interface/patient_file/summary/demographics_full.php

   1 <?php
   2 // This program is free software; you can redistribute it and/or
   3 // modify it under the terms of the GNU General Public License
   4 // as published by the Free Software Foundation; either version 2
   5 // of the License, or (at your option) any later version.
   6
   7 require_once("../../globals.php");
   8 require_once("$srcdir/acl.inc");
   9 require_once("$srcdir/options.inc.php");
  10 require_once("$srcdir/formatting.inc.php");
  11 require_once("$srcdir/erx_javascript.inc.php");
  12
  13  // Session pid must be right or bad things can happen when demographics are saved!
  14  //
  15  include_once("$srcdir/pid.inc");
  16  $set_pid = $_GET["set_pid"] ? $_GET["set_pid"] : $_GET["pid"];
  17  if ($set_pid && $set_pid != $_SESSION["pid"]) {
  18   setpid($set_pid);
  19  }
  20
  21  include_once("$srcdir/patient.inc");
  22
  23  $result = getPatientData($pid, "*, DATE_FORMAT(DOB,'%Y-%m-%d') as DOB_YMD");
  24  $result2 = getEmployerData($pid);
  25
  26  // Check authorization.
  27  $thisauth = acl_check('patients', 'demo');
  28  if ($pid) {
  29   if ($thisauth != 'write')
  30    die(xl('Updating demographics is not authorized.'));
  31   if ($result['squad'] && ! acl_check('squads', $result['squad']))
  32    die(xl('You are not authorized to access this squad.'));
  33  } else {
  34   if ($thisauth != 'write' && $thisauth != 'addonly')
  35    die(xl('Adding demographics is not authorized.'));
  36  }
  37
  38 $CPR = 4; // cells per row
  39
  40 // $statii = array('married','single','divorced','widowed','separated','domestic partner');
  41 // $langi = getLanguages();
  42 // $ethnoraciali = getEthnoRacials();
  43 // $provideri = getProviderInfo();
  44
  45 $insurancei = getInsuranceProviders();
  46
  47 $fres = sqlStatement("SELECT * FROM layout_options " .
  48   "WHERE form_id = 'DEM' AND uor > 0 " .
  49   "ORDER BY group_name, seq");
  50 ?>
  51 <html>
  52 <head>
  53 <?php html_header_show();?>
  54
  55 <link rel="stylesheet" href="<?php echo $css_header; ?>" type="text/css">
  56
  57 <style type="text/css">@import url(../../../library/dynarch_calendar.css);</style>
  58
  59 <script type="text/javascript" src="../../../library/dialog.js"></script>
  60 <script type="text/javascript" src="../../../library/textformat.js"></script>
  61 <script type="text/javascript" src="../../../library/dynarch_calendar.js"></script>
  62 <?php include_once("{$GLOBALS['srcdir']}/dynarch_calendar_en.inc.php"); ?>
  63 <script type="text/javascript" src="../../../library/dynarch_calendar_setup.js"></script>
  64
  65 <script type="text/javascript" src="../../../library/js/jquery.1.3.2.js"></script>
  66 <script type="text/javascript" src="../../../library/js/common.js"></script>
  67
  68 <script type="text/javascript" src="../../../library/js/fancybox/jquery.fancybox-1.2.6.js"></script>
  69 <link rel="stylesheet" type="text/css" href="../../../library/js/fancybox/jquery.fancybox-1.2.6.css" media="screen" />
  70
  71 <script type="text/javascript">
  72 $(document).ready(function(){
  73     tabbify();
  74     enable_modals();
  75
  76     // special size for
  77         $(".medium_modal").fancybox( {
  78                 'overlayOpacity' : 0.0,
  79                 'showCloseButton' : true,
  80                 'frameHeight' : 460,
  81                 'frameWidth' : 650
  82         });
  83
  84 });
  85
  86 var mypcc = '<?php echo $GLOBALS['phone_country_code'] ?>';
  87
  88 //code used from http://tech.irt.org/articles/js037/
  89 function replace(string,text,by) {
  90  // Replaces text with by in string
  91  var strLength = string.length, txtLength = text.length;
