interface/patient_file/summary/demographics_full.php

   1 <?
   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  if ($_GET["set_pid"] && $_GET["set_pid"] != $_SESSION["pid"]) {
   9   setpid($_GET["set_pid"]);
  10  }
  11  else if ($_GET["pid"] && $_GET["pid"] != $_SESSION["pid"]) {
  12   setpid($_GET["pid"]);
  13  }
  14
  15  include_once("$srcdir/patient.inc");
  16
  17  $result = getPatientData($pid);
  18  $result2 = getEmployerData($pid);
  19
  20  // Check authorization.
  21  $thisauth = acl_check('patients', 'demo');
  22  if ($pid) {
  23   if ($thisauth != 'write')
  24    die("Updating demographics is not authorized.");
  25   if ($result['squad'] && ! acl_check('squads', $result['squad']))
  26    die("You are not authorized to access this squad.");
  27  } else {
  28   if ($thisauth != 'write' && $thisauth != 'addonly')
  29    die("Adding demographics is not authorized.");
  30  }
  31
  32 $relats = array('','self','spouse','child','other');
  33 $statii = array('married','single','divorced','widowed','separated','domestic partner');
  34
  35 $langi = getLanguages();
  36 $ethnoraciali = getEthnoRacials();
  37 $provideri = getProviderInfo();
  38 $insurancei = getInsuranceProviders();
  39 ?>
  40 <html>
  41 <head>
  42
  43 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
  44
  45 <script type="text/javascript" src="../../../library/textformat.js"></script>
  46
  47 <SCRIPT LANGUAGE="JavaScript"><!--
  48
  49 var mypcc = '<? echo $GLOBALS['phone_country_code'] ?>';
  50
  51 //code used from http://tech.irt.org/articles/js037/
  52 function replace(string,text,by) {
  53  // Replaces text with by in string
  54  var strLength = string.length, txtLength = text.length;
  55  if ((strLength == 0) || (txtLength == 0)) return string;
  56
  57  var i = string.indexOf(text);
  58  if ((!i) && (text != string.substring(0,txtLength))) return string;
  59  if (i == -1) return string;
  60
  61  var newstr = string.substring(0,i) + by;
  62
  63  if (i+txtLength < strLength)
  64   newstr += replace(string.substring(i+txtLength,strLength),text,by);
  65
  66  return newstr;
  67 }
  68
  69 function upperFirst(string,text) {
  70  return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
  71 }
  72
  73 <? for ($i=1;$i<=3;$i++) { ?>
  74 function auto_populate_employer_address<?=$i?>(){
  75  //alert(document.demographics_form.i<?=$i?>subscriber_relationship.options[document.demographics_form.i<?=$i?>subscriber_relationship.selectedIndex].value);
  76  if (document.demographics_form.i<?=$i?>subscriber_relationship.options[document.demographics_form.i<?=$i?>subscriber_relationship.selectedIndex].value == "self") {
  77   document.demographics_form.i<?=$i?>subscriber_fname.value=document.demographics_form.fname.value;
  78   document.demographics_form.i<?=$i?>subscriber_mname.value=document.demographics_form.mname.value;
  79   document.demographics_form.i<?=$i?>subscriber_lname.value=document.demographics_form.lname.value;
  80   document.demographics_form.i<?=$i?>subscriber_street.value=document.demographics_form.street.value;
  81   document.demographics_form.i<?=$i?>subscriber_city.value=document.demographics_form.city.value;
  82   document.demographics_form.i<?=$i?>subscriber_state.value=document.demographics_form.state.value;
  83   document.demographics_form.i<?=$i?>subscriber_postal_code.value=document.demographics_form.postal_code.value;
  84   document.demographics_form.i<?=$i?>subscriber_country.value=document.demographics_form.country_code.value;
  85   document.demographics_form.i<?=$i?>subscriber_phone.value=document.demographics_form.phone_home.value;
  86   document.demographics_form.i<?=$i?>subscriber_DOB.value=document.demographics_form.dob.value;
  87   document.demographics_form.i<?=$i?>subscriber_ss.value=document.demographics_form.ss.value;
  88   document.demographics_form.i<?=$i?>subscriber_sex.selectedIndex = document.demographics_form.sex.selectedIndex;
