interface/patient_file/summary/demographics_full.php

   1 <?php
   2  include_once("../../globals.php");
   3  include_once("$srcdir/acl.inc");
   4  include_once("$srcdir/options.inc.php");
   5
   6  // Session pid must be right or bad things can happen when demographics are saved!
   7  //
   8  include_once("$srcdir/pid.inc");
   9  $set_pid = $_GET["set_pid"] ? $_GET["set_pid"] : $_GET["pid"];
  10  if ($set_pid && $set_pid != $_SESSION["pid"]) {
  11   setpid($set_pid);
  12  }
  13
  14  include_once("$srcdir/patient.inc");
  15
  16  $result = getPatientData($pid, "*, DATE_FORMAT(DOB,'%Y-%m-%d') as DOB_YMD");
  17  $result2 = getEmployerData($pid);
  18
  19  // Check authorization.
  20  $thisauth = acl_check('patients', 'demo');
  21  if ($pid) {
  22   if ($thisauth != 'write')
  23    die(xl('Updating demographics is not authorized.'));
  24   if ($result['squad'] && ! acl_check('squads', $result['squad']))
  25    die(xl('You are not authorized to access this squad.'));
  26  } else {
  27   if ($thisauth != 'write' && $thisauth != 'addonly')
  28    die(xl('Adding demographics is not authorized.'));
  29  }
  30
  31 $CPR = 4; // cells per row
  32
  33 // $statii = array('married','single','divorced','widowed','separated','domestic partner');
  34 // $langi = getLanguages();
  35 // $ethnoraciali = getEthnoRacials();
  36 // $provideri = getProviderInfo();
  37
  38 $insurancei = getInsuranceProviders();
  39
  40 $fres = sqlStatement("SELECT * FROM layout_options " .
  41   "WHERE form_id = 'DEM' AND uor > 0 " .
  42   "ORDER BY group_name, seq");
  43 ?>
  44 <html>
  45 <head>
  46 <?php html_header_show();?>
  47
  48 <link rel="stylesheet" href="<?php echo $css_header; ?>" type="text/css">
  49
  50 <style>
  51 body, td, input, select, textarea {
  52  font-family: Arial, Helvetica, sans-serif;
  53  font-size: 10pt;
  54 }
  55
  56 body {
  57  padding: 5pt 5pt 5pt 5pt;
  58 }
  59
  60 div.section {
  61  border: solid;
  62  border-width: 1px;
  63  border-color: #0000ff;
  64  margin: 0 0 0 10pt;
  65  padding: 5pt;
  66 }
  67
  68 </style>
  69
  70 <style type="text/css">@import url(../../../library/dynarch_calendar.css);</style>
  71
  72 <script type="text/javascript" src="../../../library/dialog.js"></script>
  73 <script type="text/javascript" src="../../../library/textformat.js"></script>
  74 <script type="text/javascript" src="../../../library/dynarch_calendar.js"></script>
  75 <script type="text/javascript" src="../../../library/dynarch_calendar_en.js"></script>
  76 <script type="text/javascript" src="../../../library/dynarch_calendar_setup.js"></script>
  77
  78 <script type="text/javascript" src="<?php echo $GLOBALS['webroot'] ?>/library/js/jquery.js"></script>
  79
  80 <SCRIPT LANGUAGE="JavaScript"><!--
  81
  82 var mypcc = '<?php echo $GLOBALS['phone_country_code'] ?>';
  83
  84 //code used from http://tech.irt.org/articles/js037/
  85 function replace(string,text,by) {
  86  // Replaces text with by in string
  87  var strLength = string.length, txtLength = text.length;
  88  if ((strLength == 0) || (txtLength == 0)) return string;
  89
  90  var i = string.indexOf(text);
  91  if ((!i) && (text != string.substring(0,txtLength))) return string;
  92  if (i == -1) return string;
  93
  94  var newstr = string.substring(0,i) + by;
  95
  96  if (i+txtLength < strLength)
  97   newstr += replace(string.substring(i+txtLength,strLength),text,by);
  98
  99  return newstr;
 100 }
 101
 102 function upperFirst(string,text) {
 103  return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
 104 }
 105
 106 <?php for ($i=1;$i<=3;$i++) { ?>
 107 function auto_populate_employer_address<?php echo $i ?>(){
 108  var f = document.demographics_form;
 109  if (f.form_i<?php echo $i?>subscriber_relationship.options[f.form_i<?php echo $i?>subscriber_relationship.selectedIndex].value == "self") {
