interface/patient_file/summary/demographics_full.php

   1 <?php
   2  include_once("../../globals.php");
   3  include_once("$srcdir/acl.inc");
   4
   5  // Session pid must be right or bad things can happen when demographics are saved!
   6  //
   7  include_once("$srcdir/pid.inc");
   8  $set_pid = $_GET["set_pid"] ? $_GET["set_pid"] : $_GET["pid"];
   9  if ($set_pid && $set_pid != $_SESSION["pid"]) {
  10   setpid($set_pid);
  11  }
  12
  13  include_once("$srcdir/patient.inc");
  14
  15  $result = getPatientData($pid);
  16  $result2 = getEmployerData($pid);
  17
  18  // Check authorization.
  19  $thisauth = acl_check('patients', 'demo');
  20  if ($pid) {
  21   if ($thisauth != 'write')
  22    die("Updating demographics is not authorized.");
  23   if ($result['squad'] && ! acl_check('squads', $result['squad']))
  24    die("You are not authorized to access this squad.");
  25  } else {
  26   if ($thisauth != 'write' && $thisauth != 'addonly')
  27    die("Adding demographics is not authorized.");
  28  }
  29
  30 $relats = array('','self','spouse','child','other');
  31 $statii = array('married','single','divorced','widowed','separated','domestic partner');
  32
  33 $langi = getLanguages();
  34 $ethnoraciali = getEthnoRacials();
  35 $provideri = getProviderInfo();
  36 $insurancei = getInsuranceProviders();
  37 ?>
  38 <html>
  39 <head>
  40
  41 <link rel=stylesheet href="<?php echo $css_header; ?>" type="text/css">
  42
  43 <script type="text/javascript" src="../../../library/dialog.js"></script>
  44 <script type="text/javascript" src="../../../library/textformat.js"></script>
  45
  46 <SCRIPT LANGUAGE="JavaScript"><!--
  47
  48 var mypcc = '<?php echo $GLOBALS['phone_country_code'] ?>';
  49
  50 //code used from http://tech.irt.org/articles/js037/
  51 function replace(string,text,by) {
  52  // Replaces text with by in string
  53  var strLength = string.length, txtLength = text.length;
  54  if ((strLength == 0) || (txtLength == 0)) return string;
  55
  56  var i = string.indexOf(text);
  57  if ((!i) && (text != string.substring(0,txtLength))) return string;
  58  if (i == -1) return string;
  59
  60  var newstr = string.substring(0,i) + by;
  61
  62  if (i+txtLength < strLength)
  63   newstr += replace(string.substring(i+txtLength,strLength),text,by);
  64
  65  return newstr;
  66 }
  67
  68 function upperFirst(string,text) {
  69  return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
  70 }
  71
  72 <?php for ($i=1;$i<=3;$i++) { ?>
  73 function auto_populate_employer_address<?php echo $i ?>(){
  74  if (document.demographics_form.i<?php echo $i?>subscriber_relationship.options[document.demographics_form.i<?php echo $i?>subscriber_relationship.selectedIndex].value == "self") {
  75   document.demographics_form.i<?php echo $i?>subscriber_fname.value=document.demographics_form.fname.value;
  76   document.demographics_form.i<?php echo $i?>subscriber_mname.value=document.demographics_form.mname.value;
  77   document.demographics_form.i<?php echo $i?>subscriber_lname.value=document.demographics_form.lname.value;
  78   document.demographics_form.i<?php echo $i?>subscriber_street.value=document.demographics_form.street.value;
  79   document.demographics_form.i<?php echo $i?>subscriber_city.value=document.demographics_form.city.value;
  80   document.demographics_form.i<?php echo $i?>subscriber_state.value=document.demographics_form.state.value;
  81   document.demographics_form.i<?php echo $i?>subscriber_postal_code.value=document.demographics_form.postal_code.value;
  82   document.demographics_form.i<?php echo $i?>subscriber_country.value=document.demographics_form.country_code.value;
  83   document.demographics_form.i<?php echo $i?>subscriber_phone.value=document.demographics_form.phone_home.value;
  84   document.demographics_form.i<?php echo $i?>subscriber_DOB.value=document.demographics_form.dob.value;
  85   document.demographics_form.i<?php echo $i?>subscriber_ss.value=document.demographics_form.ss.value;
  86   document.demographics_form.i<?php echo $i?>subscriber_sex.selectedIndex = document.demographics_form.sex.selectedIndex;
  87   document.demographics_form.i<?php echo $i?>subscriber_employer.value=document.demographics_form.ename.value;
  88   document.demographics_form.i<?php echo $i?>subscriber_employer_street.value=document.demographics_form.estreet.value;
  89   document.demographics_form.i<?php echo $i?>subscriber_employer_city.value=document.demographics_form.ecity.value;
  90   document.demographics_form.i<?php echo $i?>subscriber_employer_state.value=document.demographics_form.estate.value;
  91   document.demographics_form.i<?php echo $i?>subscriber_employer_postal_code.value=document.demographics_form.epostal_code.value;
  92   document.demographics_form.i<?php echo $i?>subscriber_employer_country.value=document.demographics_form.ecountry.value;
  93  }
  94 }
  95
  96 <?php } ?>
  97
  98 function popUp(URL) {
  99  day = new Date();
 100  id = day.getTime();
 101  eval("page" + id + " = window.open(URL, '" + id + "', 'toolbar=0,scrollbars=1,location=0,statusbar=0,menubar=0,resizable=1,width=400,height=300,left = 440,top = 362');");
 102 }
 103
 104 function checkNum () {
 105  var re= new RegExp();
 106  re = /^\d*\.?\d*$/;
 107  str=document.demographics_form.monthly_income.value;
 108  if(re.exec(str))
 109  {
 110  }else{
 111   alert("Please enter a dollar amount using only numbers and a decimal point.");
 112  }
 113 }
 114
 115 // Indicates which insurance slot is being updated.