  89   document.demographics_form.i<?=$i?>subscriber_employer.value=document.demographics_form.ename.value;
  90   document.demographics_form.i<?=$i?>subscriber_employer_street.value=document.demographics_form.estreet.value;
  91   document.demographics_form.i<?=$i?>subscriber_employer_city.value=document.demographics_form.ecity.value;
  92   document.demographics_form.i<?=$i?>subscriber_employer_state.value=document.demographics_form.estate.value;
  93   document.demographics_form.i<?=$i?>subscriber_employer_postal_code.value=document.demographics_form.epostal_code.value;
  94   document.demographics_form.i<?=$i?>subscriber_employer_country.value=document.demographics_form.ecountry.value;
  95  }
  96 }
  97
  98 <? } ?>
  99
 100 function popUp(URL) {
 101  day = new Date();
 102  id = day.getTime();
 103  eval("page" + id + " = window.open(URL, '" + id + "', 'toolbar=0,scrollbars=1,location=0,statusbar=0,menubar=0,resizable=1,width=400,height=300,left = 440,top = 362');");
 104 }
 105
 106 function checkNum () {
 107  var re= new RegExp();
 108  re = /^\d*\.?\d*$/;
 109  str=document.demographics_form.monthly_income.value;
 110  if(re.exec(str))
 111  {
 112  }else{
 113   alert("Please enter a dollar amount using only numbers and a decimal point.");
 114  }
 115 }
 116
 117 //-->
 118
 119 </script>
 120 </head>
 121
 122 <body <?echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
 123
 124 <form action='demographics_save.php' name='demographics_form' method='post'>
 125 <input type=hidden name=mode value=save>
 126
 127 <a href="patient_summary.php" target=Main><font class=title>Demographics</font><font class=back><?echo $tback;?></font></a>
 128
 129 <table border="0" cellpadding="0" width='100%'>
 130  <tr>
 131   <td valign="top"><span class=required>Name: </span></td>
 132   <td colspan="6">
 133    <select name=title tabindex="1">
 134     <option value="<?echo $result{"title"}?>"><?echo $result{"title"}?></option>
 135     <option value="Mr.">Mr.</option>
 136     <option value="Mrs.">Mrs.</option>
 137     <option value="Ms.">Ms.</option>
 138     <option value="Dr.">Dr.</option>
 139    </select>
 140    <input tabindex="2" type=entry size=15 name=fname value="<?echo $result{"fname"}?>"> <input tabindex="3" type=entry size=3 name=mname value="<?echo $result{"mname"}?>"> <input tabindex="4" type=entry size=15 name=lname value="<?echo $result{"lname"}?>">
 141   </td>
 142
 143  </tr>
 144  <tr>
 145   <td valign='top'><span class='required'>DOB: </span></td>
 146   <td>
 147    <input tabindex='5' type='entry' size='11' name='dob'
 148     value='<? echo $result['DOB'] ?>' onkeyup='datekeyup(this,mypcc)'
 149     onblur='dateblur(this,mypcc)' title='yyyy-mm-dd' />
 150   </td>
 151   <td rowspan="12">&nbsp;</td>
 152   <td><span class=bold><? echo ($GLOBALS['athletic_team']) ? 'Organizational ID' : 'Patient' ?> Number: </span></td>
 153   <td rowspan="12">&nbsp;</td>
 154   <td><input type='entry' size='10' name='pubpid' value="<?echo $result{"pubpid"}?>"></td>
 155  </tr>
 156  <tr>
 157   <td><span class=required>Sex: </span></td>
 158   <td>
 159    <select name=sex tabindex="6">
 160     <option value="Male" <?if ($result{"sex"} == "Male") {echo "selected";};?>>Male</option>
 161     <option value="Female" <?if ($result{"sex"} == "Female") {echo "selected";};?>>Female</option>
 162    </select>
 163   </td>
 164   <td><span class='bold'>Emergency Contact: </span></td>
 165   <td><input type='entry' size='10' name='contact_relationship' value="<?echo $result{"contact_relationship"}?>"></td>
 166  </tr>
 167  <tr>
 168   <td><span class=bold>S.S.: </span></td>
 169   <td><input tabindex="7" type=entry size=11 name=ss value="<?echo $result{"ss"}?>"></td>
 170   <td><span class=bold>Emergency Phone:</span></td>
 171   <td><input type='text' size='20' name='phone_contact' value='<?echo $result['phone_contact'] ?>' onkeyup='phonekeyup(this,mypcc)' /></td>
 172  </tr>
 173  <tr>
