interface/new/new_comprehensive.php

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