 116 var insurance_index = 0;
 117
 118 // The OnClick handler for searching/adding the insurance company.
 119 function ins_search(ins) {
 120  insurance_index = ins;
 121  dlgopen('../../practice/ins_search.php', '_blank', 550, 400);
 122  return false;
 123 }
 124
 125 // The ins_search.php window calls this to set the selected insurance.
 126 function set_insurance(ins_id, ins_name) {
 127  var thesel = document.forms[0]['i' + insurance_index + 'provider'];
 128  var theopts = thesel.options; // the array of Option objects
 129  var i = 0;
 130  for (; i < theopts.length; ++i) {
 131   if (theopts[i].value == ins_id) {
 132    theopts[i].selected = true;
 133    return;
 134   }
 135  }
 136  // no matching option was found so create one, append it to the
 137  // end of the list, and select it.
 138  theopts[i] = new Option(ins_name, ins_id, false, true);
 139 }
 140
 141 //-->
 142
 143 </script>
 144 </head>
 145
 146 <body <?php echo $top_bg_line; ?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
 147
 148 <form action='demographics_save.php' name='demographics_form' method='post'>
 149 <input type=hidden name=mode value=save>
 150
 151 <?php if ($GLOBALS['concurrent_layout']) { ?>
 152 <a href="demographics.php">
 153 <?php } else { ?>
 154 <a href="patient_summary.php" target=Main>
 155 <?php } ?>
 156 <font class=title><?php xl('Demographics','e'); ?></font>
 157 <font class=back><?php echo $tback;?></font></a>
 158
 159 <table border="0" cellpadding="0" width='100%'>
 160
 161  <tr>
 162   <td valign="top"><span class=required><?php xl('Name','e'); ?>: </span></td>
 163   <td colspan="4" nowrap>
 164    <select name=title tabindex="1">
 165     <option value="<?php echo $result{"title"} ?>"><?php echo $result{"title"} ?></option>
 166     <option value="Mrs."><?php xl('Mrs','e'); ?>.</option>
 167     <option value="Ms."><?php xl('Ms','e'); ?>.</option>
 168     <option value="Mr."><?php xl('Mr','e'); ?>.</option>
 169     <option value="Dr."><?php xl('Dr','e'); ?>.</option>
 170    </select>
 171    <input tabindex="2" type=entry size=15 name=fname value="<?php echo $result{"fname"} ?>">
 172    <input tabindex="3" type=entry size=3 name=mname value="<?php echo $result{"mname"} ?>">
 173    <input tabindex="4" type=entry size=15 name=lname value="<?php echo $result{"lname"} ?>">
 174    &nbsp;
 175    <span class='bold'><?php echo ($GLOBALS['athletic_team']) ? 'OID ' : '' ?><?php xl('Number','e'); ?>: </span>
 176   </td>
 177   <td><input type='entry' size='10' name='pubpid' value="<?php echo $result{"pubpid"} ?>"></td>
 178  </tr>
 179
 180  <tr>
 181   <td valign='top'><span class='required'><?php xl('DOB','e'); ?>: </span></td>
 182   <td>
 183    <input tabindex='5' type='entry' size='11' name='dob'
 184     value='<?php echo $result['DOB'] ?>' onkeyup='datekeyup(this,mypcc)'
 185     onblur='dateblur(this,mypcc)' title='yyyy-mm-dd' />
 186   </td>
 187   <td rowspan="12">&nbsp;</td>
 188   <td><span class='bold'><?php xl('Emergency Contact','e'); ?>: </span></td>
 189   <td rowspan="12">&nbsp;</td>
 190   <td><input type='entry' size='10' name='contact_relationship' value="<?php echo $result{"contact_relationship"}?>"></td>
 191  </tr>
 192
 193  <tr>
 194   <td><span class=required><?php xl('Sex','e'); ?>: </span></td>
 195   <td>
 196    <select name=sex tabindex="6">
