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