  92  if ((strLength == 0) || (txtLength == 0)) return string;
  93
  94  var i = string.indexOf(text);
  95  if ((!i) && (text != string.substring(0,txtLength))) return string;
  96  if (i == -1) return string;
  97
  98  var newstr = string.substring(0,i) + by;
  99
 100  if (i+txtLength < strLength)
 101   newstr += replace(string.substring(i+txtLength,strLength),text,by);
 102
 103  return newstr;
 104 }
 105
 106 function upperFirst(string,text) {
 107  return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
 108 }
 109
 110 <?php for ($i=1;$i<=3;$i++) { ?>
 111 function auto_populate_employer_address<?php echo $i ?>(){
 112  var f = document.demographics_form;
 113  if (f.form_i<?php echo $i?>subscriber_relationship.options[f.form_i<?php echo $i?>subscriber_relationship.selectedIndex].value == "self")
 114  {
 115   f.i<?php echo $i?>subscriber_fname.value=f.form_fname.value;
 116   f.i<?php echo $i?>subscriber_mname.value=f.form_mname.value;
 117   f.i<?php echo $i?>subscriber_lname.value=f.form_lname.value;
 118   f.i<?php echo $i?>subscriber_street.value=f.form_street.value;
 119   f.i<?php echo $i?>subscriber_city.value=f.form_city.value;
 120   f.form_i<?php echo $i?>subscriber_state.value=f.form_state.value;
 121   f.i<?php echo $i?>subscriber_postal_code.value=f.form_postal_code.value;
 122   if (f.form_country_code)
 123     f.form_i<?php echo $i?>subscriber_country.value=f.form_country_code.value;
 124   f.i<?php echo $i?>subscriber_phone.value=f.form_phone_home.value;
 125   f.i<?php echo $i?>subscriber_DOB.value=f.form_DOB.value;
 126   f.i<?php echo $i?>subscriber_ss.value=f.form_ss.value;
 127   f.form_i<?php echo $i?>subscriber_sex.value = f.form_sex.value;
 128   f.i<?php echo $i?>subscriber_employer.value=f.form_em_name.value;
 129   f.i<?php echo $i?>subscriber_employer_street.value=f.form_em_street.value;
 130   f.i<?php echo $i?>subscriber_employer_city.value=f.form_em_city.value;
 131   f.form_i<?php echo $i?>subscriber_employer_state.value=f.form_em_state.value;
 132   f.i<?php echo $i?>subscriber_employer_postal_code.value=f.form_em_postal_code.value;
 133   if (f.form_em_country)
 134     f.form_i<?php echo $i?>subscriber_employer_country.value=f.form_em_country.value;
 135  }
 136 }
 137
 138 <?php } ?>
 139
 140 function popUp(URL) {
 141  day = new Date();
 142  id = day.getTime();
 143  top.restoreSession();
 144  eval("page" + id + " = window.open(URL, '" + id + "', 'toolbar=0,scrollbars=1,location=0,statusbar=0,menubar=0,resizable=1,width=400,height=300,left = 440,top = 362');");
 145 }
 146
 147 function checkNum () {
 148  var re= new RegExp();
 149  re = /^\d*\.?\d*$/;
 150  str=document.demographics_form.monthly_income.value;
 151  if(re.exec(str))
 152  {
 153  }else{
 154   alert("<?php xl('Please enter a monetary amount using only numbers and a decimal point.','e'); ?>");
 155  }
 156 }
 157
 158 // Indicates which insurance slot is being updated.
 159 var insurance_index = 0;
 160
 161 // The OnClick handler for searching/adding the insurance company.
 162 function ins_search(ins) {
 163         insurance_index = ins;
 164         return false;
 165 }
 166
 167 // The ins_search.php window calls this to set the selected insurance.
 168 function set_insurance(ins_id, ins_name) {
 169  var thesel = document.forms[0]['i' + insurance_index + 'provider'];
 170  var theopts = thesel.options; // the array of Option objects
 171  var i = 0;
 172  for (; i < theopts.length; ++i) {
 173   if (theopts[i].value == ins_id) {
 174    theopts[i].selected = true;
 175    return;
 176   }
 177  }
 178  // no matching option was found so create one, append it to the
 179  // end of the list, and select it.
