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  var filteredString="";
 216  for (var i = 0; i < v.length; ++i) {
 217   var c = v.charAt(i);
 218   if ((c >= '0' && c <= '9') ||
 219      (c >= 'A' && c <= 'Z') ||
 220      (c == '*') ||
 221      (c == '-') ||
 222      (c == '_') ||
 223      (c == '(') ||
 224      (c == ')') ||
 225      (c == '#'))
 226      {
 227          filteredString+=c;
 228      }
 229  }
 230  e.value = filteredString;
 231  return;
 232 }
 233
 234 function divclick(cb, divid) {
 235  var divstyle = document.getElementById(divid).style;
 236  if (cb.checked) {
 237   divstyle.display = 'block';
 238  } else {
 239   divstyle.display = 'none';
 240  }
 241  return true;
 242 }
 243
 244 // Compute the length of a string without leading and trailing spaces.
 245 function trimlen(s) {
 246  var i = 0;
 247  var j = s.length - 1;
 248  for (; i <= j && s.charAt(i) == ' '; ++i);
 249  for (; i <= j && s.charAt(j) == ' '; --j);
 250  if (i > j) return 0;
 251  return j + 1 - i;
 252 }
 253
 254 function validate(f) {
 255   var errMsgs = new Array();
 256   <?php generate_layout_validation('DEM'); ?>
 257   <?php if($GLOBALS['erx_enable']){ ?>
 258   alertMsg='';
 259   for(i=0;i<f.length;i++){
 260     if(f[i].type=='text' && f[i].value)
 261     {
 262       if(f[i].name == 'form_fname' || f[i].name == 'form_mname' || f[i].name == 'form_lname')
 263       {
 264         alertMsg += checkLength(f[i].name,f[i].value,35);
 265         alertMsg += checkUsername(f[i].name,f[i].value);
 266       }
 267       else if(f[i].name == 'form_street' || f[i].name == 'form_city')
 268       {
 269         alertMsg += checkLength(f[i].name,f[i].value,35);
 270         alertMsg += checkAlphaNumericExtended(f[i].name,f[i].value);
 271       }
 272       else if(f[i].name == 'form_phone_home')
 273       {
 274        alertMsg += checkPhone(f[i].name,f[i].value);
 275       }
 276     }
 277   }
 278   if(alertMsg)
 279   {
 280     alert(alertMsg);
 281     return false;
 282   }
 283   <?php } ?>
 284   var msg = "";
 285   msg += "<?php echo htmlspecialchars(xl('The following fields are required'),ENT_QUOTES); ?>:\n\n";
 286   for ( var i = 0; i < errMsgs.length; i++ ) {
 287          msg += errMsgs[i] + "\n";
 288   }
 289   msg += "\n<?php echo htmlspecialchars(xl('Please fill them in before continuing.'),ENT_QUOTES); ?>";
 290
 291   if ( errMsgs.length > 0 ) {
 292          alert(msg);
 293          return false;
 294   }
 295  return true;
 296 }
 297
 298 function toggleSearch(elem) {
 299  var f = document.forms[0];
 300 <?php if ($WITH_SEARCH) { ?>
 301  // Toggle background color.
 302  if (elem.style.backgroundColor == '')
 303   elem.style.backgroundColor = '<?php echo $searchcolor; ?>';
 304  else
 305   elem.style.backgroundColor = '';
 306 <?php } ?>
 307  if (force_submit) {
 308   force_submit = false;
 309   f.create.value = '<?php xl('Create New Patient','e'); ?>';
 310  }
 311  return true;
 312 }
 313
 314 // If a <select> list is dropped down, this is its name.
 315 var open_sel_name = '';
 316
 317 function selClick(elem) {
 318  if (open_sel_name == elem.name) {
 319   open_sel_name = '';
 320  }
 321  else {
 322   open_sel_name = elem.name;
 323   toggleSearch(elem);
 324  }
 325  return true;
 326 }
 327
 328 function selBlur(elem) {
 329  if (open_sel_name == elem.name) {
 330   open_sel_name = '';
 331  }
 332  return true;
 333 }
 334
 335 // This invokes the patient search dialog.