 197     <option value="Female" <?php if ($result{"sex"} == "Female") {echo "selected";};?>><?php xl('Female','e'); ?></option>
 198     <option value="Male" <?php if ($result{"sex"} == "Male") {echo "selected";};?>><?php xl('Male','e'); ?></option>
 199    </select>
 200   </td>
 201   <td><span class=bold><?php xl('Emergency Phone','e'); ?>:</span></td>
 202   <td><input type='text' size='20' name='phone_contact' value='<?php echo $result['phone_contact'] ?>' onkeyup='phonekeyup(this,mypcc)' /></td>
 203  </tr>
 204
 205  <tr>
 206   <td><span class=bold><?php xl('S.S.','e'); ?>: </span></td>
 207   <td><input tabindex="7" type=entry size=11 name=ss value="<?php echo $result{"ss"}?>"></td>
 208   <td><span class='bold'><?php xl('Home Phone','e'); ?>: </span></td>
 209   <td><input type='text' size='20' name='phone_home' value='<?php echo $result['phone_home'] ?>' onkeyup='phonekeyup(this,mypcc)' /></td>
 210  </tr>
 211
 212  <tr>
 213   <td><span class=required><?php xl('Address','e'); ?>: </span></td>
 214   <td><input tabindex="8" type=entry size=25 name=street value="<?php echo $result{"street"}?>"></td>
 215   <td><span class=bold><?php xl('Work Phone','e'); ?>:</span></td>
 216   <td><input type='text' size='20' name='phone_biz' value='<?php echo $result['phone_biz'] ?>' onkeyup='phonekeyup(this,mypcc)' /></td>
 217  </tr>
 218
 219  <tr>
 220   <td><span class=required><?php xl('City','e'); ?>: </span></td>
 221   <td><input tabindex="9" type=entry size=15 name=city value="<?php echo $result{"city"}?>"></td>
 222   <td><span class=bold><?php xl('Mobile Phone','e'); ?>: </span></td>
 223   <td><input type='text' size='20' name='phone_cell' value='<?php echo $result['phone_cell'] ?>' onkeyup='phonekeyup(this,mypcc)' /></td>
 224  </tr>
 225
 226  <tr>
 227   <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? 'State' : 'Locality' ?>: </span></td>
 228   <td><input tabindex="10" type=entry size=15 name=state value="<?php echo $result{"state"}?>"></td>
 229   <td><span class='bold'><?php xl('License/ID','e'); ?>: </span></td>
 230   <td><input tabindex="12" type='entry' size='15' name='drivers_license' value="<?php echo $result{"drivers_license"}?>"></td>
 231  </tr>
 232
 233  <tr>
 234   <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? 'Zip' : 'Postal' ?> <?php xl('Code','e'); ?>: </span></td>
 235   <td><input tabindex="11" type=entry size=6 name=postal_code value="<?php echo $result{"postal_code"}?>"></td>
 236   <td><span class='bold'><?php xl('Contact Email','e'); ?>: </span></td><td><input type=entry size=30 name=email value="<?php echo $result{"email"}?>"></td>
 237  </tr>
 238
 239  <tr>
 240   <td><span class='required'<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 241       <?php xl('Country','e'); ?>: </span></td>
 242   <td><input tabindex="13" type='entry' size='10' name='country_code'
 243        value="<?php echo $result{"country_code"}?>"
 244        <?php if ($GLOBALS['omit_employers']) echo "style='display:none'"; ?>></td>
 245 <?php if (!$GLOBALS['weight_loss_clinic']) { ?>
 246   <td><span class='bold' colspan='2'>
 247    <?php echo $GLOBALS['omit_employers'] ? xl('List Immediate Family Members') : xl('User Defined Fields'); ?>:
 248   </span></td>
 249 <?php } ?>
 250  </tr>
 251
 252  <tr>