 180  theopts[i] = new Option(ins_name, ins_id, false, true);
 181 }
 182
 183 // This capitalizes the first letter of each word in the passed input
 184 // element.  It also strips out extraneous spaces.
 185 function capitalizeMe(elem) {
 186  var a = elem.value.split(' ');
 187  var s = '';
 188  for(var i = 0; i < a.length; ++i) {
 189   if (a[i].length > 0) {
 190    if (s.length > 0) s += ' ';
 191    s += a[i].charAt(0).toUpperCase() + a[i].substring(1);
 192   }
 193  }
 194  elem.value = s;
 195 }
 196
 197 function divclick(cb, divid) {
 198  var divstyle = document.getElementById(divid).style;
 199  if (cb.checked) {
 200   divstyle.display = 'block';
 201  } else {
 202   divstyle.display = 'none';
 203  }
 204  return true;
 205 }
 206
 207 // Compute the length of a string without leading and trailing spaces.
 208 function trimlen(s) {
 209  var i = 0;
 210  var j = s.length - 1;
 211  for (; i <= j && s.charAt(i) == ' '; ++i);
 212  for (; i <= j && s.charAt(j) == ' '; --j);
 213  if (i > j) return 0;
 214  return j + 1 - i;
 215 }
 216
 217 function validate(f) {
 218  var errCount = 0;
 219  var errMsgs = new Array();
 220 <?php generate_layout_validation('DEM'); ?>
 221
 222  var msg = "";
 223  msg += "<?php xl('The following fields are required', 'e' ); ?>:\n\n";
 224  for ( var i = 0; i < errMsgs.length; i++ ) {
 225         msg += errMsgs[i] + "\n";
 226  }
 227  msg += "\n<?php xl('Please fill them in before continuing.', 'e'); ?>";
 228
 229  if ( errMsgs.length > 0 ) {
 230         alert(msg);
 231  }
 232
 233 //Patient Data validations
 234  <?php if($GLOBALS['erx_enable']){ ?>
 235  alertMsg='';
 236  for(i=0;i<f.length;i++){
 237   if(f[i].type=='text' && f[i].value)
 238   {
 239    if(f[i].name == 'form_fname' || f[i].name == 'form_mname' || f[i].name == 'form_lname')
 240    {
 241     alertMsg += checkLength(f[i].name,f[i].value,35);
 242     alertMsg += checkUsername(f[i].name,f[i].value);
 243    }
 244    else if(f[i].name == 'form_street' || f[i].name == 'form_city')
 245    {
 246     alertMsg += checkLength(f[i].name,f[i].value,35);
 247     alertMsg += checkAlphaNumericExtended(f[i].name,f[i].value);
 248    }
 249    else if(f[i].name == 'form_phone_home')
 250    {
 251     alertMsg += checkPhone(f[i].name,f[i].value);
 252    }
 253   }
 254  }
 255  if(alertMsg)
 256  {
 257    alert(alertMsg);
 258    return false;
 259  }
 260  <?php } ?>
 261  //return false;
 262
 263 // Some insurance validation.
 264  for (var i = 1; i <= 3; ++i) {
 265   subprov = 'i' + i + 'provider';
 266   if (!f[subprov] || f[subprov].selectedIndex <= 0) continue;
 267   var subpfx = 'i' + i + 'subscriber_';
 268   var subrelat = f['form_' + subpfx + 'relationship'];
 269   var samename =
 270    f[subpfx + 'fname'].value == f.form_fname.value &&
 271    f[subpfx + 'mname'].value == f.form_mname.value &&
 272    f[subpfx + 'lname'].value == f.form_lname.value;
 273   var samess = f[subpfx + 'ss'].value == f.form_ss.value;
 274   if (subrelat.options[subrelat.selectedIndex].value == "self") {
 275    if (!samename) {
 276     if (!confirm("<?php xl('Subscriber relationship is self but name is different! Is this really OK?','e'); ?>"))
 277      return false;
 278    }
 279    if (!samess) {
 280     alert("<?php xl('Subscriber relationship is self but SS number is different!','e'); ?>");
 281     return false;
 282    }
 283   } // end self
 284   else {
 285    if (samename) {
 286     if (!confirm("<?php xl('Subscriber relationship is not self but name is the same! Is this really OK?','e'); ?>"))
 287      return false;
 288    }
 289    if (samess) {
 290     alert("<?php xl('Subscriber relationship is not self but SS number is the same!','e'); ?>");
 291     return false;
 292    }
 293   } // end not self
 294  } // end for
 295
 296  return errMsgs.length < 1;
 297 }
 298
 299 function submitme() {
 300  var f = document.forms[0];
 301  if (validate(f)) {
 302   top.restoreSession();
 303   f.submit();
 304  }
 305 }
 306
 307 // Onkeyup handler for policy number.  Allows only A-Z and 0-9.