 336 function searchme() {
 337  var f = document.forms[0];
 338  var url = '../main/finder/patient_select.php?popup=1';
 339
 340 <?php
 341 $lres = getLayoutRes();
 342
 343 while ($lrow = sqlFetchArray($lres)) {
 344   $field_id  = $lrow['field_id'];
 345   if (strpos($field_id, 'em_') === 0) continue;
 346   $data_type = $lrow['data_type'];
 347   $fldname = "form_$field_id";
 348   switch(getSearchClass($data_type)) {
 349     case  1:
 350       echo
 351       " if (f.$fldname.style.backgroundColor != '' && trimlen(f.$fldname.value) > 0) {\n" .
 352       "  url += '&$field_id=' + encodeURIComponent(f.$fldname.value);\n" .
 353       " }\n";
 354       break;
 355     case 2:
 356       echo
 357       " if (f.$fldname.style.backgroundColor != '' && f.$fldname.selectedIndex > 0) {\n" .
 358       "  url += '&$field_id=' + encodeURIComponent(f.$fldname.options[f.$fldname.selectedIndex].value);\n" .
 359       " }\n";
 360       break;
 361   }
 362 }
 363 ?>
 364
 365  dlgopen(url, '_blank', 700, 500);
 366 }
 367
 368 //-->
 369
 370 </script>
 371 </head>
 372
 373 <body class="body_top">
 374
 375 <form action='new_comprehensive_save.php' name='demographics_form' method='post' onsubmit='return validate(this)'>
 376
 377 <span class='title'><?php xl('Search or Add Patient','e'); ?></span>
 378
 379 <table width='100%' cellpadding='0' cellspacing='8'>
 380  <tr>
 381   <td align='left' valign='top'>
 382 <?php if ($SHORT_FORM) echo "  <center>\n"; ?>
 383 <?php
 384
 385 function end_cell() {
 386   global $item_count, $cell_count;
 387   if ($item_count > 0) {
 388     echo "</td>";
 389     $item_count = 0;
 390   }
 391 }
 392
 393 function end_row() {
 394   global $cell_count, $CPR;
 395   end_cell();
 396   if ($cell_count > 0) {
 397     for (; $cell_count < $CPR; ++$cell_count) echo "<td></td>";
 398     echo "</tr>\n";
 399     $cell_count = 0;
 400   }
 401 }
 402
 403 function end_group() {
 404   global $last_group, $SHORT_FORM;
 405   if (strlen($last_group) > 0) {
 406     end_row();
 407     echo " </table>\n";
 408     if (!$SHORT_FORM) echo "</div>\n";
 409   }
 410 }
 411
 412 $last_group    = '';
 413 $cell_count    = 0;
 414 $item_count    = 0;
 415 $display_style = 'block';
 416 $group_seq     = 0; // this gives the DIV blocks unique IDs
 417
 418 while ($frow = sqlFetchArray($fres)) {
 419   $this_group = $frow['group_name'];
 420   $titlecols  = $frow['titlecols'];
 421   $datacols   = $frow['datacols'];
 422   $data_type  = $frow['data_type'];
 423   $field_id   = $frow['field_id'];
 424   $list_id    = $frow['list_id'];
 425   $currvalue  = '';
 426
 427   if (strpos($field_id, 'em_') === 0) {
 428     $tmp = substr($field_id, 3);
 429     if (isset($result2[$tmp])) $currvalue = $result2[$tmp];
 430   }
 431   else {
 432     if (isset($result[$field_id])) $currvalue = $result[$field_id];
 433   }
 434
 435   // Handle a data category (group) change.
 436   if (strcmp($this_group, $last_group) != 0) {
 437     if (!$SHORT_FORM) {
 438       end_group();
 439       $group_seq++;    // ID for DIV tags
 440       $group_name = substr($this_group, 1);
 441       if (strlen($last_group) > 0) echo "<br />";
 442       echo "<span class='bold'><input type='checkbox' name='form_cb_$group_seq' id='form_cb_$group_seq' value='1' " .