 174   <td><span class=required>Address: </span></td>
 175   <td><input tabindex="8" type=entry size=25 name=street value="<?echo $result{"street"}?>"></td>
 176   <td><span class='bold'>Home Phone: </span></td>
 177   <td><input type='text' size='20' name='phone_home' value='<?echo $result['phone_home'] ?>' onkeyup='phonekeyup(this,mypcc)' /></td>
 178  </tr>
 179  <tr>
 180   <td><span class=required>City: </span></td>
 181   <td><input tabindex="9" type=entry size=15 name=city value="<?echo $result{"city"}?>"></td>
 182   <td><span class=bold>Work Phone:</span></td>
 183   <td><input type='text' size='20' name='phone_biz' value='<?echo $result['phone_biz'] ?>' onkeyup='phonekeyup(this,mypcc)' /></td>
 184  </tr>
 185  <tr>
 186   <td><span class=required><? echo ($GLOBALS['phone_country_code'] == '1') ? 'State' : 'Locality' ?>: </span></td>
 187   <td><input tabindex="10" type=entry size=15 name=state value="<?echo $result{"state"}?>"></td>
 188   <td><span class=bold>Mobile Phone: </span></td>
 189   <td><input type='text' size='20' name='phone_cell' value='<?echo $result['phone_cell'] ?>' onkeyup='phonekeyup(this,mypcc)' /></td>
 190  </tr>
 191  <tr>
 192   <td><span class=required><? echo ($GLOBALS['phone_country_code'] == '1') ? 'Zip' : 'Postal' ?> Code: </span></td><td><input tabindex="11" type=entry size=6 name=postal_code value="<?echo $result{"postal_code"}?>"></td>
 193   <td><span class=bold>Contact Email: </span></td><td><input type=entry size=30 name=email value="<?echo $result{"email"}?>"></td>
 194  </tr>
 195  <tr>
 196   <td><span class=required>Country: </span></td><td><input tabindex="12" type=entry size=10 name=country_code value="<?echo $result{"country_code"}?>"></td>
 197   <td><span class=bold>User Defined Fields</span></td>
 198  </tr>
 199  <tr>
 200   <td><span class=required>Marital Status: </span></td>
 201   <td>
 202    <select name=status tabindex="13">
 203 <?php
 204  print "<!-- ".$result["status"]." -->\n";
 205  foreach ($statii as $s) {
 206   if ($s == "unassigned") {
 207    echo "<option value=''";
 208   } else {
 209    echo "<option value='".$s."'";
 210   }
 211
 212   if ($s == $result["status"])
 213    echo " selected";
 214
 215   echo ">".ucwords($s)."</option>\n";
 216  }
 217 ?>
 218    </select>
 219   </td>
 220   <td><input name="genericname1" size=20 value="<? echo $result{"genericname1"} ?>" /></td><td><input name="genericval1" size='20' value="<? echo $result{"genericval1"} ?>" /></td>
 221  </tr>
 222  <tr>
 223   <td><span class=required>Provider: </span></td>
 224   <td>
 225    <select tabindex="14" name="providerID" onchange="javascript:document.demographics_form.referrer.value=upperFirst(this.options[this.selectedIndex].text,this.options[this.selectedIndex].text);">
 226     <option value=''>Unassigned</option>
 227 <?php
 228  foreach ($provideri as $s) {
 229   //echo "defined provider is: " .trim($s['fname']." ".$s['lname']). " compared to : " .$result["referrer"] . "<br />";
 230
 231   echo "<option value='".$s['id']."'";
 232
 233   if ($s['id'] == $result["providerID"])
 234    echo " selected";
 235    echo ">".ucwords($s['fname']." ".$s['lname'])."</option>\n";
 236  }
 237 ?>
 238    </select>
 239   </td>
 240   <td><input name="genericname2" size='20' value="<?echo $result{"genericname2"};?>" /></td>
 241   <td><input name="genericval2" size='20' value="<?echo $result{"genericval2"};?>" /></td>
 242  </tr>
 243  <tr>
 244   <td colspan='6'>
 245    <a href="javascript:document.demographics_form.submit();" target='Main' class='link_submit'>[Save Patient Demographics]</a>
 246    <hr>
 247   </td>
 248  </tr>
 249 </table>
 250
 251 <? if (! $GLOBALS['athletic_team']) { ?>
 252
 253 <table width='100%'>
 254  <tr>
 255   <th colspan='4' align='left' class='bold'>HIPAA Choices:</th>
 256  </tr>
 257  <tr>
 258   <td class='bold' width='10%' nowrap>Allow Mail:</td>
 259   <td class='bold'>
 260    <select name="hipaa_mail">
 261     <?
