interface/new/new_comprehensive.php

   1 <?php
   2 // Copyright (C) 2009-2010 Rod Roark <rod@sunsetsystems.com>
   3 //
   4 // This program is free software; you can redistribute it and/or
   5 // modify it under the terms of the GNU General Public License
   6 // as published by the Free Software Foundation; either version 2
   7 // of the License, or (at your option) any later version.
   8
   9 require_once("../globals.php");
  10 require_once("$srcdir/acl.inc");
  11 require_once("$srcdir/options.inc.php");
  12 require_once("$srcdir/patient.inc");
  13 require_once("$srcdir/erx_javascript.inc.php");
  14
  15 // Check authorization.
  16 if (!acl_check('patients','demo','',array('write','addonly') ))
  17   die("Adding demographics is not authorized.");
  18
  19 $CPR = 4; // cells per row
  20
  21 $searchcolor = empty($GLOBALS['layout_search_color']) ?
  22   '#ffff55' : $GLOBALS['layout_search_color'];
  23
  24 $WITH_SEARCH = ($GLOBALS['full_new_patient_form'] == '1' || $GLOBALS['full_new_patient_form'] == '2');
  25 $SHORT_FORM  = ($GLOBALS['full_new_patient_form'] == '2' || $GLOBALS['full_new_patient_form'] == '3');
  26
  27 function getLayoutRes() {
  28   global $SHORT_FORM;
  29   return sqlStatement("SELECT * FROM layout_options " .
  30     "WHERE form_id = 'DEM' AND uor > 0 AND field_id != '' " .
  31     ($SHORT_FORM ? "AND ( uor > 1 OR edit_options LIKE '%N%' ) " : "") .
  32     "ORDER BY group_name, seq");
  33 }
  34
  35 // Determine layout field search treatment from its data type:
  36 // 1 = text field
  37 // 2 = select list
  38 // 0 = not searchable
  39 //
  40 function getSearchClass($data_type) {
  41   switch($data_type) {
  42     case  1: // single-selection list
  43     case 10: // local provider list
  44     case 11: // provider list
  45     case 12: // pharmacy list
  46     case 13: // squads
  47     case 14: // address book list
  48     case 26: // single-selection list with add
  49     case 35: // facilities
  50       return 2;
  51     case  2: // text field
  52     case  3: // textarea
  53     case  4: // date
  54       return 1;
  55   }
  56   return 0;
  57 }
  58
  59 $fres = getLayoutRes();
  60 ?>
  61 <html>
  62 <head>
  63 <?php html_header_show(); ?>
  64
  65 <link rel="stylesheet" href="<?php echo $css_header; ?>" type="text/css">
  66
  67 <style>
  68 body, td, input, select, textarea {
  69  font-family: Arial, Helvetica, sans-serif;
  70  font-size: 10pt;
  71 }
  72
  73 body {
  74  padding: 5pt 5pt 5pt 5pt;
  75 }
  76
  77 div.section {
  78  border: solid;
  79  border-width: 1px;
  80  border-color: #0000ff;
  81  margin: 0 0 0 10pt;
  82  padding: 5pt;
  83 }
  84
  85 </style>
  86
  87 <style type="text/css">@import url(../../library/dynarch_calendar.css);</style>
  88
  89 <script type="text/javascript" src="../../library/dialog.js"></script>
  90 <script type="text/javascript" src="../../library/textformat.js"></script>
  91 <script type="text/javascript" src="../../library/dynarch_calendar.js"></script>
  92 <?php include_once("{$GLOBALS['srcdir']}/dynarch_calendar_en.inc.php"); ?>
  93 <script type="text/javascript" src="../../library/dynarch_calendar_setup.js"></script>
  94 <script type="text/javascript" src="<?php echo $GLOBALS['webroot']; ?>/library/js/jquery.js"></script>
  95
  96 <SCRIPT LANGUAGE="JavaScript"><!--
  97 //Visolve - sync the radio buttons - Start
  98 if((top.window.parent) && (parent.window)){
  99         var wname = top.window.parent.left_nav;
 100         fname = (parent.window.name)?parent.window.name:window.name;
 101         wname.syncRadios();
 102         wname.setRadio(fname, "new");
 103 }//Visolve - sync the radio buttons - End
 104
 105 var mypcc = '<?php echo $GLOBALS['phone_country_code'] ?>';
 106
 107 // This may be changed to true by the AJAX search script.