 253   <td><span class=required><?php xl('Marital Status','e'); ?>: </span></td>
 254   <td>
 255    <select name=status tabindex="14">
 256 <?php
 257  print "<!-- ".$result["status"]." -->\n";
 258  foreach ($statii as $s) {
 259   if ($s == "unassigned") {
 260    echo "<option value=''";
 261   } else {
 262    echo "<option value='".$s."'";
 263   }
 264
 265   if ($s == $result["status"])
 266    echo " selected";
 267
 268   echo ">".ucwords($s)."</option>\n";
 269  }
 270 ?>
 271    </select>
 272   </td>
 273
 274 <?php if ($GLOBALS['weight_loss_clinic']) { ?>
 275   <td class='bold'>Starting Weight</td>
 276   <td class='bold'>
 277    <input name="genericname1" size='4' value="<?php echo $result{"genericname1"} ?>" />
 278    &nbsp;Date:
 279    <input name="genericval1" size='10' value="<?php echo $result{"genericval1"} ?>" />
 280   </td>
 281 <?php } else { ?>
 282   <td><input name="genericname1" size='20' value="<?php echo $result{"genericname1"} ?>" /></td>
 283   <td><input name="genericval1" size='20' value="<?php echo $result{"genericval1"} ?>" /></td>
 284 <?php } ?>
 285
 286  </tr>
 287
 288  <tr>
 289   <td><span class=required><?php xl('Provider','e'); ?>: </span></td>
 290   <td>
 291    <select tabindex="15" name="providerID" onchange="javascript:document.demographics_form.referrer.value=upperFirst(this.options[this.selectedIndex].text,this.options[this.selectedIndex].text);">
 292     <option value=''><?php xl('Unassigned','e'); ?></option>
 293 <?php
 294  foreach ($provideri as $s) {
 295   //echo "defined provider is: " .trim($s['fname']." ".$s['lname']). " compared to : " .$result["referrer"] . "<br />";
 296
 297   echo "<option value='".$s['id']."'";
 298
 299   if ($s['id'] == $result["providerID"])
 300    echo " selected";
 301    echo ">".ucwords($s['fname']." ".$s['lname'])."</option>\n";
 302  }
 303 ?>
 304    </select>
 305   </td>
 306
 307 <?php if ($GLOBALS['weight_loss_clinic']) { ?>
 308   <td class='bold'>Ending Weight</td>
 309   <td class='bold'>
 310    <input name="genericname2" size='4' value="<?php echo $result{"genericname2"} ?>" />
 311    &nbsp;Date:
 312    <input name="genericval2" size='10' value="<?php echo $result{"genericval2"} ?>" />
 313   </td>
 314 <?php } else { ?>
 315   <td><input name="genericname2" size='20' value="<?php echo $result{"genericname2"};?>" /></td>
 316   <td><input name="genericval2" size='20' value="<?php echo $result{"genericval2"};?>" /></td>
 317 <?php } ?>
 318
 319  </tr>
 320
 321  <tr>
 322   <td><span class=bold><?php xl('Pharmacy','e'); ?>: </span></td>
 323   <td colspan='5'>
 324    <select name='pharmacy_id'>
 325     <option value='0'></option>
 326     <?php
 327      $pres = sqlStatement("SELECT d.id, d.name, a.line1, a.city, " .
 328      "p.area_code, p.prefix, p.number FROM pharmacies AS d " .
 329      "LEFT OUTER JOIN addresses AS a ON a.foreign_id = d.id " .
 330      "LEFT OUTER JOIN phone_numbers AS p ON p.foreign_id = d.id AND p.type = 2 " .
 331      "ORDER BY name, area_code, prefix, number");
 332      while ($prow = sqlFetchArray($pres)) {
 333       $key = $prow['id'];
 334       echo "    <option value='$key'";
 335       if ($result['pharmacy_id'] == $key) echo " selected";
 336       echo '>' . $prow['name'] . ' ' . $prow['area_code'] . '-' .
 337        $prow['prefix'] . '-' . $prow['number'] . ' / ' .