 110   f.i<?php echo $i?>subscriber_fname.value=f.form_fname.value;
 111   f.i<?php echo $i?>subscriber_mname.value=f.form_mname.value;
 112   f.i<?php echo $i?>subscriber_lname.value=f.form_lname.value;
 113   f.i<?php echo $i?>subscriber_street.value=f.form_street.value;
 114   f.i<?php echo $i?>subscriber_city.value=f.form_city.value;
 115   f.form_i<?php echo $i?>subscriber_state.value=f.form_state.value;
 116   f.i<?php echo $i?>subscriber_postal_code.value=f.form_postal_code.value;
 117   if (f.form_country_code)
 118     f.form_i<?php echo $i?>subscriber_country.value=f.form_country_code.value;
 119   f.i<?php echo $i?>subscriber_phone.value=f.form_phone_home.value;
 120   f.i<?php echo $i?>subscriber_DOB.value=f.form_DOB.value;
 121   f.i<?php echo $i?>subscriber_ss.value=f.form_ss.value;
 122   f.form_i<?php echo $i?>subscriber_sex.value = f.form_sex.value;
 123   f.i<?php echo $i?>subscriber_employer.value=f.form_em_name.value;
 124   f.i<?php echo $i?>subscriber_employer_street.value=f.form_em_street.value;
 125   f.i<?php echo $i?>subscriber_employer_city.value=f.form_em_city.value;
 126   f.form_i<?php echo $i?>subscriber_employer_state.value=f.form_em_state.value;
 127   f.i<?php echo $i?>subscriber_employer_postal_code.value=f.form_em_postal_code.value;
 128   if (f.form_em_country)
 129     f.form_i<?php echo $i?>subscriber_employer_country.value=f.form_em_country.value;
 130  }
 131 }
 132
 133 <?php } ?>
 134
 135 function popUp(URL) {
 136  day = new Date();
 137  id = day.getTime();
 138  top.restoreSession();
 139  eval("page" + id + " = window.open(URL, '" + id + "', 'toolbar=0,scrollbars=1,location=0,statusbar=0,menubar=0,resizable=1,width=400,height=300,left = 440,top = 362');");
 140 }
 141
 142 function checkNum () {
 143  var re= new RegExp();
 144  re = /^\d*\.?\d*$/;
 145  str=document.demographics_form.monthly_income.value;
 146  if(re.exec(str))
 147  {
 148  }else{
 149   alert("<?php xl('Please enter a monetary amount using only numbers and a decimal point.','e'); ?>");
 150  }
 151 }
 152
 153 // Indicates which insurance slot is being updated.
 154 var insurance_index = 0;
 155
 156 // The OnClick handler for searching/adding the insurance company.
 157 function ins_search(ins) {
 158  insurance_index = ins;
 159  dlgopen('../../practice/ins_search.php', '_blank', 550, 400);
 160  return false;
 161 }
 162
 163 // The ins_search.php window calls this to set the selected insurance.
 164 function set_insurance(ins_id, ins_name) {
 165  var thesel = document.forms[0]['i' + insurance_index + 'provider'];
 166  var theopts = thesel.options; // the array of Option objects
 167  var i = 0;
 168  for (; i < theopts.length; ++i) {
 169   if (theopts[i].value == ins_id) {
 170    theopts[i].selected = true;
 171    return;
 172   }
 173  }
 174  // no matching option was found so create one, append it to the
 175  // end of the list, and select it.
 176  theopts[i] = new Option(ins_name, ins_id, false, true);
 177 }
 178
 179 // This capitalizes the first letter of each word in the passed input
 180 // element.  It also strips out extraneous spaces.
 181 function capitalizeMe(elem) {
 182  var a = elem.value.split(' ');
 183  var s = '';
 184  for(var i = 0; i < a.length; ++i) {
 185   if (a[i].length > 0) {
 186    if (s.length > 0) s += ' ';
 187    s += a[i].charAt(0).toUpperCase() + a[i].substring(1);
 188   }
 189  }
 190  elem.value = s;
 191 }
 192
 193 function divclick(cb, divid) {
 194  var divstyle = document.getElementById(divid).style;
 195  if (cb.checked) {
 196   divstyle.display = 'block';
 197  } else {
 198   divstyle.display = 'none';
 199  }
 200  return true;
 201 }
 202
 203 // Compute the length of a string without leading and trailing spaces.