 108 var force_submit = false;
 109
 110 //code used from http://tech.irt.org/articles/js037/
 111 function replace(string,text,by) {
 112  // Replaces text with by in string
 113  var strLength = string.length, txtLength = text.length;
 114  if ((strLength == 0) || (txtLength == 0)) return string;
 115
 116  var i = string.indexOf(text);
 117  if ((!i) && (text != string.substring(0,txtLength))) return string;
 118  if (i == -1) return string;
 119
 120  var newstr = string.substring(0,i) + by;
 121
 122  if (i+txtLength < strLength)
 123   newstr += replace(string.substring(i+txtLength,strLength),text,by);
 124
 125  return newstr;
 126 }
 127
 128 <?php for ($i=1;$i<=3;$i++) { ?>
 129 function auto_populate_employer_address<?php echo $i ?>(){
 130  var f = document.demographics_form;
 131  if (f.form_i<?php echo $i?>subscriber_relationship.options[f.form_i<?php echo $i?>subscriber_relationship.selectedIndex].value == "self") {
 132   f.i<?php echo $i?>subscriber_fname.value=f.form_fname.value;
 133   f.i<?php echo $i?>subscriber_mname.value=f.form_mname.value;
 134   f.i<?php echo $i?>subscriber_lname.value=f.form_lname.value;
 135   f.i<?php echo $i?>subscriber_street.value=f.form_street.value;
 136   f.i<?php echo $i?>subscriber_city.value=f.form_city.value;
 137   f.form_i<?php echo $i?>subscriber_state.value=f.form_state.value;
 138   f.i<?php echo $i?>subscriber_postal_code.value=f.form_postal_code.value;
 139   if (f.form_country_code)
 140     f.form_i<?php echo $i?>subscriber_country.value=f.form_country_code.value;
 141   f.i<?php echo $i?>subscriber_phone.value=f.form_phone_home.value;
 142   f.i<?php echo $i?>subscriber_DOB.value=f.form_DOB.value;
 143   f.i<?php echo $i?>subscriber_ss.value=f.form_ss.value;
 144   f.form_i<?php echo $i?>subscriber_sex.value = f.form_sex.value;
 145   f.i<?php echo $i?>subscriber_employer.value=f.form_em_name.value;
 146   f.i<?php echo $i?>subscriber_employer_street.value=f.form_em_street.value;
 147   f.i<?php echo $i?>subscriber_employer_city.value=f.form_em_city.value;
 148   f.form_i<?php echo $i?>subscriber_employer_state.value=f.form_em_state.value;
 149   f.i<?php echo $i?>subscriber_employer_postal_code.value=f.form_em_postal_code.value;
 150   if (f.form_em_country)
 151     f.form_i<?php echo $i?>subscriber_employer_country.value=f.form_em_country.value;
 152  }
 153 }
 154
 155 <?php } ?>
 156
 157 function upperFirst(string,text) {
 158  return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
 159 }
 160
 161 // The ins_search.php window calls this to set the selected insurance.
 162 function set_insurance(ins_id, ins_name) {
 163  var thesel = document.forms[0]['i' + insurance_index + 'provider'];
 164  var theopts = thesel.options; // the array of Option objects
 165  var i = 0;
 166  for (; i < theopts.length; ++i) {
 167   if (theopts[i].value == ins_id) {
 168    theopts[i].selected = true;
 169    return;
 170   }
 171  }
 172  // no matching option was found so create one, append it to the
 173  // end of the list, and select it.
 174  theopts[i] = new Option(ins_name, ins_id, false, true);
 175 }
 176
 177 // Indicates which insurance slot is being updated.
 178 var insurance_index = 0;
 179
 180 // The OnClick handler for searching/adding the insurance company.
 181 function ins_search(ins) {
 182  insurance_index = ins;
 183  dlgopen('../../interface/practice/ins_search.php', '_blank', 550, 400);
 184  return false;
 185 }
 186
 187 function checkNum () {
 188  var re= new RegExp();
 189  re = /^\d*\.?\d*$/;
 190  str=document.forms[0].monthly_income.value;
 191  if(re.exec(str))
 192  {
 193  }else{
 194   alert("Please enter a dollar amount using only numbers and a decimal point.");
 195  }
 196 }
 197
 198 // This capitalizes the first letter of each word in the passed input
 199 // element.  It also strips out extraneous spaces.