 338        $prow['line1'] . ' / ' . $prow['city'] . "</option>\n";
 339      }
 340     ?>
 341    </select>
 342   </td>
 343  </tr>
 344
 345  <tr>
 346   <td colspan='6'>
 347    <a href="javascript:document.demographics_form.submit();" class='link_submit'>[<?php xl('Save Patient Demographics','e'); ?>]</a>
 348    <hr>
 349   </td>
 350  </tr>
 351 </table>
 352
 353 <?php if (! $GLOBALS['athletic_team']) { ?>
 354
 355 <table width='100%'>
 356  <tr>
 357   <th colspan='4' align='left' class='bold'><?php xl('HIPAA Choices','e'); ?>:</th>
 358  </tr>
 359  <tr>
 360   <td class='bold' width='10%' nowrap><?php xl('Did you receive a copy of the HIPAA Notice?','e'); ?> </td>
 361   <td class='bold'>
 362    <select name = "hipaa_notice">
 363 <?php
 364  echo "    <option>NO</option>\n";
 365  $opt_sel = ($result['hipaa_notice'] == 'YES' || ($GLOBALS['weight_loss_clinic'] && !$result['hipaa_notice']))
 366   ? ' selected' : '';
 367  echo "    <option$opt_sel>YES</option>\n";
 368 ?>
 369    </select>
 370   </td>
 371   <td class='bold' width='10%' nowrap><?php xl('Allow Voice Msg','e'); ?>:</td>
 372   <td class='bold'>
 373    <select name="hipaa_voice">
 374 <?php
 375  echo "    <option>NO</option>\n";
 376  $opt_sel = ($result['hipaa_voice'] == 'YES' || ($GLOBALS['weight_loss_clinic'] && !$result['hipaa_voice']))
 377   ? ' selected' : '';
 378  echo "    <option$opt_sel>YES</option>\n";
 379 ?>
 380    </select>
 381   </td>
 382  </tr>
 383  <tr>
 384   <td class='bold' width='10%' nowrap><?php xl('Allow Mail','e'); ?>:</td>
 385   <td class='bold'>
 386    <select name="hipaa_mail">
 387 <?php
 388  echo "    <option>NO</option>\n";
 389  $opt_sel = ($result['hipaa_mail'] == 'YES' || ($GLOBALS['weight_loss_clinic'] && !$result['hipaa_mail']))
 390   ? ' selected' : '';
 391  echo "    <option$opt_sel>YES</option>\n";
 392 ?>
 393    </select>
 394   </td>
 395   <td class='bold' width='10%' nowrap><?php xl('Who may we leave a message with?','e'); ?> </td>
 396   <td><input name="hipaa_message" size='20' value="<?php echo $result['hipaa_message']; ?>" /></td>
 397  </tr>
 398  <tr>
 399   <td colspan='4'>
 400    <a href="javascript:document.demographics_form.submit();" class=link_submit>[<?php xl('Save Patient Demographics','e'); ?>]</a>
 401    <br><hr>
 402   </td>
 403  </tr>
 404 </table>
 405
 406 <?php } ?>
 407
 408 <table width='100%'<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 409  <tr>
 410   <td valign=top>
 411    <input type=hidden size=30 name=referrer value="<?php echo ucfirst($result{"referrer"});?>">
 412    <input type=hidden size=20 name=referrerID value="<?php echo $result{"referrerID"}?>">
 413    <input type=hidden size=20 name=db_id value="<?php echo $result{"id"}?>">
 414    <table>
 415     <tr>
 416      <td><span class=bold><?php xl('Occupation','e'); ?>: </span></td>
 417      <td><input type=entry size=20 name=occupation value="<?php echo $result{"occupation"}?>"></td>
 418     </tr>
 419     <tr>
 420      <td class='bold'><?php xl('Employer','e'); ?>:</td>
 421      <td><input type=entry size=20 name=ename value="<?php echo $result2{"name"}?>"></td>
 422     </tr>
 423     <tr>
 424      <td colspan='2' class='bold' style='font-weight:normal'>(<?php xl('if unemployed enter Student, PT Student, or leave blank','e'); ?>)</td>
 425     </tr>
 426 <?php if ($GLOBALS['athletic_team']) { ?>
 427     <tr>
 428      <td colspan='2' class='bold' style='font-weight:normal'>&nbsp;</td>
 429     </tr>
 430     <tr>
 431      <td><span class='bold'><?php xl('Squad','e'); ?>: </span></td>
 432      <td>
 433       <select name='squad'>
 434        <option value=''>&nbsp;</option>
 435 <?php
 436  $squads = acl_get_squads();
 437  if ($squads) {
 438   foreach ($squads as $key => $value) {
 439    echo "       <option value='$key'";
 440    if ($result['squad'] == $key) echo " selected";
 441    echo ">" . $value[3] . "</option>\n";
 442   }
 443  }
 444 ?>
 445       </select>
 446      </td>
 447     </tr>
 448 <?php } ?>
 449    </table>
 450   </td>
 451   <td valign=top>
 452
 453 <?php if (! $GLOBALS['simplified_demographics']) { ?>
 454
 455    <table>
 456     <tr>
 457      <td><span class=bold><?php xl('Employer Address','e'); ?></span></td><td><span class=bold></span><input type=entry size=25 name=estreet value="<?php echo $result2{"street"}?>"></td>