 204 function trimlen(s) {
 205  var i = 0;
 206  var j = s.length - 1;
 207  for (; i <= j && s.charAt(i) == ' '; ++i);
 208  for (; i <= j && s.charAt(j) == ' '; --j);
 209  if (i > j) return 0;
 210  return j + 1 - i;
 211 }
 212
 213 function validate(f) {
 214 <?php generate_layout_validation('DEM'); ?>
 215
 216 // Some insurance validation.
 217  for (var i = 1; i <= 3; ++i) {
 218   subprov = 'i' + i + 'provider';
 219   if (!f[subprov] || f[subprov].selectedIndex <= 0) continue;
 220   var subpfx = 'i' + i + 'subscriber_';
 221   var subrelat = f['form_' + subpfx + 'relationship'];
 222   var samename =
 223    f[subpfx + 'fname'].value == f.form_fname.value &&
 224    f[subpfx + 'mname'].value == f.form_mname.value &&
 225    f[subpfx + 'lname'].value == f.form_lname.value;
 226   var samess = f[subpfx + 'ss'].value == f.form_ss.value;
 227   if (subrelat.options[subrelat.selectedIndex].value == "self") {
 228    if (!samename) {
 229     if (!confirm("<?php xl('Subscriber relationship is self but name is different! Is this really OK?','e'); ?>"))
 230      return false;
 231    }
 232    if (!samess) {
 233     alert("<?php xl('Subscriber relationship is self but SS number is different!','e'); ?>");
 234     return false;
 235    }
 236   } // end self
 237   else {
 238    if (samename) {
 239     if (!confirm("<?php xl('Subscriber relationship is not self but name is the same! Is this really OK?','e'); ?>"))
 240      return false;
 241    }
 242    if (samess) {
 243     alert("<?php xl('Subscriber relationship is not self but SS number is the same!','e'); ?>");
 244     return false;
 245    }
 246   } // end not self
 247  } // end for
 248
 249  return true;
 250 }
 251
 252 function submitme() {
 253  var f = document.forms[0];
 254  if (validate(f)) {
 255   top.restoreSession();
 256   f.submit();
 257  }
 258 }
 259
 260 // Onkeyup handler for policy number.  Allows only A-Z and 0-9.
 261 function policykeyup(e) {
 262  var v = e.value.toUpperCase();
 263  for (var i = 0; i < v.length; ++i) {
 264   var c = v.charAt(i);
 265   if (c >= '0' && c <= '9') continue;
 266   if (c >= 'A' && c <= 'Z') continue;
 267   v = v.substring(0, i) + v.substring(i + i);
 268   --i;
 269  }
 270  e.value = v;
 271  return;
 272 }
 273
 274 // Added 06/2009 by BM to make compatible with list_options table and functions - using jquery
 275 $(document).ready(function() {
 276
 277  <?php for ($i=1;$i<=3;$i++) { ?>
 278   $("#form_i<?php echo $i?>subscriber_relationship").change(function() { auto_populate_employer_address<?php echo $i?>(); });
 279  <?php } ?>
 280
 281 });
 282
 283 //-->
 284
 285 </script>
 286 </head>
 287
 288 <body class="body_top">
 289
 290 <form action='demographics_save.php' name='demographics_form' method='post' onsubmit='return validate(this)'>
 291 <input type='hidden' name='mode' value='save' />
 292 <input type='hidden' name='db_id' value="<?php echo $result['id']?>" />
 293
 294 <?php if ($GLOBALS['concurrent_layout']) { ?>
 295 <a href="demographics.php" onclick="top.restoreSession()">
 296 <?php } else { ?>
 297 <a href="patient_summary.php" target="Main" onclick="top.restoreSession()">
 298 <?php } ?>
 299 <font class=title><?php xl('Demographics','e'); ?></font>
 300 <font class=back><?php echo $tback;?></font></a>
 301
 302 <?php
 303
 304 function end_cell() {
 305   global $item_count, $cell_count;
 306   if ($item_count > 0) {
 307     echo "</td>";
 308     $item_count = 0;
 309   }
 310 }
 311
 312 function end_row() {
 313   global $cell_count, $CPR;
 314   end_cell();
 315   if ($cell_count > 0) {
 316     for (; $cell_count < $CPR; ++$cell_count) echo "<td></td>";
 317     echo "</tr>\n";
 318     $cell_count = 0;
 319   }
 320 }
 321
 322 function end_group() {
 323   global $last_group;
 324   if (strlen($last_group) > 0) {
 325     end_row();
 326     echo " </table>\n";
 327     echo "</div>\n";
 328   }
 329 }
 330
 331 $last_group = '';
 332 $cell_count = 0;
 333 $item_count = 0;
 334 $display_style = 'block';
 335
 336 $group_seq=0; // this gives the DIV blocks unique IDs
 337
 338 while ($frow = sqlFetchArray($fres)) {
 339   $this_group = $frow['group_name'];
 340   $titlecols  = $frow['titlecols'];
 341   $datacols   = $frow['datacols'];
 342   $data_type  = $frow['data_type'];
 343   $field_id   = $frow['field_id'];
 344   $list_id    = $frow['list_id'];
 345   $currvalue  = '';
 346
 347   if (strpos($field_id, 'em_') === 0) {
 348     $tmp = substr($field_id, 3);
 349     if (isset($result2[$tmp])) $currvalue = $result2[$tmp];
 350   }
 351   else {
 352     if (isset($result[$field_id])) $currvalue = $result[$field_id];
 353   }
 354
 355   // Handle a data category (group) change.