 200 function capitalizeMe(elem) {
 201  var a = elem.value.split(' ');
 202  var s = '';
 203  for(var i = 0; i < a.length; ++i) {
 204   if (a[i].length > 0) {
 205    if (s.length > 0) s += ' ';
 206    s += a[i].charAt(0).toUpperCase() + a[i].substring(1);
 207   }
 208  }
 209  elem.value = s;
 210 }
 211
 212 // Onkeyup handler for policy number.  Allows only A-Z and 0-9.
 213 function policykeyup(e) {
 214  var v = e.value.toUpperCase();
 215  for (var i = 0; i < v.length; ++i) {
 216   var c = v.charAt(i);
 217   if (c >= '0' && c <= '9') continue;
 218   if (c >= 'A' && c <= 'Z') continue;
 219   if (c == '*') continue;
 220   if (c == '-') continue;
 221   if (c == '_') continue;
 222   if (c == '(') continue;
 223   if (c == ')') continue;
 224   if (c == '#') continue;
 225   v = v.substring(0, i) + v.substring(i + i);
 226   --i;
 227  }
 228  e.value = v;
 229  return;
 230 }
 231
 232 function divclick(cb, divid) {
 233  var divstyle = document.getElementById(divid).style;
 234  if (cb.checked) {
 235   divstyle.display = 'block';
 236  } else {
 237   divstyle.display = 'none';
 238  }
 239  return true;
 240 }
 241
 242 // Compute the length of a string without leading and trailing spaces.
 243 function trimlen(s) {
 244  var i = 0;
 245  var j = s.length - 1;
 246  for (; i <= j && s.charAt(i) == ' '; ++i);
 247  for (; i <= j && s.charAt(j) == ' '; --j);
 248  if (i > j) return 0;
 249  return j + 1 - i;
 250 }
 251
 252 function validate(f) {
 253   var errMsgs = new Array();
 254   <?php generate_layout_validation('DEM'); ?>
 255   <?php if($GLOBALS['erx_enable']){ ?>
 256   alertMsg='';
 257   for(i=0;i<f.length;i++){
 258     if(f[i].type=='text' && f[i].value)
 259     {
 260       if(f[i].name == 'form_fname' || f[i].name == 'form_mname' || f[i].name == 'form_lname')
 261       {
 262         alertMsg += checkLength(f[i].name,f[i].value,35);
 263         alertMsg += checkUsername(f[i].name,f[i].value);
 264       }
 265       else if(f[i].name == 'form_street' || f[i].name == 'form_city')
 266       {
 267         alertMsg += checkLength(f[i].name,f[i].value,35);
 268         alertMsg += checkAlphaNumericExtended(f[i].name,f[i].value);
 269       }
 270       else if(f[i].name == 'form_phone_home')
 271       {
 272        alertMsg += checkPhone(f[i].name,f[i].value);
 273       }
 274     }
 275   }
 276   if(alertMsg)
 277   {
 278     alert(alertMsg);
 279     return false;
 280   }
 281   <?php } ?>
 282   var msg = "";
 283   msg += "<?php echo htmlspecialchars(xl('The following fields are required'),ENT_QUOTES); ?>:\n\n";
 284   for ( var i = 0; i < errMsgs.length; i++ ) {
 285          msg += errMsgs[i] + "\n";
 286   }
 287   msg += "\n<?php echo htmlspecialchars(xl('Please fill them in before continuing.'),ENT_QUOTES); ?>";
 288
 289   if ( errMsgs.length > 0 ) {
 290          alert(msg);
 291          return false;
 292   }
 293  return true;
 294 }
 295
 296 function toggleSearch(elem) {
 297  var f = document.forms[0];
 298 <?php if ($WITH_SEARCH) { ?>
 299  // Toggle background color.
 300  if (elem.style.backgroundColor == '')
 301   elem.style.backgroundColor = '<?php echo $searchcolor; ?>';
 302  else
 303   elem.style.backgroundColor = '';
 304 <?php } ?>
 305  if (force_submit) {
 306   force_submit = false;
 307   f.create.value = '<?php xl('Create New Patient','e'); ?>';
 308  }
 309  return true;
 310 }
 311
 312 // If a <select> list is dropped down, this is its name.