 443         "onclick='return divclick(this,\"div_$group_seq\");'";
 444       if ($display_style == 'block') echo " checked";
 445
 446       // Modified 6-09 by BM - Translate if applicable
 447       echo " /><b>" . xl_layout_label($group_name) . "</b></span>\n";
 448
 449       echo "<div id='div_$group_seq' class='section' style='display:$display_style;'>\n";
 450       echo " <table border='0' cellpadding='0'>\n";
 451       $display_style = 'none';
 452     }
 453     else if (strlen($last_group) == 0) {
 454       echo " <table border='0' cellpadding='0'>\n";
 455     }
 456     $last_group = $this_group;
 457   }
 458
 459   // Handle starting of a new row.
 460   if (($titlecols > 0 && $cell_count >= $CPR) || $cell_count == 0) {
 461     end_row();
 462     echo "  <tr>";
 463   }
 464
 465   if ($item_count == 0 && $titlecols == 0) $titlecols = 1;
 466
 467   // Handle starting of a new label cell.
 468   if ($titlecols > 0) {
 469     end_cell();
 470     echo "<td colspan='$titlecols'";
 471     echo ($frow['uor'] == 2) ? " class='required'" : " class='bold'";
 472     if ($cell_count == 2) echo " style='padding-left:10pt'";
 473     echo ">";
 474     $cell_count += $titlecols;
 475   }
 476   ++$item_count;
 477
 478   echo "<b>";
 479
 480   // Modified 6-09 by BM - Translate if applicable
 481   if ($frow['title']) echo (xl_layout_label($frow['title']).":"); else echo "&nbsp;";
 482
 483   echo "</b>";
 484
 485   // Handle starting of a new data cell.
 486   if ($datacols > 0) {
 487     end_cell();
 488     echo "<td colspan='$datacols' class='text'";
 489     if ($cell_count > 0) echo " style='padding-left:5pt'";
 490     echo ">";
 491     $cell_count += $datacols;
 492   }
 493
 494   ++$item_count;
 495   generate_form_field($frow, $currvalue);
 496 }
 497
 498 end_group();
 499 ?>
 500
 501 <?php
 502 if (! $GLOBALS['simplified_demographics']) {
 503   $insurancei = getInsuranceProviders();
 504   $pid = 0;
 505   $insurance_headings = array(xl("Primary Insurance Provider"), xl("Secondary Insurance Provider"), xl("Tertiary Insurance provider"));
 506   $insurance_info = array();
 507   $insurance_info[1] = getInsuranceData($pid,"primary");
 508   $insurance_info[2] = getInsuranceData($pid,"secondary");
 509   $insurance_info[3] = getInsuranceData($pid,"tertiary");
 510
 511   echo "<br /><span class='bold'><input type='checkbox' name='form_cb_ins' value='1' " .