 458     </tr>
 459     <tr>
 460      <td><span class=bold><?php xl('City','e'); ?>: </span></td><td><input type=entry size=15 name=ecity value="<?php echo $result2{"city"}?>"></td>
 461     </tr>
 462     <tr>
 463      <td><span class=bold><?php echo ($GLOBALS['phone_country_code'] == '1') ? 'State' : 'Locality' ?>: </span></td><td><input type=entry size=15 name=estate value="<?php echo $result2{"state"}?>"></td>
 464     </tr>
 465     <tr>
 466      <td><span class=bold><?php echo ($GLOBALS['phone_country_code'] == '1') ? 'Zip' : 'Postal' ?> <?php xl('Code','e'); ?>: </span></td><td><input type=entry size=10 name=epostal_code value="<?php echo $result2{"postal_code"}?>"></td>
 467     </tr>
 468     <tr>
 469      <td><span class=bold><?php xl('Country','e'); ?>: </span></td><td><input type=entry size=10 name=ecountry value="<?php echo $result2{"country"}?>"></td>
 470     </tr>
 471    </table>
 472
 473 <?php } ?>
 474
 475   </td>
 476   <td valign=top></td>
 477  </tr>
 478
 479  <tr>
 480   <td colspan=4>
 481    <a href="javascript:document.demographics_form.submit();" class=link_submit>[<?php xl('Save Patient Demographics','e'); ?>]</a><hr></td>
 482  </tr>
 483
 484 <?php if (! $GLOBALS['athletic_team'] && ! $GLOBALS['simplified_demographics']) { ?>
 485
 486  <tr>
 487   <td valign='top'>
 488    <span class='bold'><?php xl('Language','e'); ?>: </span><br>
 489    <select onchange="javascript:document.demographics_form.language.value=upperFirst(this.options[this.selectedIndex].value,this.options[this.selectedIndex].value);">
 490 <?php
 491  foreach ($langi as $s) {
 492   if ($s == "unassigned") {
 493    echo "<option value=''";
 494   } else {
 495    echo "<option value='".$s."'";
 496   }
 497   if ($s == strtolower($result["language"]))
 498    echo " selected";
 499   echo ">".ucwords($s)."</option>\n";
 500  }
 501 ?>
 502    </select><br>
 503    <input type=entry size=30 name=language value="<?php echo ucfirst($result{"language"});?>"><br><br />
 504    <span class=bold><?php xl('Race/Ethnicity','e'); ?>: </span><br>
 505    <select onchange="javascript:document.demographics_form.ethnoracial.value=upperFirst(this.options[this.selectedIndex].value,this.options[this.selectedIndex].value);">
 506 <?php
 507  foreach ($ethnoraciali as $s) {
 508   if ($s == "unassigned") {
 509    echo "<option value=''";
 510   } else {
 511    echo "<option value='".$s."'";
 512   }
 513   if ($s == strtolower($result["ethnoracial"]))
 514    echo " selected";
 515   echo ">".ucwords($s)."</option>\n";
 516  }
 517 ?>
 518    </select>
 519    <br>
 520    <input type=entry size=30 name=ethnoracial value="<?php echo ucfirst($result{"ethnoracial"});?>"><br>
 521   </td>
 522   <td valign=top>
 523    <table>
 524     <tr>
 525      <td><span class=bold><?php xl('Financial Review Date','e'); ?>: </span></td><td><input type=entry size=11 name=financial_review value="<?php if ($result{"financial_review"} != "0000-00-00 00:00:00") {echo date("m/d/Y",strtotime($result{"financial_review"}));} else {echo "MM/DD/YYYY";}?>"></td>
 526     </tr>
 527     <tr>
 528      <td><span class=bold><?php xl('Family Size','e'); ?>: </span></td><td><input type=entry size=20 name=family_size value="<?php echo $result{"family_size"}?>"></td>
 529     </tr>
 530     <tr>
 531      <td><span class=bold><?php xl('Monthly Income','e'); ?>: </span></td><td><input type=entry size=20 name=monthly_income onblur="javascript:checkNum();" value="<?php echo $result{"monthly_income"}?>"><span class=small>(<?php xl('Numbers only','e'); ?>)</span></td>
 532     </tr>
 533     <tr>
 534      <td><span class=bold><?php xl('Homeless, etc.','e'); ?>: </span></td><td><input type=entry size=20 name=homeless value="<?php echo $result{"homeless"}?>"></td>
 535     </tr>
 536     <tr>
 537      <td><span class=bold><?php xl('Interpreter','e'); ?>: </span></td><td><input type=entry size=20 name=interpretter value="<?php echo $result{"interpretter"}?>"></td>
 538     </tr>
 539     <tr>
 540      <td><span class=bold><?php xl('Migrant/Seasonal','e'); ?>: </span></td><td><input type=entry size=20 name=migrantseasonal value="<?php echo $result{"migrantseasonal"}?>"></td>
