
.multi-select span.selected {
  color: white;
  background-color: hsl(10,80%,50%);
}
.multi-select span:last-child {
  border-right: none;
}

.left-right-item td {
  padding: 5px;
}

.form-item td {
  padding: 5px;
}

.form-container input[type="text"] {
  font-size: 1.0em;
  font-family: Lato;
  color: #222;
  border: 1px solid #ccc;
  border-radius: 5px;
  padding: 5px;
}

.form-item table input[type="text"] {
  box-sizing: border-box;
  width: 100%;
}

.semmes {
  text-align: center;
}

.title {
  text-align: center;
  font-family: helvetica;
  font-weight: bold;
  margin-bottom: 10px;
}

.semmes .point-container {
  display: inline-block;
  position: relative;
}

.test-point {
  cursor: pointer;
  position: absolute;
  width: 100px;
  height: 100px;
  background-color: hsla(5,70%,60%,0.5);
  border: 1px solid hsla(5,70%,55%,0.55);
  border-radius: 100px;
  transform: scale(0.6,0.6);
  transition: 0.3s;
}
.test-point.selected {
  background-color: hsla(120,70%,60%,0.5);
  border-color: hsla(120,70%,55%,0.55);
}
.test-point:before {
  position: absolute;
  content: " ";
  width: 50px;
  height: 50px;
  background-color: hsl(5,60%,50%);
  border: 1px solid hsl(5,60%,40%);
  border-radius: 50px;
  top: 50%;
  margin-top: -26px;
  left: 50%;
  margin-left: -26px;
  transition: 0.3s;
}
.test-point.selected:before {
  background-color: hsl(120,60%,50%);
  border-color: hsl(120,60%,40%);
}
.test-point span {
  position: absolute;
  content: " ";
  width: 26px;
  height: 10px;
  background-color: hsla(0,0%,100%,1);
  top: 50%;
  margin-top: -5px;
  left: 50%;
  margin-left: -13px;
  border-radius: 2px;
  transition: 0.7s ease-out;
}
.test-point.selected span {
  transform: rotateZ(310deg);
  margin-left: -9px;
  margin-top: -4px;
}

.test-point span:after {
  position: absolute;
  content: " ";
  width: 10px;
  height: 10px;
  background-color: hsla(0,0%,100%,1);
  bottom: 0;
  left: 0;
  border-radius: 2px;
  transition: 0.2s;
  /* transition-delay: 0.9s; */
}
.test-point.selected span:after {
  height: 18px;
  /* transition-delay: 0s; */
}

.test-point[data-point-number="1"] {
  top: 35px;
  left: 65px;
}
.test-point[data-point-number="2"] {
  top: 160px;
  left: 100px;
}
.test-point[data-point-number="3"] {
  top: 180px;
  left: 20px;
}
.test-point[data-point-number="4"] {
  top: 230px;
  left: -30px;
}
.test-point[data-point-number="5"] {
  top: 280px;
  left: 89px;
}
.test-point[data-point-number="6"] {
  top: 260px;
  left: 29px;
}
.test-point[data-point-number="7"] {
  top: 300px;
  left: -20px;
}
.test-point[data-point-number="8"] {
  top: 400px;
  left: 50px;
}
.test-point[data-point-number="9"] {
  top: 410px;
  left: -15px;
}
.test-point[data-point-number="10"] {
  top: 560px;
  left: 35px;
}
.test-point[data-point-number="11"] {
  top: 35px;
  right: 65px;
}
.test-point[data-point-number="12"] {
  top: 160px;
  right: 100px;
}
.test-point[data-point-number="13"] {
  top: 180px;
  right: 20px;
}
.test-point[data-point-number="14"] {
  top: 230px;
  right: -30px;
}
.test-point[data-point-number="15"] {
  top: 280px;
  right: 89px;
}
.test-point[data-point-number="16"] {
  top: 260px;
  right: 29px;
}
.test-point[data-point-number="17"] {
  top: 300px;
  right: -20px;
}
.test-point[data-point-number="18"] {
  top: 400px;
  right: 50px;
}
.test-point[data-point-number="19"] {
  top: 410px;
  right: -15px;
}
.test-point[data-point-number="20"] {
  top: 560px;
  right: 35px;
}

.feet-diagram {
  text-align: center;
  margin: 10px auto;
  padding: 10px;
}
.diagram-container {
  position: relative;
  display: inline-block;
}