 313 var open_sel_name = '';
 314
 315 function selClick(elem) {
 316  if (open_sel_name == elem.name) {
 317   open_sel_name = '';
 318  }
 319  else {
 320   open_sel_name = elem.name;
 321   toggleSearch(elem);
 322  }
 323  return true;
 324 }
 325
 326 function selBlur(elem) {
 327  if (open_sel_name == elem.name) {
 328   open_sel_name = '';
 329  }
 330  return true;
 331 }
 332
 333 // This invokes the patient search dialog.
 334 function searchme() {
 335  var f = document.forms[0];
 336  var url = '../main/finder/patient_select.php?popup=1';
 337
 338 <?php
 339 $lres = getLayoutRes();
 340
 341 while ($lrow = sqlFetchArray($lres)) {
 342   $field_id  = $lrow['field_id'];
 343   if (strpos($field_id, 'em_') === 0) continue;
 344   $data_type = $lrow['data_type'];
 345   $fldname = "form_$field_id";
 346   switch(getSearchClass($data_type)) {
 347     case  1:
 348       echo
 349       " if (f.$fldname.style.backgroundColor != '' && trimlen(f.$fldname.value) > 0) {\n" .
 350       "  url += '&$field_id=' + encodeURIComponent(f.$fldname.value);\n" .
 351       " }\n";
 352       break;
 353     case 2:
 354       echo
 355       " if (f.$fldname.style.backgroundColor != '' && f.$fldname.selectedIndex > 0) {\n" .
 356       "  url += '&$field_id=' + encodeURIComponent(f.$fldname.options[f.$fldname.selectedIndex].value);\n" .
 357       " }\n";
 358       break;
 359   }
 360 }
 361 ?>
 362
 363  dlgopen(url, '_blank', 700, 500);
 364 }
 365
 366 //-->
 367
 368 </script>
 369 </head>
 370
 371 <body class="body_top">
 372
 373 <form action='new_comprehensive_save.php' name='demographics_form' method='post' onsubmit='return validate(this)'>
 374
 375 <span class='title'><?php xl('Search or Add Patient','e'); ?></span>
 376
 377 <table width='100%' cellpadding='0' cellspacing='8'>
 378  <tr>
 379   <td align='left' valign='top'>
 380 <?php if ($SHORT_FORM) echo "  <center>\n"; ?>
 381 <?php
 382
 383 function end_cell() {
 384   global $item_count, $cell_count;
 385   if ($item_count > 0) {
 386     echo "</td>";
 387     $item_count = 0;
 388   }
 389 }
 390
 391 function end_row() {
 392   global $cell_count, $CPR;
 393   end_cell();
 394   if ($cell_count > 0) {
 395     for (; $cell_count < $CPR; ++$cell_count) echo "<td></td>";
 396     echo "</tr>\n";
 397     $cell_count = 0;
 398   }
 399 }
 400
 401 function end_group() {
 402   global $last_group, $SHORT_FORM;
 403   if (strlen($last_group) > 0) {
 404     end_row();
 405     echo " </table>\n";
 406     if (!$SHORT_FORM) echo "</div>\n";
 407   }
 408 }
 409
 410 $last_group    = '';
 411 $cell_count    = 0;
 412 $item_count    = 0;
 413 $display_style = 'block';
 414 $group_seq     = 0; // this gives the DIV blocks unique IDs
 415
 416 while ($frow = sqlFetchArray($fres)) {
 417   $this_group = $frow['group_name'];
 418   $titlecols  = $frow['titlecols'];
 419   $datacols   = $frow['datacols'];
 420   $data_type  = $frow['data_type'];
 421   $field_id   = $frow['field_id'];
 422   $list_id    = $frow['list_id'];
 423   $currvalue  = '';
 424
 425   if (strpos($field_id, 'em_') === 0) {
 426     $tmp = substr($field_id, 3);
 427     if (isset($result2[$tmp])) $currvalue = $result2[$tmp];
 428   }
 429   else {
 430     if (isset($result[$field_id])) $currvalue = $result[$field_id];
 431   }
 432
 433   // Handle a data category (group) change.
 434   if (strcmp($this_group, $last_group) != 0) {
 435     if (!$SHORT_FORM) {
 436       end_group();
 437       $group_seq++;    // ID for DIV tags
 438       $group_name = substr($this_group, 1);
 439       if (strlen($last_group) > 0) echo "<br />";
 440       echo "<span class='bold'><input type='checkbox' name='form_cb_$group_seq' id='form_cb_$group_seq' value='1' " .