 541     </tr>
 542    </table>
 543   </td>
 544   <td valign=top></td>
 545  </tr>
 546
 547  <tr>
 548   <td colspan=4>
 549    <a href="javascript:document.demographics_form.submit();" class=link_submit>[<?php xl('Save Patient Demographics','e'); ?>]</a>
 550    <hr>
 551   </td>
 552  </tr>
 553
 554 <?php } ?>
 555
 556 </table>
 557
 558 <?php
 559  if (! $GLOBALS['simplified_demographics']) {
 560   $insurance_headings = array("Primary Insurance Provider:", "Secondary Insurance Provider", "Tertiary Insurance provider");
 561   $insurance_info = array();
 562   $insurance_info[1] = getInsuranceData($pid,"primary");
 563   $insurance_info[2] = getInsuranceData($pid,"secondary");
 564   $insurance_info[3] = getInsuranceData($pid,"tertiary");
 565   for($i=1;$i<=3;$i++) {
 566    $result3 = $insurance_info[$i];
 567 ?>
 568 <table border="0">
 569  <tr>
 570   <td valign=top>
 571    <table border="0">
 572     <tr>
 573      <td colspan="5"><span class='required'><?php echo $insurance_headings[$i -1]?></span></td>
 574     </tr>
 575     <tr>
 576      <td colspan="5">
 577       <select name="i<?php echo $i?>provider">
 578        <option value=""><?php xl('Unassigned','e'); ?></option>
 579 <?php
 580  foreach ($insurancei as $iid => $iname) {
 581   echo "<option value='" . $iid . "'";
 582   if (strtolower($iid) == strtolower($result3{"provider"}))
 583    echo " selected";
 584   echo ">" . $iname . "</option>\n";
 585  }
 586 ?>
 587       </select>&nbsp;<a href='' onclick='return ins_search(<?php echo $i?>)'><?php xl('Search/Add Insurer','e'); ?></a>
 588      </td>
 589     </tr>
 590     <tr>
 591      <td><span class=required><?php xl('Plan Name','e'); ?>: </span></td><td><input type=entry size=20 name=i<?php echo $i?>plan_name value="<?php echo $result3{"plan_name"}?>"></td>
 592     </tr>
 593     <tr>
 594      <td><span class=required><?php xl('Policy Number','e'); ?>: </span></td><td><input type=entry size=16 name=i<?php echo $i?>policy_number value="<?php echo $result3{"policy_number"}?>"></td>
 595     </tr>
 596     <tr>
 597      <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 $result3{"group_number"}?>"></td>
 598     </tr>
 599
 600     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 601      <td class='required'><?php xl('Subscriber Employer (SE)','e'); ?><br><span style='font-weight:normal'>
 602       (<?php xl('if unemployed enter Student','e'); ?>,<br><?php xl('PT Student, or leave blank','e'); ?>): </span></td>
 603      <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer value="<?php echo $result3{"subscriber_employer"}?>"></td>
 604     </tr>
 605
 606     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 607      <td><span class=required><?php xl('SE Address','e'); ?>: </span></td><td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer_street value="<?php echo $result3{"subscriber_employer_street"}?>"></td>
 608     </tr>
 609
 610     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 611      <td colspan="2">
 612       <table>
 613        <tr>
 614         <td><span class=required><?php xl('SE City','e'); ?>: </span></td>
 615         <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_city value="<?php echo $result3{"subscriber_employer_city"}?>"></td>
 616         <td><span class=required><?php xl('SE','e'); ?> <?php echo ($GLOBALS['phone_country_code'] == '1') ? 'State' : 'Locality' ?>: </span></td>
 617         <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_state value="<?php echo $result3{"subscriber_employer_state"}?>"></td>
 618        </tr>
 619        <tr>
 620         <td><span class=required><?php xl('SE','e'); ?> <?php echo ($GLOBALS['phone_country_code'] == '1') ? 'Zip' : 'Postal' ?> <?php xl('Code','e'); ?>: </span></td>
 621         <td><input type=entry size=10 name=i<?php echo $i?>subscriber_employer_postal_code value="<?php echo $result3{"subscriber_employer_postal_code"}?>"></td>
 622         <td><span class=required><?php xl('SE Country','e'); ?>: </span></td>