.notes {
  cursor: pointer;
  position: absolute;
  right: 10px;
  top: 6px;
  z-index: 1;
  width: 30px;
  height: 34px;
  opacity: 0.4;
  background-color: hsl(45,10%,80%);
  border: 1px solid hsl(45,10%,65%);
  transition: 0.3s;
}

.notes.open, .notes.content, .notes:hover {
  background-color: hsl(45,90%,80%);
  border-color: hsl(45,90%,65%);
}

.notes:hover {
  opacity: 0.6;
}

.notes:before {
  position: absolute;
  content: " ";
  top: -1px;
  right: -1px;
  border-top: 6px solid white;
  border-right: 6px solid white;
  border-bottom: 6px solid transparent;
  border-left: 6px solid transparent;
}
.notes:after {
  position: absolute;
  content: " ";
  top: -1px;
  right: -1px;
  border-left: 6px solid hsl(45,10%,65%);
  border-bottom: 6px solid hsl(45,10%,65%);
  border-top: 6px solid transparent;
  border-right: 6px solid transparent;
  transition: 0.3s;
}
.notes.content:after, .notes:hover:after {
  border-left-color: hsl(45,90%,65%);
  border-bottom-color: hsl(45,90%,65%);
}

.notes.open, .notes.content {
  opacity: 1;
}

.notes.open {
  cursor: default;
  width: 200px;
  min-height: 150px;
  height: auto;
  z-index: 2;
  padding: 15px 5px 5px 5px;
}

.notes.open:before, .notes.open:after {
  display: none;
}

.note-clipper {
  overflow: hidden;
}
.note-input, .notes .close-button {
  display: none;
}
.open .note-input {
  display: block;
  outline: none;
  width: 100%;
  margin-top: 13px;
  min-height: 150px;
  min-width: 200px;
  line-height: 1.35em;
}

.notes.open .close-button {
  cursor: pointer;
  display: block;
  position: absolute;
  top: 3px;
  right: 3px;
  content: " ";
  left: 0;
  height: 25px;
  /* border: 1px solid black; */
}
.notes.open .close-button:after {
  position: absolute;
  top: 6px;
  right: 0px;
  content: " ";
  width: 16px;
  height: 4px;
  background-color: hsl(45,90%,60%);
  transform: rotateZ(-45deg);
}
.notes.open .close-button:before {
  position: absolute;
  top: 0px;
  right: 0px;
  content: " ";
  width: 15px;
  height: 15px;
  box-shadow: inset -2px 2px 0px 2px hsl(45,90%,60%); 
}

.foot-diagram-notes {
  width: 100%;
}

.foot-diagram-notes tbody {
  border: 1px solid #ccc;
  border-left: none;
  border-right: none;
}

.foot-diagram-notes tr:first-child td:nth-child(1),
.foot-diagram-notes tr:first-child td:nth-child(2),
.foot-diagram-notes tr:first-child td:nth-child(4) {
  width: 1px;
}

.diagram-note-input {
  vertical-align: top;
}
.diagram-note-input div[contenteditable] {
  background-color: hsl(45,90%,80%);
  border: 1px solid hsl(45,90%,65%);
  padding: 5px;
  min-height: 140px;
}

.add-picture {
  width: 150px;
  height: 150px;
  background-color: #999;
  border: 1px solid #666;
  color: white;
  text-align: center;
  line-height: 150px;
  font-size: 0.8em;
}

.foot-diagram-notes td {
  /* border: 1px solid black; */
}

.feet-diagram .feet-diagram-point {
  cursor: move;
}

.feet-diagram .left,
.feet-diagram .right {
  position: relative;
  /* border: 1px solid black; */
}

.feet-diagram-point {
  position: relative;
  display: inline-block;
  box-sizing: border-box;
  width: 35px;
  height: 35px;
  background-color: hsl(200,80%,50%);
  border: 1px solid hsl(200,50%,50%);
  border-radius: 50px;
  text-align: center;
  line-height: 33px;
  padding-right: 1px;
  color: white;
  font-size: 14px;
}
.feet-diagram-point:after {
  position: absolute;
  content: " ";
  top: 100%;
  left: 50%;
  margin-top: -5px;
  margin-left: -9px;
  border-top: 20px solid hsl(200,80%,50%);
  border-right: 9px solid transparent;
  border-left: 9px solid transparent;
}
.feet-diagram-point:before {
  position: absolute;
  content: " ";
  top: 100%;
  left: 50%;
  margin-top: -3px;
  margin-left: -9px;
  border-top: 20px solid hsl(200,50%,50%);
  border-right: 9px solid transparent;
  border-left: 9px solid transparent;
}