 441         "onclick='return divclick(this,\"div_$group_seq\");'";
 442       if ($display_style == 'block') echo " checked";
 443
 444       // Modified 6-09 by BM - Translate if applicable
 445       echo " /><b>" . xl_layout_label($group_name) . "</b></span>\n";
 446
 447       echo "<div id='div_$group_seq' class='section' style='display:$display_style;'>\n";
 448       echo " <table border='0' cellpadding='0'>\n";
 449       $display_style = 'none';
 450     }
 451     else if (strlen($last_group) == 0) {
 452       echo " <table border='0' cellpadding='0'>\n";
 453     }
 454     $last_group = $this_group;
 455   }
 456
 457   // Handle starting of a new row.
 458   if (($titlecols > 0 && $cell_count >= $CPR) || $cell_count == 0) {
 459     end_row();
 460     echo "  <tr>";
 461   }
 462
 463   if ($item_count == 0 && $titlecols == 0) $titlecols = 1;
 464
 465   // Handle starting of a new label cell.
 466   if ($titlecols > 0) {
 467     end_cell();
 468     echo "<td colspan='$titlecols'";
 469     echo ($frow['uor'] == 2) ? " class='required'" : " class='bold'";
 470     if ($cell_count == 2) echo " style='padding-left:10pt'";
 471     echo ">";
 472     $cell_count += $titlecols;
 473   }
 474   ++$item_count;
 475
 476   echo "<b>";
 477
 478   // Modified 6-09 by BM - Translate if applicable
 479   if ($frow['title']) echo (xl_layout_label($frow['title']).":"); else echo "&nbsp;";
 480
 481   echo "</b>";
 482
 483   // Handle starting of a new data cell.
 484   if ($datacols > 0) {
 485     end_cell();
 486     echo "<td colspan='$datacols' class='text'";
 487     if ($cell_count > 0) echo " style='padding-left:5pt'";
 488     echo ">";
 489     $cell_count += $datacols;
 490   }
 491
 492   ++$item_count;
 493   generate_form_field($frow, $currvalue);
 494 }
 495
 496 end_group();
 497 ?>
 498
 499 <?php
 500 if (! $GLOBALS['simplified_demographics']) {
 501   $insurancei = getInsuranceProviders();
 502   $pid = 0;
 503   $insurance_headings = array(xl("Primary Insurance Provider"), xl("Secondary Insurance Provider"), xl("Tertiary Insurance provider"));
 504   $insurance_info = array();
 505   $insurance_info[1] = getInsuranceData($pid,"primary");
 506   $insurance_info[2] = getInsuranceData($pid,"secondary");
 507   $insurance_info[3] = getInsuranceData($pid,"tertiary");
 508
 509   echo "<br /><span class='bold'><input type='checkbox' name='form_cb_ins' value='1' " .
 510     "onclick='return divclick(this,\"div_ins\");'";
 511   if ($display_style == 'block') echo " checked";
 512   echo " /><b>" . xl('Insurance') . "</b></span>\n";
 513   echo "<div id='div_ins' class='section' style='display:$display_style;'>\n";
 514
 515   for($i=1;$i<=3;$i++) {
 516    $result3 = $insurance_info[$i];
 517 ?>
 518 <table border="0">
 519  <tr>
 520   <td valign='top' colspan='2'>
 521    <span class='required'><?php echo $insurance_headings[$i -1].":"?></span>
 522    <select name="i<?php echo $i?>provider">
 523     <option value=""><?php xl('Unassigned','e'); ?></option>
 524 <?php
 525  foreach ($insurancei as $iid => $iname) {
 526   echo "<option value='" . $iid . "'";
 527   if (strtolower($iid) == strtolower($result3{"provider"}))
 528    echo " selected";
 529   echo ">" . $iname . "</option>\n";
 530  }
 531 ?>
 532    </select>&nbsp;<a href='' onclick='return ins_search(<?php echo $i?>)'>
 533    <?php xl('Search/Add Insurer','e'); ?></a>
 534   </td>
 535  </tr>
 536  <tr>
 537   <td valign=top>
 538    <table border="0">
 539
 540     <tr>
 541      <td>
 542       <span class='required'><?php xl('Plan Name','e'); ?>: </span>
 543      </td>
 544      <td>
 545       <input type='entry' size='20' name='i<?php echo $i?>plan_name' value="<?php echo $result3{"plan_name"} ?>"
 546        onchange="capitalizeMe(this);" />&nbsp;&nbsp;
 547      </td>
 548     </tr>
 549
 550     <tr>
 551      <td>
 552       <span class='required'><?php xl('Effective Date','e'); ?>: </span>
 553      </td>
 554      <td>
 555       <input type='entry' size='11' name='i<?php echo $i ?>effective_date'
 556        id='i<?php echo $i ?>effective_date'