 262      echo ('<option>NO</option>');
 263      $result{"hipaa_mail"}=='YES' ? $opt_out='<option selected>YES</option>' : $opt_out='<option>YES</option>' ;
 264      echo $opt_out;
 265     ?>
 266    </select>
 267   </td>
 268   <td class='bold' width='10%' nowrap>Allow Voice Msg:</td>
 269   <td class='bold'>
 270    <select name="hipaa_voice">
 271     <?
 272      echo ('<option>NO</option>');
 273      $result{"hipaa_voice"}=='YES' ? $opt_out='<option selected>YES</option>' : $opt_out='<option>YES</option>' ;
 274      echo $opt_out;
 275     ?>
 276    </select>
 277   </td>
 278  </tr>
 279  <tr>
 280   <td colspan='4'>
 281    <a href="javascript:document.demographics_form.submit();" target=Main class=link_submit>[Save Patient Demographics]</a>
 282    <br><hr>
 283   </td>
 284  </tr>
 285 </table>
 286
 287 <? } ?>
 288
 289 <table width='100%'>
 290  <tr>
 291   <td valign=top>
 292    <input type=hidden size=30 name=referrer value="<?echo ucfirst($result{"referrer"});?>">
 293    <input type=hidden size=20 name=referrerID value="<?echo $result{"referrerID"}?>">
 294    <input type=hidden size=20 name=db_id value="<?echo $result{"id"}?>">
 295    <table>
 296     <tr>
 297      <td><span class=bold>Occupation: </span></td>
 298      <td><input type=entry size=20 name=occupation value="<?echo $result{"occupation"}?>"></td>
 299     </tr>
 300     <tr>
 301      <td class='bold'>Employer:</td>
 302      <td><input type=entry size=20 name=ename value="<?echo $result2{"name"}?>"></td>
 303     </tr>
 304     <tr>
 305      <td colspan='2' class='bold' style='font-weight:normal'>(if unemployed enter Student, PT Student, or leave blank)</td>
 306     </tr>
 307 <? if ($GLOBALS['athletic_team']) { ?>
 308     <tr>
 309      <td colspan='2' class='bold' style='font-weight:normal'>&nbsp;</td>
 310     </tr>
 311     <tr>
 312      <td><span class='bold'>Squad: </span></td>
 313      <td>
 314       <select name='squad'>
 315        <option value=''>&nbsp;</option>
 316 <?