 308 function policykeyup(e) {
 309  var v = e.value.toUpperCase();
 310  for (var i = 0; i < v.length; ++i) {
 311   var c = v.charAt(i);
 312   if (c >= '0' && c <= '9') continue;
 313   if (c >= 'A' && c <= 'Z') continue;
 314   if (c == '*') continue;
 315   if (c == '-') continue;
 316   if (c == '_') continue;
 317   if (c == '(') continue;
 318   if (c == ')') continue;
 319   if (c == '#') continue;
 320   v = v.substring(0, i) + v.substring(i + i);
 321   --i;
 322  }
 323  e.value = v;
 324  return;
 325 }
 326
 327 // Added 06/2009 by BM to make compatible with list_options table and functions - using jquery
 328 $(document).ready(function() {
 329
 330  <?php for ($i=1;$i<=3;$i++) { ?>
 331   $("#form_i<?php echo $i?>subscriber_relationship").change(function() { auto_populate_employer_address<?php echo $i?>(); });
 332  <?php } ?>
 333
 334 });
 335
 336 </script>
 337 </head>
 338
 339 <body class="body_top">
 340 <form action='demographics_save.php' name='demographics_form' method='post' onsubmit='return validate(this)'>
 341 <input type='hidden' name='mode' value='save' />
 342 <input type='hidden' name='db_id' value="<?php echo $result['id']?>" />
 343 <table cellpadding='0' cellspacing='0' border='0'>
 344         <tr>
 345                 <td>
 346                         <?php if ($GLOBALS['concurrent_layout']) { ?>
 347                         <a href="demographics.php" onclick="top.restoreSession()">
 348                         <?php } else { ?>
 349                         <a href="patient_summary.php" target="Main" onclick="top.restoreSession()">
 350                         <?php } ?>
 351                         <font class=title><?php xl('Current Patient','e'); ?></font>
 352                         </a>
 353                         &nbsp;&nbsp;
 354                 </td>
 355                 <td>
 356                         <a href="javascript:submitme();" class='css_button'>
 357                                 <span><?php xl('Save','e'); ?></span>
 358                         </a>
 359                 </td>
 360                 <td>
 361                         <?php if ($GLOBALS['concurrent_layout']) { ?>
 362                         <a class="css_button" href="demographics.php" onclick="top.restoreSession()">
 363                         <?php } else { ?>
 364                         <a href="patient_summary.php" target="Main" onclick="top.restoreSession()">
 365                         <?php } ?>
 366                         <span><?php xl('Cancel','e'); ?></span>
 367                         </a>
 368                 </td>
 369         </tr>
 370 </table>
 371 <?php
 372
 373 function end_cell() {
 374   global $item_count, $cell_count;
 375   if ($item_count > 0) {
 376     echo "</td>";
 377     $item_count = 0;
 378   }
 379 }
 380
 381 function end_row() {
 382   global $cell_count, $CPR;
 383   end_cell();
 384   if ($cell_count > 0) {
 385     for (; $cell_count < $CPR; ++$cell_count) echo "<td></td>";
 386     echo "</tr>\n";
 387     $cell_count = 0;
 388   }
 389 }
 390
 391 function end_group() {
 392   global $last_group;
 393   if (strlen($last_group) > 0) {
 394     end_row();
 395     echo " </table>\n";
 396     echo "</div>\n";
 397   }
 398 }
 399
 400 $last_group = '';
 401 $cell_count = 0;
 402 $item_count = 0;
 403 $display_style = 'block';
 404
 405 $group_seq=0; // this gives the DIV blocks unique IDs
 406
 407 ?>
 408 <br>
 409   <div class="section-header">
 410    <span class="text"><b> <?php xl("Demographics", "e" )?></b></span>
 411 </div>
 412
 413 <div id="DEM" >
 414
 415         <ul class="tabNav">
 416            <?php display_layout_tabs('DEM', $result, $result2); ?>
 417         </ul>
 418
 419         <div class="tabContainer">
 420                 <?php display_layout_tabs_data_editable('DEM', $result, $result2); ?>
 421         </div>
 422 </div>
 423 <br>
 424   <div class="section-header">
 425     <span class="text"><b><?php xl("Insurance", "e" )?></b></span>
 426 </div>
 427 <div id="DEM" >
 428
 429
 430 <?php
 431  if (! $GLOBALS['simplified_demographics']) {
 432
 433           $insurance_headings = array(xl("Primary Insurance Provider"), xl("Secondary Insurance Provider"), xl("Tertiary Insurance provider"));
 434           $insurance_info = array();
 435           $insurance_info[1] = getInsuranceData($pid,"primary");
 436           $insurance_info[2] = getInsuranceData($pid,"secondary");
 437           $insurance_info[3] = getInsuranceData($pid,"tertiary");
 438
 439         ?>
 440         <div id="INSURANCE" >
 441                 <ul class="tabNav">