 557        value='<?php echo $result3['date'] ?>'
 558        onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)'
 559        title='yyyy-mm-dd' />
 560
 561       <img src='../../interface/pic/show_calendar.gif' align='absbottom' width='24' height='22'
 562       id='img_i<?php echo $i ?>effective_date' border='0' alt='[?]' style='cursor:pointer'
 563       title='<?php xl('Click here to choose a date','e'); ?>'>
 564
 565       <script LANGUAGE="JavaScript">
 566       Calendar.setup({inputField:"i<?php echo $i ?>effective_date", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i; ?>effective_date"});
 567       </script>
 568
 569
 570      </td>
 571     </tr>
 572
 573     <tr>
 574      <td><span class=required><?php xl('Policy Number','e'); ?>: </span></td>
 575      <td><input type='entry' size='16' name='i<?php echo $i?>policy_number' value="<?php echo $result3{"policy_number"}?>"
 576       onkeyup='policykeyup(this)'></td>
 577     </tr>
 578
 579     <tr>
 580      <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 $result3{"group_number"}?>" onkeyup='policykeyup(this)'></td>
 581     </tr>
 582
 583     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 584      <td class='required'><?php xl('Subscriber Employer (SE)','e'); ?><br><span style='font-weight:normal'>
 585       (<?php xl('if unemployed enter Student','e'); ?>,<br><?php xl('PT Student, or leave blank','e'); ?>): </span></td>
 586      <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer
 587       value="<?php echo $result3{"subscriber_employer"}?>"
 588        onchange="capitalizeMe(this);" /></td>
 589     </tr>
 590
 591     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 592      <td><span class=required><?php xl('SE Address','e'); ?>: </span></td>
 593      <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer_street
 594       value="<?php echo $result3{"subscriber_employer_street"}?>"
 595        onchange="capitalizeMe(this);" /></td>
 596     </tr>
 597
 598     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 599      <td colspan="2">
 600       <table>
 601        <tr>
 602         <td><span class=required><?php xl('SE City','e'); ?>: </span></td>
 603         <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_city
 604          value="<?php echo $result3{"subscriber_employer_city"}?>"
 605           onchange="capitalizeMe(this);" /></td>
 606         <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE State','e') : xl('SE Locality','e') ?>: </span></td>
 607         <td>
 608          <?php
 609           // Modified 7/2009 by BM to incorporate data types
 610           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'), $result3['subscriber_employer_state']);
 611          ?>
 612         </td>
 613        </tr>
 614        <tr>
 615         <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE Zip Code','e') : xl('SE Postal Code','e') ?>: </span></td>
 616         <td><input type=entry size=10 name=i<?php echo $i?>subscriber_employer_postal_code value="<?php echo $result3{"subscriber_employer_postal_code"}?>"></td>
 617         <td><span class=required><?php xl('SE Country','e'); ?>: </span></td>
 618         <td>
 619          <?php
 620           // Modified 7/2009 by BM to incorporate data types
 621           generate_form_field(array('data_type'=>$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']);
 622          ?>
 623         </td>
 624        </tr>
 625       </table>
 626      </td>
 627     </tr>
 628
 629    </table>
 630   </td>
 631
 632   <td valign=top>
 633    <span class=required><?php xl('Subscriber','e'); ?>: </span>
 634    <input type=entry size=10 name=i<?php echo $i?>subscriber_fname
 635     value="<?php echo $result3{"subscriber_fname"}?>"
 636     onchange="capitalizeMe(this);" />
 637    <input type=entry size=3 name=i<?php echo $i?>subscriber_mname
 638     value="<?php echo $result3{"subscriber_mname"}?>"
 639     onchange="capitalizeMe(this);" />
 640    <input type=entry size=10 name=i<?php echo $i?>subscriber_lname
 641     value="<?php echo $result3{"subscriber_lname"}?>"