.delete-foot-point,
.delete-anticoagulant,
.delete-product {
  cursor: pointer;
  position: relative;
  display: inline-block;
  box-sizing: border-box;
  width: 23px;
  height: 23px;
  background-color: hsl(5,80%,50%);
  border: 1px solid hsl(5,50%,50%);
  border-radius: 50px;
  text-align: center;
  line-height: 19px;
  color: white;
  font-size: 12px;
  top: -4px;
}

tr:last-child .delete-anticoagulant,
tr:last-child .delete-product {
  display: none;
}

.final-notes {
  background-color: hsl(45,90%,80%);
  border: 1px solid hsl(45,90%,65%);
  padding: 10px;
  margin: 10px;
  min-height: 200px;
  box-sizing: border-box;
}

.product-wrap {
  width: 500px;
  margin: 0 auto;
}
.products {
  display: inline-block;
  table-layout: fixed;
  border-top-left-radius: 5px;
  width: calc(100% + 10px);
  overflow: hidden;
}
.products thead td {
  border-bottom: 1px solid #aaa;
  background-color: #ddd;
}
.products thead td:last-child {
  width: 1px;
  border-bottom: none;
  background-color: transparent;
}
.products thead td:nth-child(1) {
  width: 1px;
}
.products thead td:nth-child(2) {
  width: 50px;
}
.products thead td:nth-child(4) {
  width: 125px;
}
.products thead td:nth-child(5) {
  border-top-right-radius: 5px;
  overflow: hidden;
  width: 125px;
}

.products tbody td {
  border-bottom: 1px solid #ccc;
}
.products tbody td:last-child,
.products tbody tr:last-child td {
  border-bottom: none;
}
.products tbody input,
.products tbody select {
  width: 100%;
}

.products tbody tr:nth-child(2n) td {
  background-color: #f0f0f0;
}
.products tbody tr:nth-child(2n) td:last-child {
  background-color: transparent;
}

.product-totals {
  float: right;
}
.product-totals .amount {
  font-weight: bold;
  text-align: right;
  width: 125px;
  border-bottom: 1px dotted #ccc;
}
              
            
!

JS

              
                FastClick.attach(document.body);
!function(a){function f(a,b){if(!(a.originalEvent.touches.length>1)){a.preventDefault();var c=a.originalEvent.changedTouches[0],d=document.createEvent("MouseEvents");d.initMouseEvent(b,!0,!0,window,1,c.screenX,c.screenY,c.clientX,c.clientY,!1,!1,!1,!1,0,null),a.target.dispatchEvent(d)}}if(a.support.touch="ontouchend"in document,a.support.touch){var e,b=a.ui.mouse.prototype,c=b._mouseInit,d=b._mouseDestroy;b._touchStart=function(a){var b=this;!e&&b._mouseCapture(a.originalEvent.changedTouches[0])&&(e=!0,b._touchMoved=!1,f(a,"mouseover"),f(a,"mousemove"),f(a,"mousedown"))},b._touchMove=function(a){e&&(this._touchMoved=!0,f(a,"mousemove"))},b._touchEnd=function(a){e&&(f(a,"mouseup"),f(a,"mouseout"),this._touchMoved||f(a,"click"),e=!1)},b._mouseInit=function(){var b=this;b.element.bind({touchstart:a.proxy(b,"_touchStart"),touchmove:a.proxy(b,"_touchMove"),touchend:a.proxy(b,"_touchEnd")}),c.call(b)},b._mouseDestroy=function(){var b=this;b.element.unbind({touchstart:a.proxy(b,"_touchStart"),touchmove:a.proxy(b,"_touchMove"),touchend:a.proxy(b,"_touchEnd")}),d.call(b)}}}(jQuery);

var formContainer = $(".form-container");
var navigatorContainer = $(".navigator-container");
var anticoagulantTable = formContainer.find(".anticoagulant");