 356   if (strcmp($this_group, $last_group) != 0) {
 357     end_group();
 358     //$group_seq  = substr($this_group, 0, 1);  -- replaced by a simple counter
 359     $group_seq++;    // ID for DIV tags
 360     $group_name = substr($this_group, 1);
 361     $last_group = $this_group;
 362     echo "<br /><span class='bold'><input type='checkbox' name='form_cb_$group_seq' value='1' " .
 363       "onclick='return divclick(this,\"div_$group_seq\");'";
 364     if ($display_style == 'block') echo " checked";
 365
 366     // Modified 6-09 by BM - Translate if applicable
 367     echo " /><b>" . xl_layout_label($group_name) . "</b></span>\n";
 368
 369     echo "<div id='div_$group_seq' class='section' style='display:$display_style;'>\n";
 370     echo " <table border='0' cellpadding='0'>\n";
 371     $display_style = 'none';
 372   }
 373
 374   // Handle starting of a new row.
 375   if (($titlecols > 0 && $cell_count >= $CPR) || $cell_count == 0) {
 376     end_row();
 377     echo "  <tr>";
 378   }
 379
 380   if ($item_count == 0 && $titlecols == 0) $titlecols = 1;
 381
 382   // Handle starting of a new label cell.
 383   if ($titlecols > 0) {
 384     end_cell();
 385     echo "<td colspan='$titlecols'";
 386     echo ($frow['uor'] == 2) ? " class='required'" : " class='bold'";
 387     if ($cell_count == 2) echo " style='padding-left:10pt'";
 388     echo ">";
 389     $cell_count += $titlecols;
 390   }
 391   ++$item_count;
 392
 393   echo "<b>";
 394
 395   // Modified 6-09 by BM - Translate if applicable
 396   if ($frow['title']) echo (xl_layout_label($frow['title']).":"); else echo "&nbsp;";
 397
 398   echo "</b>";
 399
 400   // Handle starting of a new data cell.
 401   if ($datacols > 0) {
 402     end_cell();
 403     echo "<td colspan='$datacols' class='text'";
 404     if ($cell_count > 0) echo " style='padding-left:5pt'";
 405     echo ">";
 406     $cell_count += $datacols;
 407   }
 408
 409   ++$item_count;
 410   generate_form_field($frow, $currvalue);
 411 }
 412
 413 end_group();
 414
 415  if (! $GLOBALS['simplified_demographics']) {
 416   $insurance_headings = array(xl("Primary Insurance Provider"), xl("Secondary Insurance Provider"), xl("Tertiary Insurance provider"));
 417   $insurance_info = array();
 418   $insurance_info[1] = getInsuranceData($pid,"primary");
 419   $insurance_info[2] = getInsuranceData($pid,"secondary");
 420   $insurance_info[3] = getInsuranceData($pid,"tertiary");
 421
 422   echo "<br /><span class='bold'><input type='checkbox' name='form_cb_ins' value='1' " .