 642     onchange="capitalizeMe(this);" />
 643    <br>
 644    <span class=required><?php xl('Relationship','e'); ?>: </span>
 645    <?php
 646     // Modified 6/2009 by BM to use list_options and function
 647     generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_relationship'),'list_id'=>'sub_relation','empty_title'=>' '), $result3['subscriber_relationship']);
 648    ?>
 649    <a href="javascript:popUp('../../interface/patient_file/summary/browse.php?browsenum=<?php echo $i?>')" class=text>(<?php xl('Browse','e'); ?>)</a><br />
 650
 651    <span class=bold><?php xl('D.O.B.','e'); ?>: </span>
 652    <input type='entry' size='11' name='i<?php echo $i?>subscriber_DOB'
 653     id='i<?php echo $i?>subscriber_DOB'
 654     value='<?php echo $result3['subscriber_DOB'] ?>'
 655     onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)'
 656     title='yyyy-mm-dd' />
 657
 658    <img src='../../interface/pic/show_calendar.gif' align='absbottom' width='24' height='22'
 659     id='img_i<?php echo $i; ?>dob_date' border='0' alt='[?]' style='cursor:pointer'
 660     title='<?php xl('Click here to choose a date','e'); ?>'>
 661
 662     <script LANGUAGE="JavaScript">
 663     Calendar.setup({inputField:"i<?php echo $i?>subscriber_DOB", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i; ?>dob_date"});
 664     </script>
 665
 666
 667    <span class=bold><?php xl('S.S.','e'); ?>: </span><input type=entry size=11 name=i<?php echo $i?>subscriber_ss value="<?php echo $result3{"subscriber_ss"}?>">&nbsp;
 668    <span class=bold><?php xl('Sex','e'); ?>: </span>
 669    <?php
 670     // Modified 6/2009 by BM to use list_options and function
 671     generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_sex'),'list_id'=>'sex'), $result3['subscriber_sex']);
 672    ?>
 673    <br>
 674    <span class=required><?php xl('Subscriber Address','e'); ?>: </span>
 675    <input type=entry size=25 name=i<?php echo $i?>subscriber_street
 676     value="<?php echo $result3{"subscriber_street"}?>"
 677     onchange="capitalizeMe(this);" /><br>
 678    <span class=required><?php xl('City','e'); ?>: </span>
 679    <input type=entry size=15 name=i<?php echo $i?>subscriber_city
 680     value="<?php echo $result3{"subscriber_city"}?>"
 681     onchange="capitalizeMe(this);" />
 682    <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('State','e') : xl('Locality','e') ?>: </span>
 683    <?php
 684     // Modified 7/2009 by BM to incorporate data types
 685     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'), $result3['subscriber_state']);
 686    ?>
 687    <br />
 688    <span class=required><?php echo ($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 $result3{"subscriber_postal_code"}?>">
 689    <span class='required'<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 690    <?php xl('Country','e'); ?>: </span>
 691    <?php
 692     // Modified 7/2009 by BM to incorporate data types
 693     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']);
 694    ?>
 695    <br />
 696    <span class=bold><?php xl('Subscriber Phone','e'); ?>:
 697    <input type='text' size='20' name='i<?php echo $i?>subscriber_phone' value='<?php echo $result3["subscriber_phone"] ?>' onkeyup='phonekeyup(this,mypcc)' />
 698    </span><br />
 699    <span class=bold><?php xl('CoPay','e'); ?>: <input type=text size="6" name=i<?php echo $i?>copay value="<?php echo $result3{"copay"}?>">
 700    </span><br />
 701    <span class='required'><?php xl('Accept Assignment','e'); ?>: </span>
 702    <select name=i<?php echo $i?>accept_assignment>
 703      <option value="TRUE" <?php if (strtoupper($result3{"accept_assignment"}) == "TRUE") echo "selected"?>><?php xl('YES','e'); ?></option>
 704      <option value="FALSE" <?php if (strtoupper($result3{"accept_assignment"}) == "FALSE") echo "selected"?>><?php xl('NO','e'); ?></option>
 705    </select>
 706   </td>
 707  </tr>
 708
 709 </table>
 710 <hr />
 711 <?php
 712   }
 713   echo "</div>\n";
 714  } // end of "if not simplified_demographics"
 715 ?>
 716
 717 <?php if (!$SHORT_FORM) echo "  <center>\n"; ?>
 718 <br />