$("img[src]").each(function(index) {
  this.src = "http://datacenter.qwantech.com:9013" + this.src.split("codepen.io")[1];
});

var headerContainerHeight = $(".header-container").height();

formContainer.find("[data-form-item]").each(function(i) {
  var $this = $(this);
  var id = $this.data("form-item");
  var display = $this.data("display") || id.charAt(0).toUpperCase() + id.slice(1);
  
  if ($this.hasClass("check-item")) {
  	$this.append("<input id='"+id+"' type='checkbox' data-input-name='"+id+"' data-input-type='checkbox'/><label for='"+id+"'>"+display+"</label>");
  }
  $this.append("<div class='notes'><div class='note-clipper'><div class='note-input' data-input-name='"+id+"_note' data-input-type='contenteditable' contenteditable></div></div><div class='close-button'></div></div>")
});

$(".multi-select span").click(function(e) {
  var $this = $(this);
  var isRadio = $this.closest(".multi-select").data("radio");
  if (isRadio) { $this.siblings().removeClass("selected"); }
  $this.toggleClass("selected");
});

var lastSection;
var sectionDiv = $("<div>");
$(".form-section").each(function(index) {
  var title = $(this).data("title");
  var section = $(this).data("section");
  
  if (lastSection !== section) {
    $(".navigator-container").append(sectionDiv);
    sectionDiv = $("<div>");
    sectionDiv.append("<div class='header'>"+section+"</div>");
  }
  lastSection = section;
  
  var titleDiv = $("<div class='form-item' data-title='"+title+"' title='"+title+"'>"+title+"</div>");
  titleDiv.click(navigationClick);
  sectionDiv.append(titleDiv);
});

formContainer.scroll(function(e) {
  var scrollTop = formContainer.scrollTop();
  var lastSectionTitle;
  $(".form-section").each(function(index) {
    if ($(this).offset().top - headerContainerHeight > 0) {
      return false
    }
    lastSectionTitle = $(this).data("title");
  });
  
  navigatorContainer.find(".form-item").removeClass("selected");
  navigatorContainer.find("[data-title='"+lastSectionTitle+"']").addClass("selected");
});
formContainer.scroll();

function navigationClick(e) {
  var title = $(this).data("title");
  var offset = formContainer.find("[data-title='"+title+"']").offset().top;
  
  if (offset) {
  	formContainer.animate({
      scrollTop: (formContainer.scrollTop() + offset - headerContainerHeight)
    }, 400);
  }
}

formContainer.find(".test-point").click(function() {
  $(this).toggleClass("selected");
});

$(".close-button").click(function(e) {
  var note = $(this).closest(".notes");
  note.removeClass("open");
  if (note.find(".note-input").text() !== "") {
    note.addClass("content");
  } else {
    note.removeClass("content");
  }
  e.stopPropagation();
})
$(".notes").click(function() {
  $this = $(this);
  if (!$this.hasClass("open")) {
    formContainer.find(".notes").removeClass("open");
    $this.addClass("open");
  }  
});

function createAnticoagulant() {
  var rowItem = $('<tr class="anticoagulant-item"><td><input type="text" name="name"/></td><td><input type="text" name="dosage"/></td><td><div class="delete-anticoagulant">x</div></td></tr>');
  
  rowItem.find("input").keyup(anticoagulantInputHandler);
  rowItem.find(".delete-anticoagulant").click(anticoagulantDelete);
  
  anticoagulantTable.find("tbody").append(rowItem);
}
function anticoagulantInputHandler() {
  if ($(this).closest("tr").is(":last-child")) {
    createAnticoagulant();
  }
}
function anticoagulantDelete() {
  $(this).closest("tr").remove();
}
createAnticoagulant();

formContainer.find(".feet-diagram .diagram-container").click(function(e) {
  if (e.target.nodeName == "IMG") {
    var feetDiagramContainer = $(this).closest(".feet-diagram-container");
    
    var index = feetDiagramContainer.data("index") || 0;
    index++;
    feetDiagramContainer.data("index", index);
    
    var id = Math.floor(Math.random()*1000);
    
    var type = feetDiagramContainer.data("type");
    var pin = $("<div class='feet-diagram-point' data-point-id='"+id+"'>"+index+"</div>");
    var $target = $(e.target);
    var offsetX = $target.hasClass("image-flip") ? $target.width() - e.offsetX -17.5 : e.offsetX -17.5;
    var offsetY = e.offsetY -35 -15;
    