 623         <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer_country value="<?php echo $result3{"subscriber_employer_country"}?>"></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><input type=entry size=10 name=i<?php echo $i?>subscriber_fname value="<?php echo $result3{"subscriber_fname"}?>"><input type=entry size=3 name=i<?php echo $i?>subscriber_mname value="<?php echo $result3{"subscriber_mname"}?>"><input type=entry size=10 name=i<?php echo $i?>subscriber_lname value="<?php echo $result3{"subscriber_lname"}?>">
 634    <br>
 635    <span class=required><?php xl('Relationship','e'); ?>: </span>
 636    <select name=i<?php echo $i?>subscriber_relationship onchange="javascript:auto_populate_employer_address<?php echo $i?>();">
 637 <?php
 638  foreach ($relats as $s) {
 639   if ($s == "unassigned") {
 640    echo "<option value=''";
 641   } else {
 642    echo "<option value='".$s."'";
 643   }
 644   if ($s == $result3{"subscriber_relationship"})
 645    echo " selected";
 646   echo ">".ucfirst($s)."</option>\n";
 647 }
 648 ?>
 649    </select>
 650    <a href="javascript:popUp('browse.php?browsenum=<?php echo $i?>')" class=text>(<?php xl('Browse','e'); ?>)</a><br />
 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     value='<?php echo $result3['subscriber_DOB'] ?>'
 654     onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)'
 655     title='yyyy-mm-dd' />
 656    <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;
 657    <span class=bold><?php xl('Sex','e'); ?>: </span>
 658    <select name=i<?php echo $i?>subscriber_sex>
 659     <option value="Male" <?php if (strtolower($result3{"subscriber_sex"}) == "male") echo "selected"?>><?php xl('Male','e'); ?></option>
 660     <option value="Female" <?php if (strtolower($result3{"subscriber_sex"}) == "female") echo "selected"?>><?php xl('Female','e'); ?></option>
 661    </select>
 662    <br>
 663    <span class=required><?php xl('Subscriber Address','e'); ?>: </span><input type=entry size=25 name=i<?php echo $i?>subscriber_street value="<?php echo $result3{"subscriber_street"}?>"><br>
 664    <span class=required><?php xl('City','e'); ?>: </span><input type=entry size=15 name=i<?php echo $i?>subscriber_city value="<?php echo $result3{"subscriber_city"}?>">
 665    <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? 'State' : 'Locality' ?>: </span><input type=entry size=15 name=i<?php echo $i?>subscriber_state value="<?php echo $result3{"subscriber_state"}?>"><br>
 666    <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? 'Zip' : 'Postal' ?> <?php xl('Code','e'); ?>: </span><input type=entry size=10 name=i<?php echo $i?>subscriber_postal_code value="<?php echo $result3{"subscriber_postal_code"}?>">
 667    <span class='required'<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 668    <?php xl('Country','e'); ?>:
 669    <input type=entry size=10 name=i<?php echo $i?>subscriber_country
 670     value="<?php echo $result3{"subscriber_country"}?>"><br></span>
 671    <span class=bold><?php xl('Subscriber Phone','e'); ?>:
 672    <input type='text' size='20' name='i<?php echo $i?>subscriber_phone' value='<?php echo $result3["subscriber_phone"] ?>' onkeyup='phonekeyup(this,mypcc)' />
 673    </span><br />
 674    <span class=bold><?php xl('CoPay','e'); ?>: <input type=text size="6" name=i<?php echo $i?>copay value="<?php echo $result3{"copay"}?>">
 675   </td>
 676  </tr>
 677 </table>
 678 <a href="javascript:document.demographics_form.submit();" class=link_submit>[<?php xl('Save Patient Demographics','e'); ?>]</a>
 679 <hr>
 680
 681 <?php
 682   } //end insurer for loop
 683  } // end of "if not simplified_demographics"
 684 ?>
 685
 686 </form>
 687
 688 <br>
 689
 690 <script language="JavaScript">
 691
 692  // fix inconsistently formatted phone numbers from the database
 693  var f = document.forms[0];
 694  phonekeyup(f.phone_contact,mypcc);
 695  phonekeyup(f.phone_home,mypcc);
 696  phonekeyup(f.phone_biz,mypcc);
 697  phonekeyup(f.phone_cell,mypcc);
 698
 699 <?php if (! $GLOBALS['simplified_demographics']) { ?>
 700  phonekeyup(f.i1subscriber_phone,mypcc);
 701  phonekeyup(f.i2subscriber_phone,mypcc);
 702  phonekeyup(f.i3subscriber_phone,mypcc);
 703 <?php } ?>
 704
 705 <?php if ($GLOBALS['concurrent_layout'] && $set_pid) { ?>
 706  parent.left_nav.setPatient(<?php echo "'" . $result['fname'] . " " . $result['lname'] . "',$pid,''"; ?>);
 707  parent.left_nav.setRadio(window.name, 'dem');
 708 <?php } ?>
 709
 710 </script>
 711
 712 </body>
 713 </html>