 442                 <?php
 443                 foreach (array('primary','secondary','tertiary') as $instype) {
 444                         ?><li <?php echo $instype == 'primary' ? 'class="current"' : '' ?>><a href="/play/javascript-tabbed-navigation/"><?php $CapInstype=ucfirst($instype); xl($CapInstype,'e'); ?></a></li><?php
 445                 }
 446                 ?>
 447                 </ul>
 448
 449         <div class="tabContainer">
 450
 451         <?php
 452           for($i=1;$i<=3;$i++) {
 453            $result3 = $insurance_info[$i];
 454         ?>
 455
 456                 <div class="tab <?php echo $i == 1 ? 'current': '' ?>" style='height:auto;width:auto'>          <!---display icky, fix to auto-->
 457
 458                 <table border="0">
 459
 460                  <tr>
 461                   <td valign=top width="430">
 462                    <table border="0">
 463
 464                          <tr>
 465                           <td valign='top'>
 466                            <span class='required'><?php echo $insurance_headings[$i -1]."&nbsp;"?></span>
 467                           </td>
 468                           <td class='required'>:</td>
 469                           <td>
 470                            <a href="../../practice/ins_search.php" class="iframe medium_modal css_button" onclick="ins_search(<?php echo $i?>)">
 471                                 <span><?php echo xl('Search/Add') ?></span>
 472                                 </a>
 473                                 <select name="i<?php echo $i?>provider">
 474                                 <option value=""><?php xl('Unassigned','e'); ?></option>
 475                                 <?php
 476                                  foreach ($insurancei as $iid => $iname) {
 477                                   echo "<option value='" . $iid . "'";
 478                                   if (strtolower($iid) == strtolower($result3{"provider"}))
 479                                    echo " selected";
 480                                   echo ">" . $iname . "</option>\n";
 481                                  }
 482                                 ?>
 483                            </select>
 484
 485                           </td>
 486                          </tr>
 487
 488                         <tr>
 489                          <td>
 490                           <span class='required'><?php xl('Plan Name','e'); ?> </span>
 491                          </td>
 492                          <td class='required'>:</td>
 493                          <td>
 494                           <input type='entry' size='20' name='i<?php echo $i?>plan_name' value="<?php echo $result3{"plan_name"} ?>"
 495                            onchange="capitalizeMe(this);" />&nbsp;&nbsp;
 496                          </td>
 497                         </tr>
 498
 499                         <tr>
 500                          <td>
 501                           <span class='required'><?php xl('Effective Date','e'); ?></span>
 502                          </td>
 503                          <td class='required'>:</td>
 504                          <td>
 505                           <input type='entry' size='16' id='i<?php echo $i ?>effective_date' name='i<?php echo $i ?>effective_date'
 506                            value='<?php echo $result3['date'] ?>'
 507                            onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)'
 508                            title='yyyy-mm-dd' />
 509                           <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'); ?>'>
 510                          </td>
 511                         </tr>
 512
 513                         <tr>
 514                          <td><span class=required><?php xl('Policy Number','e'); ?></span></td>
 515                          <td class='required'>:</td>
 516                          <td><input type='entry' size='16' name='i<?php echo $i?>policy_number' value="<?php echo $result3{"policy_number"}?>"
 517                           onkeyup='policykeyup(this)'></td>
 518                         </tr>
 519
 520                         <tr>
 521                          <td><span class=required><?php xl('Group Number','e'); ?></span></td>
 522                          <td class='required'>:</td>
 523                          <td><input type=entry size=16 name=i<?php echo $i?>group_number value="<?php echo $result3{"group_number"}?>" onkeyup='policykeyup(this)'></td>
 524                         </tr>
 525