    pin.draggable({
      create: function( event, ui ) {
        $(this).css({
          position: "absolute",
          top: offsetY,
          left: offsetX,
          zIndex: 2
        });
      },
      containment: "[data-type='"+type+"'] .diagram-container"
    });
    $(this).append(pin);
        
    var rowItem = $('<tbody data-point-id="'+id+'"><tr><td class="text-center vert-middle"><div class="feet-diagram-point">1</div></td><td><div class="add-picture">Add a picture</div></td><td class="diagram-note-input"><div contenteditable data-ph="Notes..."></div></td><td class="text-center vert-middle"><div class="delete-foot-point">x</div></td></tr></tbody>');
    
    rowItem.find(".feet-diagram-point").text(index);
    rowItem.find(".delete-foot-point").click(deleteFootPoint);
    
    feetDiagramContainer.find(".foot-diagram-notes").append(rowItem);
  }
});

function deleteFootPoint() {
  var $this = $(this);
  var pointId = $this.closest("tbody").data("point-id");
  
  var feetDiagramContainer = $this.closest(".feet-diagram-container");
  feetDiagramContainer.find("[data-point-id='"+pointId+"']").remove();
  
  var lastIndex = 0;
  feetDiagramContainer.find("tbody").each(function(index) {
    var rowItem = $(this);
    var id = rowItem.data("point-id");
    rowItem.find(".feet-diagram-point").text(index+1);
    feetDiagramContainer.find(".feet-diagram-point[data-point-id='"+id+"']").text(index+1);
    lastIndex = index+1;
    console.log(lastIndex)
  });
  feetDiagramContainer.data("index", lastIndex);
}

function saveForm() {
  var form = {};
  
  formContainer.find("[data-input-name]").each(function(index) {
    var $this = $(this);
    var key = $this.data("input-name");
    var type = $this.data("input-type");
    
    if (type == "checkbox") {
      if ($this.prop("checked")) {
      	form[key] = true;
      }
    } else if (type == "contenteditable") {
      var text = $this.text();
      if (text && text != "") {
      	form[key] = text;
      }
    } else if (type == "multi-select") {
      var selectedItems;
      $this.find("[data-value]").each(function(multi_index) {
        var selectItem = $(this);
        if (selectItem.hasClass("selected")) {
          selectedItems = selectedItems || {};
          selectedItems[selectItem.data("value")] = true;
        }
      });
      if (selectedItems) {
      	form[key] = selectedItems;
      }
    } else if (type == "multi-select-radio") {
      var value = $this.find(".selected").data("value");
      if (value) {
      	form[key] = value;
      }
    } else if (type == "select") {
      var value = $this.val();
      if (value && value != "") {
      	form[key] = value;
      }
    } else if (type == "semmes-point") {
      var selected = $this.hasClass("selected");
      if (selected) {
      	form[key] = selected;
      }
    }
  });
  
  var anticoagulants = [];
  anticoagulantTable.find("tr.anticoagulant-item").each(function(index) {
    var rowItem = $(this);
    var name = rowItem.find("[name='name']").val();
    var dosage = rowItem.find("[name='dosage']").val();
    anticoagulants.push({name: name, dosage: dosage});
  });
  anticoagulants.pop();
  if (anticoagulants.length > 0) {
    form.anticoagulants = anticoagulants;
  }
  
  formContainer.find(".feet-diagram-container").each(function(index) {
    var feetDiagramContainer = $(this);
    var type = feetDiagramContainer.data("type");
    
    var diagramContainer = feetDiagramContainer.find(".diagram-container");
    var diagramContainerWidth = diagramContainer.width();
    var diagramContainerHeight = diagramContainer.height();
    
    var points = [];
    feetDiagramContainer.find("tbody[data-point-id]").each(function(note_index) {
      var rowItem = $(this);
      var pointId = rowItem.data("point-id");
      var note = rowItem.find(".diagram-note-input [contenteditable]").text();
      var diagramPoint = feetDiagramContainer.find(".feet-diagram-point[data-point-id='"+pointId+"']");
      
      points.push({
        note: note,
        left: (diagramPoint.position().left +17.5) / diagramContainerWidth,
        top: (diagramPoint.position().top +35 +15) / diagramContainerHeight
      });
    });
    
    if (points.length > 0) {
      form[type+"_notes"] = points;
    }
  });
  
  console.log("form data",form)
}
$(".save-button").click(function() {
	saveForm();
});
              
            
!
999px

Console