 423     "onclick='return divclick(this,\"div_ins\");'";
 424   if ($display_style == 'block') echo " checked";
 425   echo " /><b>" . xl('Insurance') . "</b></span>\n";
 426   echo "<div id='div_ins' class='section' style='display:$display_style;'>\n";
 427
 428   for($i=1;$i<=3;$i++) {
 429    $result3 = $insurance_info[$i];
 430 ?>
 431 <table border="0">
 432  <tr>
 433   <td valign='top' colspan='2'>
 434    <span class='required'><?php echo $insurance_headings[$i -1].":"?></span>
 435    <select name="i<?php echo $i?>provider">
 436     <option value=""><?php xl('Unassigned','e'); ?></option>
 437 <?php
 438  foreach ($insurancei as $iid => $iname) {
 439   echo "<option value='" . $iid . "'";
 440   if (strtolower($iid) == strtolower($result3{"provider"}))
 441    echo " selected";
 442   echo ">" . $iname . "</option>\n";
 443  }
 444 ?>
 445    </select>&nbsp;<a href='' onclick='return ins_search(<?php echo $i?>)'>
 446    <?php xl('Search/Add Insurer','e'); ?></a>
 447   </td>
 448  </tr>
 449
 450  <tr>
 451   <td valign=top>
 452    <table border="0">
 453
 454     <tr>
 455      <td>
 456       <span class='required'><?php xl('Plan Name','e'); ?>: </span>
 457      </td>
 458      <td>
 459       <input type='entry' size='20' name='i<?php echo $i?>plan_name' value="<?php echo $result3{"plan_name"} ?>"
 460        onchange="capitalizeMe(this);" />&nbsp;&nbsp;
 461      </td>
 462     </tr>
 463
 464     <tr>
 465      <td>
 466       <span class='required'><?php xl('Effective Date','e'); ?>: </span>
 467      </td>
 468      <td>
 469       <input type='entry' size='11' id='i<?php echo $i ?>effective_date' name='i<?php echo $i ?>effective_date'
 470        value='<?php echo $result3['date'] ?>'
 471        onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)'
 472        title='yyyy-mm-dd' />
 473      <img src='../../pic/show_calendar.gif' align='absbottom' width='24' height='22' id='img_i<?php echo $i ?>effective_date' border='0' alt='[?]' style='cursor:pointer' title='<?php xl('Click here to choose a date','e'); ?>'>
 474      </td>
 475     </tr>
 476
 477     <tr>
 478      <td><span class=required><?php xl('Policy Number','e'); ?>: </span></td>
 479      <td><input type='entry' size='16' name='i<?php echo $i?>policy_number' value="<?php echo $result3{"policy_number"}?>"
 480       onkeyup='policykeyup(this)'></td>
 481     </tr>
 482
 483     <tr>
 484      <td><span class=required><?php xl('Group Number','e'); ?>: </span></td><td><input type=entry size=16 name=i<?php echo $i?>group_number value="<?php echo $result3{"group_number"}?>"></td>
 485     </tr>
 486
 487     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 488      <td class='required'><?php xl('Subscriber Employer (SE)','e'); ?><br><span style='font-weight:normal'>
 489       (<?php xl('if unemployed enter Student','e'); ?>,<br><?php xl('PT Student, or leave blank','e'); ?>): </span></td>
 490      <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer
 491       value="<?php echo $result3{"subscriber_employer"}?>"
 492        onchange="capitalizeMe(this);" /></td>
 493     </tr>
 494
 495     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 496      <td><span class=required><?php xl('SE Address','e'); ?>: </span></td>
 497      <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer_street
 498       value="<?php echo $result3{"subscriber_employer_street"}?>"
 499        onchange="capitalizeMe(this);" /></td>
 500     </tr>
 501
 502     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 503      <td colspan="2">
 504       <table>
 505        <tr>
 506         <td><span class=required><?php xl('SE City','e'); ?>: </span></td>
 507         <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_city
 508          value="<?php echo $result3{"subscriber_employer_city"}?>"
 509           onchange="capitalizeMe(this);" /></td>
 510         <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE State','e') : xl('SE Locality','e') ?>: </span></td>