 526                         <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 527                          <td class='required'><?php xl('Subscriber Employer (SE)','e'); ?><br><span style='font-weight:normal'>
 528                           (<?php xl('if unemployed enter Student','e'); ?>,<br><?php xl('PT Student, or leave blank','e'); ?>) </span></td>
 529                           <td class='required'>:</td>
 530                          <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer
 531                           value="<?php echo $result3{"subscriber_employer"}?>"
 532                            onchange="capitalizeMe(this);" /></td>
 533                         </tr>
 534
 535                         <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 536                          <td><span class=required><?php xl('SE Address','e'); ?></span></td>
 537                          <td class='required'>:</td>
 538                          <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer_street
 539                           value="<?php echo $result3{"subscriber_employer_street"}?>"
 540                            onchange="capitalizeMe(this);" /></td>
 541                         </tr>
 542
 543                         <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 544                          <td colspan="3">
 545                           <table>
 546                            <tr>
 547                                 <td><span class=required><?php xl('SE City','e'); ?>: </span></td>
 548                                 <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_city
 549                                  value="<?php echo $result3{"subscriber_employer_city"}?>"
 550                                   onchange="capitalizeMe(this);" /></td>
 551                                 <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE State','e') : xl('SE Locality','e') ?>: </span></td>
 552                         <td>
 553                                  <?php
 554                                   // Modified 7/2009 by BM to incorporate data types
 555                           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'), $result3['subscriber_employer_state']);
 556                                  ?>
 557                                 </td>
 558                            </tr>
 559                            <tr>
 560                                 <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE Zip Code','e') : xl('SE Postal Code','e') ?>: </span></td>
 561                                 <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_postal_code value="<?php echo $result3{"subscriber_employer_postal_code"}?>"></td>
 562                                 <td><span class=required><?php xl('SE Country','e'); ?>: </span></td>
 563                         <td>
 564                                  <?php
 565                                   // Modified 7/2009 by BM to incorporate data types
 566                           generate_form_field(array('data_type'=>$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'), $result3['subscriber_employer_country']);
 567                                  ?>
 568                         </td>
 569                            </tr>
 570                           </table>
 571                          </td>
 572                         </tr>
 573
 574                    </table>
 575                   </td>
 576
 577                   <td valign=top>
 578                 <table border="0">
 579                         <tr>
 580                                 <td><span class=required><?php xl('Relationship','e'); ?></span></td>
 581                                 <td class=required>:</td>
 582                                 <td colspan=3><?php
 583                                         // Modified 6/2009 by BM to use list_options and function
 584                                         generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_relationship'),'list_id'=>'sub_relation','empty_title'=>' '), $result3['subscriber_relationship']);
 585                                         ?>
 586
 587                                 <a href="javascript:popUp('browse.php?browsenum=<?php echo $i?>')" class=text>(<?php xl('Browse','e'); ?>)</a></td>
 588                                 <td></td><td></td><td></td><td></td>
 589                         </tr>
 590                         <tr>
 591                                 <td width=120><span class=required><?php xl('Subscriber','e'); ?> </span></td>
 592                                 <td class=required>:</td>