 317  $squads = acl_get_squads();
 318  if ($squads) {
 319   foreach ($squads as $key => $value) {
 320    echo "       <option value='$key'";
 321    if ($result['squad'] == $key) echo " selected";
 322    echo ">" . $value[3] . "</option>\n";
 323   }
 324  }
 325 ?>
 326       </select>
 327      </td>
 328     </tr>
 329 <? } ?>
 330    </table>
 331   </td>
 332   <td valign=top>
 333    <table>
 334     <tr>
 335      <td><span class=bold>Employer Address</span></td><td><span class=bold></span><input type=entry size=25 name=estreet value="<?echo $result2{"street"}?>"></td>
 336     </tr>
 337     <tr>
 338      <td><span class=bold>City: </span></td><td><input type=entry size=15 name=ecity value="<?echo $result2{"city"}?>"></td>
 339     </tr>
 340     <tr>
 341      <td><span class=bold><? echo ($GLOBALS['phone_country_code'] == '1') ? 'State' : 'Locality' ?>: </span></td><td><input type=entry size=15 name=estate value="<?echo $result2{"state"}?>"></td>
 342     </tr>
 343     <tr>
 344      <td><span class=bold><? echo ($GLOBALS['phone_country_code'] == '1') ? 'Zip' : 'Postal' ?> Code: </span></td><td><input type=entry size=10 name=epostal_code value="<?echo $result2{"postal_code"}?>"></td>
 345     </tr>
 346     <tr>
 347      <td><span class=bold>Country: </span></td><td><input type=entry size=10 name=ecountry value="<?echo $result2{"country"}?>"></td>
 348     </tr>
 349    </table>
 350   </td>
 351   <td valign=top></td>
 352  </tr>
 353
 354  <tr>
 355   <td colspan=4>
 356    <a href="javascript:document.demographics_form.submit();" target=Main class=link_submit>[Save Patient Demographics]</a><hr></td>
 357  </tr>
 358
 359 <? if (! $GLOBALS['athletic_team']) { ?>
 360
 361  <tr>
 362   <td valign='top'>
 363    <span class='bold'>Language: </span><br>
 364    <select onchange="javascript:document.demographics_form.language.value=upperFirst(this.options[this.selectedIndex].value,this.options[this.selectedIndex].value);">
 365 <?php
 366  foreach ($langi as $s) {
 367   if ($s == "unassigned") {
 368    echo "<option value=''";
 369   } else {
 370    echo "<option value='".$s."'";
 371   }
 372   if ($s == strtolower($result["language"]))
 373    echo " selected";
 374   echo ">".ucwords($s)."</option>\n";
 375  }
 376 ?>
 377    </select><br>
 378    <input type=entry size=30 name=language value="<?echo ucfirst($result{"language"});?>"><br><br />
 379    <span class=bold>Race/Ethnicity: </span><br>
 380    <select onchange="javascript:document.demographics_form.ethnoracial.value=upperFirst(this.options[this.selectedIndex].value,this.options[this.selectedIndex].value);">
 381 <?php
 382  foreach ($ethnoraciali as $s) {
 383   if ($s == "unassigned") {
 384    echo "<option value=''";
 385   } else {
 386    echo "<option value='".$s."'";
 387   }
 388   if ($s == strtolower($result["ethnoracial"]))
 389    echo " selected";
 390   echo ">".ucwords($s)."</option>\n";
 391  }
 392 ?>
 393    </select>
 394    <br>
 395    <input type=entry size=30 name=ethnoracial value="<?echo ucfirst($result{"ethnoracial"});?>"><br>
 396   </td>
 397   <td valign=top>
 398    <table>
 399     <tr>
 400      <td><span class=bold>Financial Review Date: </span></td><td><input type=entry size=11 name=financial_review value="<?if ($result{"financial_review"} != "0000-00-00 00:00:00") {echo date("m/d/Y",strtotime($result{"financial_review"}));} else {echo "MM/DD/YYYY";}?>"></td>
 401     </tr>
 402     <tr>
 403      <td><span class=bold>Family Size: </span></td><td><input type=entry size=20 name=family_size value="<?echo $result{"family_size"}?>"></td>
 404     </tr>
 405     <tr>
 406      <td><span class=bold>Monthly Income: </span></td><td><input type=entry size=20 name=monthly_income onblur="javascript:checkNum();" value="<?echo $result{"monthly_income"}?>"><span class=small>(Numbers only)</span></td>
 407     </tr>
 408     <tr>
 409      <td><span class=bold>Homeless, etc.: </span></td><td><input type=entry size=20 name=homeless value="<?echo $result{"homeless"}?>"></td>
 410     </tr>
 411     <tr>
 412      <td><span class=bold>Interpreter: </span></td><td><input type=entry size=20 name=interpretter value="<?echo $result{"interpretter"}?>"></td>
 413     </tr>
 414     <tr>
 415      <td><span class=bold>Migrant/Seasonal: </span></td><td><input type=entry size=20 name=migrantseasonal value="<?echo $result{"migrantseasonal"}?>"></td>
 416     </tr>
 417    </table>
 418   </td>
 419   <td valign=top></td>
 420  </tr>
 421
 422  <tr>
 423   <td colspan=4>
 424    <a href="javascript:document.demographics_form.submit();" target=Main class=link_submit>[Save Patient Demographics]</a>
 425    <hr>
 426   </td>
 427  </tr>
 428
 429 <? } ?>
 430
 431 </table>
 432
 433 <?