 512     "onclick='return divclick(this,\"div_ins\");'";
 513   if ($display_style == 'block') echo " checked";
 514   echo " /><b>" . xl('Insurance') . "</b></span>\n";
 515   echo "<div id='div_ins' class='section' style='display:$display_style;'>\n";
 516
 517   for($i=1;$i<=3;$i++) {
 518    $result3 = $insurance_info[$i];
 519 ?>
 520 <table border="0">
 521  <tr>
 522   <td valign='top' colspan='2'>
 523    <span class='required'><?php echo $insurance_headings[$i -1].":"?></span>
 524    <select name="i<?php echo $i?>provider">
 525     <option value=""><?php xl('Unassigned','e'); ?></option>
 526 <?php
 527  foreach ($insurancei as $iid => $iname) {
 528   echo "<option value='" . $iid . "'";
 529   if (strtolower($iid) == strtolower($result3{"provider"}))
 530    echo " selected";
 531   echo ">" . $iname . "</option>\n";
 532  }
 533 ?>
 534    </select>&nbsp;<a href='' onclick='return ins_search(<?php echo $i?>)'>
 535    <?php xl('Search/Add Insurer','e'); ?></a>
 536   </td>
 537  </tr>
 538  <tr>
 539   <td valign=top>
 540    <table border="0">
 541
 542     <tr>
 543      <td>
 544       <span class='required'><?php xl('Plan Name','e'); ?>: </span>
 545      </td>
 546      <td>
 547       <input type='entry' size='20' name='i<?php echo $i?>plan_name' value="<?php echo $result3{"plan_name"} ?>"
 548        onchange="capitalizeMe(this);" />&nbsp;&nbsp;
 549      </td>
 550     </tr>
 551
 552     <tr>
 553      <td>
 554       <span class='required'><?php xl('Effective Date','e'); ?>: </span>
 555      </td>
 556      <td>
 557       <input type='entry' size='11' name='i<?php echo $i ?>effective_date'
 558        id='i<?php echo $i ?>effective_date'
 559        value='<?php echo $result3['date'] ?>'
 560        onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)'
 561        title='yyyy-mm-dd' />
 562
 563       <img src='../../interface/pic/show_calendar.gif' align='absbottom' width='24' height='22'
 564       id='img_i<?php echo $i ?>effective_date' border='0' alt='[?]' style='cursor:pointer'
 565       title='<?php xl('Click here to choose a date','e'); ?>'>
 566
 567       <script LANGUAGE="JavaScript">
 568       Calendar.setup({inputField:"i<?php echo $i ?>effective_date", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i; ?>effective_date"});
 569       </script>
 570
 571
 572      </td>
 573     </tr>
 574
 575     <tr>
 576      <td><span class=required><?php xl('Policy Number','e'); ?>: </span></td>
 577      <td><input type='entry' size='16' name='i<?php echo $i?>policy_number' value="<?php echo $result3{"policy_number"}?>"
 578       onkeyup='policykeyup(this)'></td>
 579     </tr>
 580
 581     <tr>
 582      <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 $result3{"group_number"}?>" onkeyup='policykeyup(this)'></td>
 583     </tr>
 584
 585     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 586      <td class='required'><?php xl('Subscriber Employer (SE)','e'); ?><br><span style='font-weight:normal'>
 587       (<?php xl('if unemployed enter Student','e'); ?>,<br><?php xl('PT Student, or leave blank','e'); ?>): </span></td>
 588      <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer
 589       value="<?php echo $result3{"subscriber_employer"}?>"
 590        onchange="capitalizeMe(this);" /></td>
 591     </tr>
 592
 593     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 594      <td><span class=required><?php xl('SE Address','e'); ?>: </span></td>
 595      <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer_street
 596       value="<?php echo $result3{"subscriber_employer_street"}?>"
 597        onchange="capitalizeMe(this);" /></td>
 598     </tr>
 599
 600     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 601      <td colspan="2">
 602       <table>
 603        <tr>
 604         <td><span class=required><?php xl('SE City','e'); ?>: </span></td>
 605         <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_city
 606          value="<?php echo $result3{"subscriber_employer_city"}?>"
 607           onchange="capitalizeMe(this);" /></td>
 608         <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE State','e') : xl('SE Locality','e') ?>: </span></td>
 609         <td>
 610          <?php
 611           // Modified 7/2009 by BM to incorporate data types
 612           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'), $result3['subscriber_employer_state']);
 613          ?>
 614         </td>
 615        </tr>
 616        <tr>