 593                                 <td colspan=3><input type=entry size=10 name=i<?php echo $i?>subscriber_fname   value="<?php echo $result3{"subscriber_fname"}?>" onchange="capitalizeMe(this);" />
 594                                 <input type=entry size=3 name=i<?php echo $i?>subscriber_mname value="<?php echo $result3{"subscriber_mname"}?>" onchange="capitalizeMe(this);" />
 595                                 <input type=entry size=10 name=i<?php echo $i?>subscriber_lname value="<?php echo $result3{"subscriber_lname"}?>" onchange="capitalizeMe(this);" /></td>
 596                                 <td></td><td></td><td></td><td></td>
 597                         </tr>
 598                         <tr>
 599                                 <td><span class=bold><?php xl('D.O.B.','e'); ?> </span></td>
 600                                 <td class=required>:</td>
 601                                 <td><input type='entry' size='11' id='i<?php echo $i?>subscriber_DOB' name='i<?php echo $i?>subscriber_DOB' value='<?php echo $result3['subscriber_DOB'] ?>' onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)' title='yyyy-mm-dd' /><img src='../../pic/show_calendar.gif' align='absbottom' width='24' height='22' id='img_i<?php echo $i; ?>dob_date' border='0' alt='[?]' style='cursor:pointer' title='<?php xl('Click here to choose a date','e'); ?>'></td>
 602
 603                                 <td><span class=bold><?php xl('Sex','e'); ?>: </span></td>
 604                                 <td><?php
 605                                         // Modified 6/2009 by BM to use list_options and function
 606                                         generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_sex'),'list_id'=>'sex'), $result3['subscriber_sex']);
 607                                         ?>
 608                                 </td>
 609                                 <td></td><td></td> <td></td><td></td>
 610                         </tr>
 611                         <tr>
 612                                 <td class=leftborder><span class=bold><?php xl('S.S.','e'); ?> </span></td>
 613                                 <td class=required>:</td>
 614                                 <td><input type=entry size=11 name=i<?php echo $i?>subscriber_ss value="<?php echo $result3{"subscriber_ss"}?>"></td>
 615                         </tr>
 616
 617                         <tr>
 618                                 <td><span class=required><?php xl('Subscriber Address','e'); ?> </span></td>
 619                                 <td class=required>:</td>
 620                                 <td><input type=entry size=20 name=i<?php echo $i?>subscriber_street value="<?php echo $result3{"subscriber_street"}?>" onchange="capitalizeMe(this);" /></td>
 621
 622                                 <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('State','e') : xl('Locality','e') ?>: </span></td>
 623                                 <td>
 624                                         <?php
 625                                         // Modified 7/2009 by BM to incorporate data types
 626                                         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']);
 627                                 ?>
 628                                 </td>
 629                         </tr>
 630                         <tr>
 631                                 <td class=leftborder><span class=required><?php xl('City','e'); ?></span></td>
 632                                 <td class=required>:</td>
 633                                 <td><input type=entry size=11 name=i<?php echo $i?>subscriber_city value="<?php echo $result3{"subscriber_city"}?>" onchange="capitalizeMe(this);" /></td><td class=leftborder><span class='required'<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>><?php xl('Country','e'); ?>: </span></td><td>
 634                                         <?php
 635                                         // Modified 7/2009 by BM to incorporate data types
 636                                         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'), $result3['subscriber_country']);
 637                                         ?>
 638                                 </td>
 639 </tr>
 640                         <tr>
 641                                 <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('Zip Code','e') : xl('Postal Code','e') ?> </span></td><td class=required>:</td><td><input type=entry size=10 name=i<?php echo $i?>subscriber_postal_code value="<?php echo $result3{"subscriber_postal_code"}?>"></td>