 434  // if (! $GLOBALS['athletic_team']) {
 435   $insurance_headings = array("Primary Insurance Provider:", "Secondary Insurance Provider", "Tertiary Insurance provider");
 436   $insurance_info = array();
 437   $insurance_info[1] = getInsuranceData($pid,"primary");
 438   $insurance_info[2] = getInsuranceData($pid,"secondary");
 439   $insurance_info[3] = getInsuranceData($pid,"tertiary");
 440   for($i=1;$i<=3;$i++) {
 441    $result3 = $insurance_info[$i];
 442 ?>
 443 <table border="0">
 444  <tr>
 445   <td valign=top>
 446    <table border="0">
 447     <tr>
 448      <td colspan="5"><span class='required'><?=$insurance_headings[$i -1]?></span></td>
 449     </tr>
 450     <tr>
 451      <td colspan="5">
 452       <select name="i<?=$i?>provider">
 453        <option value="">Unassigned</option>
 454 <?php
 455  foreach ($insurancei as $iid => $iname) {
 456   echo "<option value='".$iid."'";
 457   if (strtolower($iid) == strtolower($result3{"provider"}))
 458    echo " selected";
 459   echo ">".$iname."</option>\n";
 460  }
 461 ?>
 462       </select>&nbsp;<a href="<? echo  $GLOBALS['webroot'] ?>/controller.php?practice_settings&insurance_company&action=edit">Add New Insurer</a>
 463      </td>
 464     </tr>
 465     <tr>
 466      <td><span class=required>Plan Name: </span></td><td><input type=entry size=20 name=i<?=$i?>plan_name value="<?echo $result3{"plan_name"}?>"></td>
 467     </tr>
 468     <tr>
 469      <td><span class=required>Policy Number: </span></td><td><input type=entry size=16 name=i<?=$i?>policy_number value="<?echo $result3{"policy_number"}?>"></td>
 470     </tr>
 471     <tr>
 472      <td><span class=required>Group Number: </span></td><td><input type=entry size=16 name=i<?=$i?>group_number value="<?echo $result3{"group_number"}?>"></td>
 473     </tr>
 474     <tr>
 475      <td class='required'>Subscriber Employer (SE) <br><span style='font-weight:normal'>
 476       (if unemployed enter Student,<br>PT Student, or leave blank): </span></td>
 477      <td><input type=entry size=25 name=i<?=$i?>subscriber_employer value="<?echo $result3{"subscriber_employer"}?>"></td>
 478     </tr>
 479     <tr>
 480      <td><span class=required>SE Address: </span></td><td><input type=entry size=25 name=i<?=$i?>subscriber_employer_street value="<?echo $result3{"subscriber_employer_street"}?>"></td>
 481     </tr>
 482     <tr>
 483      <td colspan="2">
 484       <table>
 485        <tr>
 486         <td><span class=required>SE City: </span></td>
 487         <td><input type=entry size=15 name=i<?=$i?>subscriber_employer_city value="<?echo $result3{"subscriber_employer_city"}?>"></td>
 488         <td><span class=required>SE <? echo ($GLOBALS['phone_country_code'] == '1') ? 'State' : 'Locality' ?>: </span></td>
 489         <td><input type=entry size=15 name=i<?=$i?>subscriber_employer_state value="<?echo $result3{"subscriber_employer_state"}?>"></td>
 490        </tr>
 491        <tr>
 492         <td><span class=required>SE <? echo ($GLOBALS['phone_country_code'] == '1') ? 'Zip' : 'Postal' ?> Code: </span></td>
 493         <td><input type=entry size=10 name=i<?=$i?>subscriber_employer_postal_code value="<?echo $result3{"subscriber_employer_postal_code"}?>"></td>
 494         <td><span class=required>SE Country: </span></td>
 495         <td><input type=entry size=25 name=i<?=$i?>subscriber_employer_country value="<?echo $result3{"subscriber_employer_country"}?>"></td>
 496        </tr>
 497       </table>
 498      </td>
 499     </tr>
 500    </table>
 501   </td>
 502
 503   <td valign=top>