 719 <?php if ($WITH_SEARCH) { ?>
 720 <input type="button" id="search" value=<?php xl('Search','e','\'','\''); ?>
 721  style='background-color:<?php echo $searchcolor; ?>' />
 722 &nbsp;&nbsp;
 723 <?php } ?>
 724 <input type="button" name='create' id="create" value=<?php xl('Create New Patient','e','\'','\''); ?> />
 725
 726 </center>
 727
 728   </td>
 729   <td align='right' valign='top' width='1%' nowrap>
 730    <!-- Image upload stuff was here but got moved. -->
 731   </td>
 732  </tr>
 733 </table>
 734
 735 </form>
 736
 737 <!-- include support for the list-add selectbox feature -->
 738 <?php include($GLOBALS['fileroot']."/library/options_listadd.inc"); ?>
 739
 740 </body>
 741
 742 <script language="JavaScript">
 743
 744 // fix inconsistently formatted phone numbers from the database
 745 var f = document.forms[0];
 746 if (f.form_phone_contact) phonekeyup(f.form_phone_contact,mypcc);
 747 if (f.form_phone_home   ) phonekeyup(f.form_phone_home   ,mypcc);
 748 if (f.form_phone_biz    ) phonekeyup(f.form_phone_biz    ,mypcc);
 749 if (f.form_phone_cell   ) phonekeyup(f.form_phone_cell   ,mypcc);
 750
 751 <?php echo $date_init; ?>
 752
 753 // -=- jQuery makes life easier -=-
 754
 755 // var matches = 0; // number of patients that match the demographic information being entered
 756 // var override = false; // flag that overrides the duplication warning
 757
 758 $(document).ready(function() {
 759
 760     // added to integrate insurance stuff
 761     <?php for ($i=1;$i<=3;$i++) { ?>
 762     $("#form_i<?php echo $i?>subscriber_relationship").change(function() { auto_populate_employer_address<?php echo $i?>(); });
 763     <?php } ?>
 764
 765     $('#search').click(function() { searchme(); });
 766     $('#create').click(function() { submitme(); });
 767
 768     var submitme = function() {
 769       top.restoreSession();
 770       var f = document.forms[0];
 771
 772       if (validate(f)) {
 773         if (force_submit) {
 774           // In this case dups were shown already and Save should just save.
 775           f.submit();
 776           return;
 777         }
 778 <?php
 779 // D in edit_options indicates the field is used in duplication checking.
 780 // This constructs a list of the names of those fields.
 781 $mflist = "";
 782 $mfres = sqlStatement("SELECT * FROM layout_options " .
 783   "WHERE form_id = 'DEM' AND uor > 0 AND field_id != '' AND " .
 784   "edit_options LIKE '%D%' " .
 785   "ORDER BY group_name, seq");
 786 while ($mfrow = sqlFetchArray($mfres)) {
 787   $field_id  = $mfrow['field_id'];
 788   if (strpos($field_id, 'em_') === 0) continue;
 789   if (!empty($mflist)) $mflist .= ",";
 790   $mflist .= "'" . htmlentities($field_id) . "'";
 791 }
 792 ?>
 793         // Build and invoke the URL to create the dup-checker dialog.
 794         var url = 'new_search_popup.php';
 795         var flds = new Array(<?php echo $mflist; ?>);
 796         var separator = '?';
 797         for (var i = 0; i < flds.length; ++i) {
 798           var fval = $('#form_' + flds[i]).val();
 799           if (fval && fval != '') {
 800             url += separator;
 801             separator = '&';
 802             url += 'mf_' + flds[i] + '=' + encodeURIComponent(fval);
 803           }
 804         }
 805         dlgopen(url, '_blank', 700, 500);
 806
 807       } // end if validate
 808     } // end function
 809
 810 // Set onclick/onfocus handlers for toggling background color.
 811 <?php
 812 $lres = getLayoutRes();
 813 while ($lrow = sqlFetchArray($lres)) {
 814   $field_id  = $lrow['field_id'];
 815   if (strpos($field_id, 'em_') === 0) continue;
 816   switch(getSearchClass($lrow['data_type'])) {
 817     case 1:
 818       echo "    \$('#form_$field_id').click(function() { toggleSearch(this); });\n";
 819       break;
 820     case 2:
 821       echo "    \$('#form_$field_id').click(function() { selClick(this); });\n";
 822       echo "    \$('#form_$field_id').blur(function() { selBlur(this); });\n";
 823       break;
 824   }
 825 }
 826 ?>
 827
 828 }); // end document.ready
 829
 830 </script>
 831
 832 </html>
 833