 642
 643                                 <td colspan=2>
 644                                 </td><td></td>
 645                         </tr>
 646                         <tr>
 647                                 <td><span class=bold><?php xl('Subscriber Phone','e'); ?></span></td>
 648                                 <td class=required>:</td>
 649                                 <td><input type='text' size='20' name='i<?php echo $i?>subscriber_phone' value='<?php echo $result3["subscriber_phone"] ?>' onkeyup='phonekeyup(this,mypcc)' /></td>
 650                                 <td colspan=2><span class=bold><?php xl('CoPay','e'); ?>: <input type=text size="6" name=i<?php echo $i?>copay value="<?php echo $result3{"copay"}?>"></span></td>
 651                                 <td colspan=2>
 652                                 </td><td></td><td></td>
 653                         </tr>
 654                         <tr>
 655                                 <td colspan=0><span class='required'><?php xl('Accept Assignment','e'); ?></span></td>
 656                                 <td class=required>:</td>
 657                                 <td colspan=2>
 658                                         <select name=i<?php echo $i?>accept_assignment>
 659                                                 <option value="TRUE" <?php if (strtoupper($result3{"accept_assignment"}) == "TRUE") echo "selected"?>><?php xl('YES','e'); ?></option>
 660                                                 <option value="FALSE" <?php if (strtoupper($result3{"accept_assignment"}) == "FALSE") echo "selected"?>><?php xl('NO','e'); ?></option>
 661                                         </select>
 662                                 </td>
 663                                 <td></td><td></td>
 664                                 <td colspan=2>
 665                                 </td><td></td>
 666                         </tr>
 667       <tr>
 668         <td><span class='bold'><?php xl('Secondary Medicare Type','e'); ?></span></td>
 669         <td class='bold'>:</td>
 670         <td colspan='6'>
 671           <select name=i<?php echo $i?>policy_type>
 672 <?php
 673   foreach ($policy_types AS $key => $value) {
 674     echo "            <option value ='$key'";
 675     if ($key == $result3['policy_type']) echo " selected";
 676     echo ">" . htmlspecialchars($value) . "</option>\n";
 677   }
 678 ?>
 679           </select>
 680         </td>
 681       </tr>
 682                 </table>
 683
 684                   </td>
 685                  </tr>
 686                 </table>
 687
 688                 </div>
 689
 690         <?php } //end insurer for loop ?>
 691
 692         </div>
 693 </div>
 694
 695 <?php } // end of "if not simplified_demographics" ?>
 696 </div></div>
 697
 698 </form>
 699
 700 <br>
 701
 702 <script language="JavaScript">
 703
 704  // fix inconsistently formatted phone numbers from the database
 705  var f = document.forms[0];
 706  if (f.form_phone_contact) phonekeyup(f.form_phone_contact,mypcc);
 707  if (f.form_phone_home   ) phonekeyup(f.form_phone_home   ,mypcc);
 708  if (f.form_phone_biz    ) phonekeyup(f.form_phone_biz    ,mypcc);
 709  if (f.form_phone_cell   ) phonekeyup(f.form_phone_cell   ,mypcc);
 710
 711 <?php if (! $GLOBALS['simplified_demographics']) { ?>
 712  phonekeyup(f.i1subscriber_phone,mypcc);
 713  phonekeyup(f.i2subscriber_phone,mypcc);
 714  phonekeyup(f.i3subscriber_phone,mypcc);
 715 <?php } ?>
 716
 717 <?php if ($GLOBALS['concurrent_layout'] && $set_pid) { ?>
 718  parent.left_nav.setPatient(<?php echo "'" . addslashes($result['fname']) . " " . addslashes($result['lname']) . "',$pid,'" . addslashes($result['pubpid']) . "','', ' " . xl('DOB') . ": " . oeFormatShortDate($result['DOB_YMD']) . " " . xl('Age') . ": " . getPatientAge($result['DOB_YMD']) . "'"; ?>);
 719  parent.left_nav.setRadio(window.name, 'dem');
 720 <?php } ?>
 721
 722 <?php echo $date_init; ?>
 723 <?php if (! $GLOBALS['simplified_demographics']) { for ($i=1; $i<=3; $i++): ?>
 724  Calendar.setup({inputField:"i<?php echo $i?>effective_date", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i?>effective_date"});
 725  Calendar.setup({inputField:"i<?php echo $i?>subscriber_DOB", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i?>dob_date"});
 726 <?php endfor; } ?>
 727 </script>
 728
 729 <!-- include support for the list-add selectbox feature -->
 730 <?php include $GLOBALS['fileroot']."/library/options_listadd.inc"; ?>
 731
 732 </body>
 733
 734 </html>