 511         <td>
 512          <?php
 513           // Modified 7/2009 by BM to incorporate data types
 514           generate_form_field(array('data_type'=>$GLOBALS['state_data_type'],'field_id'=>('i'.$i.'subscriber_employer_state'),'list_id'=>$GLOBALS['state_list'],'fld_length'=>'15','max_length'=>'63','edit_options'=>'C'), $result3['subscriber_employer_state']);
 515          ?>
 516         </td>
 517        </tr>
 518        <tr>
 519         <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE Zip Code','e') : xl('SE Postal Code','e') ?>: </span></td>
 520         <td><input type=entry size=10 name=i<?php echo $i?>subscriber_employer_postal_code value="<?php echo $result3{"subscriber_employer_postal_code"}?>"></td>
 521         <td><span class=required><?php xl('SE Country','e'); ?>: </span></td>
 522         <td>
 523          <?php
 524           // Modified 7/2009 by BM to incorporate data types
 525           generate_form_field(array('data_type'=>$GLOBALS['country_data_type'],'field_id'=>('i'.$i.'subscriber_employer_country'),'list_id'=>$GLOBALS['country_list'],'fld_length'=>'10','max_length'=>'63','edit_options'=>'C'), $result3['subscriber_employer_country']);
 526          ?>
 527         </td>
 528        </tr>
 529       </table>
 530      </td>
 531     </tr>
 532
 533    </table>
 534   </td>
 535
 536   <td valign=top>
 537    <span class=required><?php xl('Subscriber','e'); ?>: </span>
 538    <input type=entry size=10 name=i<?php echo $i?>subscriber_fname
 539     value="<?php echo $result3{"subscriber_fname"}?>"
 540     onchange="capitalizeMe(this);" />
 541    <input type=entry size=3 name=i<?php echo $i?>subscriber_mname
 542     value="<?php echo $result3{"subscriber_mname"}?>"
 543     onchange="capitalizeMe(this);" />
 544    <input type=entry size=10 name=i<?php echo $i?>subscriber_lname
 545     value="<?php echo $result3{"subscriber_lname"}?>"
 546     onchange="capitalizeMe(this);" />
 547    <br>
 548    <span class=required><?php xl('Relationship','e'); ?>: </span>
 549    <?php
 550     // Modified 6/2009 by BM to use list_options and function
 551     generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_relationship'),'list_id'=>'sub_relation','empty_title'=>''), $result3['subscriber_relationship']);
 552    ?>
 553    <a href="javascript:popUp('browse.php?browsenum=<?php echo $i?>')" class=text>(<?php xl('Browse','e'); ?>)</a><br />
 554    <span class=bold><?php xl('D.O.B.','e'); ?>: </span>
 555    <input type='entry' size='11' id='i<?php echo $i?>subscriber_DOB' name='i<?php echo $i?>subscriber_DOB'
 556     value='<?php echo $result3['subscriber_DOB'] ?>'
 557     onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)'
 558     title='yyyy-mm-dd' />
 559
 560    <img src='../../pic/show_calendar.gif' align='absbottom' width='24' height='22'
 561     id='img_i<?php echo $i; ?>dob_date' border='0' alt='[?]' style='cursor:pointer'
 562     title='<?php xl('Click here to choose a date','e'); ?>'>
 563
 564    <span class=bold><?php xl('S.S.','e'); ?>: </span><input type=entry size=11 name=i<?php echo $i?>subscriber_ss value="<?php echo $result3{"subscriber_ss"}?>">&nbsp;
 565    <span class=bold><?php xl('Sex','e'); ?>: </span>
 566    <?php
 567     // Modified 6/2009 by BM to use list_options and function
 568     generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_sex'),'list_id'=>'sex'), $result3['subscriber_sex']);
 569    ?>
 570    <br>
 571    <span class=required><?php xl('Subscriber Address','e'); ?>: </span>
 572    <input type=entry size=25 name=i<?php echo $i?>subscriber_street
 573     value="<?php echo $result3{"subscriber_street"}?>"
 574     onchange="capitalizeMe(this);" /><br>
 575    <span class=required><?php xl('City','e'); ?>: </span>
 576    <input type=entry size=15 name=i<?php echo $i?>subscriber_city
 577     value="<?php echo $result3{"subscriber_city"}?>"
 578     onchange="capitalizeMe(this);" />
 579    <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('State','e') : xl('Locality','e') ?>: </span>