 504    <span class=required>Subscriber: </span><input type=entry size=10 name=i<?=$i?>subscriber_fname value="<?echo $result3{"subscriber_fname"}?>"><input type=entry size=3 name=i<?=$i?>subscriber_mname value="<?echo $result3{"subscriber_mname"}?>"><input type=entry size=10 name=i<?=$i?>subscriber_lname value="<?echo $result3{"subscriber_lname"}?>">
 505    <br>
 506    <span class=required>Relationship: </span>
 507    <select name=i<?=$i?>subscriber_relationship onchange="javascript:auto_populate_employer_address<?=$i?>();">
 508 <?php
 509  foreach ($relats as $s) {
 510   if ($s == "unassigned") {
 511    echo "<option value=''";
 512   } else {
 513    echo "<option value='".$s."'";
 514   }
 515   if ($s == $result3{"subscriber_relationship"})
 516    echo " selected";
 517   echo ">".ucfirst($s)."</option>\n";
 518 }
 519 ?>
 520    </select>
 521    <a href="javascript:popUp('browse.php?browsenum=<?=$i?>')" class=text>(Browse)</a><br />
 522    <span class=bold>D.O.B.: </span>
 523    <input type='entry' size='11' name='i<?=$i?>subscriber_DOB'
 524     value='<? echo $result3['subscriber_DOB'] ?>'
 525     onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)'
 526     title='yyyy-mm-dd' />
 527    <span class=bold>S.S.: </span><input type=entry size=11 name=i<?=$i?>subscriber_ss value="<?echo $result3{"subscriber_ss"}?> ">&nbsp;
 528    <span class=bold>Sex: </span>
 529    <select name=i<?=$i?>subscriber_sex>
 530     <option value="Male" <? if (strtolower($result3{"subscriber_sex"}) == "male") echo "selected"?>>Male</option>
 531     <option value="Female" <? if (strtolower($result3{"subscriber_sex"}) == "female") echo "selected"?>>Female</option>
 532    </select>
 533    <br>
 534    <span class=required>Subscriber Address: </span><input type=entry size=25 name=i<?=$i?>subscriber_street value="<?echo $result3{"subscriber_street"}?>"><br>
 535    <span class=required>City: </span><input type=entry size=15 name=i<?=$i?>subscriber_city value="<?echo $result3{"subscriber_city"}?>">
 536    <span class=required><? echo ($GLOBALS['phone_country_code'] == '1') ? 'State' : 'Locality' ?>: </span><input type=entry size=15 name=i<?=$i?>subscriber_state value="<?echo $result3{"subscriber_state"}?>"><br>
 537    <span class=required><? echo ($GLOBALS['phone_country_code'] == '1') ? 'Zip' : 'Postal' ?> Code: </span><input type=entry size=10 name=i<?=$i?>subscriber_postal_code value="<?echo $result3{"subscriber_postal_code"}?>">
 538    <span class=required>Country: </span><input type=entry size=10 name=i<?=$i?>subscriber_country value="<?echo $result3{"subscriber_country"}?>"><br>
 539    <span class=bold>Subscriber Phone:
 540    <input type='text' size='20' name='i<?=$i?>subscriber_phone' value='<?echo $result3["subscriber_phone"] ?>' onkeyup='phonekeyup(this,mypcc)' />
 541    </span><br />
 542    <span class=bold>CoPay: <input type=text size="6" name=i<?=$i?>copay value="<?echo $result3{"copay"}?>">
 543   </td>
 544  </tr>
 545 </table>
 546 <a href="javascript:document.demographics_form.submit();" target=Main class=link_submit>[Save Patient Demographics]</a>
 547 <hr>
 548
 549 <?
 550   } //end insurer for loop
 551  // } // end of "if not athletic team"
 552 ?>
 553
 554 </form>
 555
 556 <br>
 557
 558 <script language="JavaScript">
 559  // fix inconsistently formatted phone numbers from the database
 560  var f = document.forms[0];
 561  phonekeyup(f.phone_contact,mypcc);
 562  phonekeyup(f.phone_home,mypcc);
 563  phonekeyup(f.phone_biz,mypcc);
 564  phonekeyup(f.phone_cell,mypcc);
 565  phonekeyup(f.i1subscriber_phone,mypcc);
 566  phonekeyup(f.i2subscriber_phone,mypcc);
 567  phonekeyup(f.i3subscriber_phone,mypcc);
 568 </script>
 569
 570 </body>
 571 </html>