 580    <?php
 581     // Modified 7/2009 by BM to incorporate data types
 582     generate_form_field(array('data_type'=>$GLOBALS['state_data_type'],'field_id'=>('i'.$i.'subscriber_state'),'list_id'=>$GLOBALS['state_list'],'fld_length'=>'15','max_length'=>'63','edit_options'=>'C'), $result3['subscriber_state']);
 583    ?>
 584    <br />
 585    <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('Zip Code','e') : xl('Postal Code','e') ?>: </span><input type=entry size=10 name=i<?php echo $i?>subscriber_postal_code value="<?php echo $result3{"subscriber_postal_code"}?>">
 586    <span class='required'<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 587    <?php xl('Country','e'); ?>: </span>
 588    <?php
 589     // Modified 7/2009 by BM to incorporate data types
 590     generate_form_field(array('data_type'=>$GLOBALS['country_data_type'],'field_id'=>('i'.$i.'subscriber_country'),'list_id'=>$GLOBALS['country_list'],'fld_length'=>'10','max_length'=>'63','edit_options'=>'C'), $result3['subscriber_country']);
 591    ?>
 592    <br />
 593    <span class=bold><?php xl('Subscriber Phone','e'); ?>:
 594    <input type='text' size='20' name='i<?php echo $i?>subscriber_phone' value='<?php echo $result3["subscriber_phone"] ?>' onkeyup='phonekeyup(this,mypcc)' />
 595    </span><br />
 596    <span class=bold><?php xl('CoPay','e'); ?>: <input type=text size="6" name=i<?php echo $i?>copay value="<?php echo $result3{"copay"}?>">
 597    </span><br />
 598    <span class='required'><?php xl('Accept Assignment','e'); ?>: </span>
 599    <select name=i<?php echo $i?>accept_assignment>
 600      <option value="TRUE" <?php if (strtoupper($result3{"accept_assignment"}) == "TRUE") echo "selected"?>><?php xl('YES','e'); ?></option>
 601      <option value="FALSE" <?php if (strtoupper($result3{"accept_assignment"}) == "FALSE") echo "selected"?>><?php xl('NO','e'); ?></option>
 602    </select>
 603   </td>
 604  </tr>
 605 </table>
 606
 607 <?php
 608     if ($i < 3) echo "<hr />\n";
 609   } //end insurer for loop
 610   echo "</div>\n";
 611  } // end of "if not simplified_demographics"
 612 ?>
 613
 614 <center><br />
 615 <a href="javascript:submitme();"
 616  class='link_submit'>[<?php xl('Save Patient Demographics','e'); ?>]</a>
 617 </center>
 618
 619 </form>
 620
 621 <br>
 622
 623 <script language="JavaScript">
 624
 625  // fix inconsistently formatted phone numbers from the database
 626  var f = document.forms[0];
 627  if (f.form_phone_contact) phonekeyup(f.form_phone_contact,mypcc);
 628  if (f.form_phone_home   ) phonekeyup(f.form_phone_home   ,mypcc);
 629  if (f.form_phone_biz    ) phonekeyup(f.form_phone_biz    ,mypcc);
 630  if (f.form_phone_cell   ) phonekeyup(f.form_phone_cell   ,mypcc);
 631
 632 <?php if (! $GLOBALS['simplified_demographics']) { ?>
 633  phonekeyup(f.i1subscriber_phone,mypcc);
 634  phonekeyup(f.i2subscriber_phone,mypcc);
 635  phonekeyup(f.i3subscriber_phone,mypcc);
 636 <?php } ?>
 637
 638 <?php if ($GLOBALS['concurrent_layout'] && $set_pid) { ?>
 639  parent.left_nav.setPatient(<?php echo "'" . addslashes($result['fname']) . " " . addslashes($result['lname']) . "',$pid,'" . addslashes($result['pubpid']) . "','', ' ".xl('DOB').": ".$result['DOB_YMD']." ".xl('Age').": ".getPatientAge($result['DOB_YMD'])."'"; ?>);
 640  parent.left_nav.setRadio(window.name, 'dem');
 641 <?php } ?>
 642
 643 <?php echo $date_init; ?>
 644 <?php if (! $GLOBALS['simplified_demographics']) { for ($i=1; $i<=3; $i++): ?>
 645  Calendar.setup({inputField:"i<?php echo $i?>effective_date", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i?>effective_date"});
 646  Calendar.setup({inputField:"i<?php echo $i?>subscriber_DOB", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i?>dob_date"});
 647 <?php endfor; } ?>
 648 </script>
 649
 650 <!-- include support for the list-add selectbox feature -->
 651 <?php include $GLOBALS['fileroot']."/library/options_listadd.inc"; ?>
 652
 653 </body>
 654
 655 </html>