 617         <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE Zip Code','e') : xl('SE Postal Code','e') ?>: </span></td>
 618         <td><input type=entry size=10 name=i<?php echo $i?>subscriber_employer_postal_code value="<?php echo $result3{"subscriber_employer_postal_code"}?>"></td>
 619         <td><span class=required><?php xl('SE Country','e'); ?>: </span></td>
 620         <td>
 621          <?php
 622           // Modified 7/2009 by BM to incorporate data types
 623           generate_form_field(array('data_type'=>$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']);
 624          ?>
 625         </td>
 626        </tr>
 627       </table>
 628      </td>
 629     </tr>
 630
 631    </table>
 632   </td>
 633
 634   <td valign=top>
 635    <span class=required><?php xl('Subscriber','e'); ?>: </span>
 636    <input type=entry size=10 name=i<?php echo $i?>subscriber_fname
 637     value="<?php echo $result3{"subscriber_fname"}?>"
 638     onchange="capitalizeMe(this);" />
 639    <input type=entry size=3 name=i<?php echo $i?>subscriber_mname
 640     value="<?php echo $result3{"subscriber_mname"}?>"
 641     onchange="capitalizeMe(this);" />
 642    <input type=entry size=10 name=i<?php echo $i?>subscriber_lname
 643     value="<?php echo $result3{"subscriber_lname"}?>"
 644     onchange="capitalizeMe(this);" />
 645    <br>
 646    <span class=required><?php xl('Relationship','e'); ?>: </span>
 647    <?php
 648     // Modified 6/2009 by BM to use list_options and function
 649     generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_relationship'),'list_id'=>'sub_relation','empty_title'=>' '), $result3['subscriber_relationship']);
 650    ?>
 651    <a href="javascript:popUp('../../interface/patient_file/summary/browse.php?browsenum=<?php echo $i?>')" class=text>(<?php xl('Browse','e'); ?>)</a><br />
 652
 653    <span class=bold><?php xl('D.O.B.','e'); ?>: </span>
 654    <input type='entry' size='11' name='i<?php echo $i?>subscriber_DOB'
 655     id='i<?php echo $i?>subscriber_DOB'
 656     value='<?php echo $result3['subscriber_DOB'] ?>'
 657     onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)'
 658     title='yyyy-mm-dd' />
 659
 660    <img src='../../interface/pic/show_calendar.gif' align='absbottom' width='24' height='22'
 661     id='img_i<?php echo $i; ?>dob_date' border='0' alt='[?]' style='cursor:pointer'
 662     title='<?php xl('Click here to choose a date','e'); ?>'>
 663
 664     <script LANGUAGE="JavaScript">
 665     Calendar.setup({inputField:"i<?php echo $i?>subscriber_DOB", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i; ?>dob_date"});
 666     </script>
 667
 668
 669    <span class=bold><?php xl('S.S.','e'); ?>: </span><input type=entry size=11 name=i<?php echo $i?>subscriber_ss value="<?php echo $result3{"subscriber_ss"}?>">&nbsp;
 670    <span class=bold><?php xl('Sex','e'); ?>: </span>
 671    <?php
 672     // Modified 6/2009 by BM to use list_options and function
 673     generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_sex'),'list_id'=>'sex'), $result3['subscriber_sex']);
 674    ?>
 675    <br>
 676    <span class=required><?php xl('Subscriber Address','e'); ?>: </span>
 677    <input type=entry size=25 name=i<?php echo $i?>subscriber_street
 678     value="<?php echo $result3{"subscriber_street"}?>"
 679     onchange="capitalizeMe(this);" /><br>
 680    <span class=required><?php xl('City','e'); ?>: </span>
 681    <input type=entry size=15 name=i<?php echo $i?>subscriber_city
 682     value="<?php echo $result3{"subscriber_city"}?>"
 683     onchange="capitalizeMe(this);" />
 684    <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('State','e') : xl('Locality','e') ?>: </span>
 685    <?php
 686     // Modified 7/2009 by BM to incorporate data types
 687     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'), $result3['subscriber_state']);
 688    ?>
 689    <br />
 690    <span class=required><?php echo ($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 $result3{"subscriber_postal_code"}?>">
 691    <span class='required'<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 692    <?php xl('Country','e'); ?>: </span>
 693    <?php
 694     // Modified 7/2009 by BM to incorporate data types
 695     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']);
 696    ?>
 697    <br />
 698    <span class=bold><?php xl('Subscriber Phone','e'); ?>:
 699    <input type='text' size='20' name='i<?php echo $i?>subscriber_phone' value='<?php echo $result3["subscriber_phone"] ?>' onkeyup='phonekeyup(this,mypcc)' />
 700    </span><br />
 701    <span class=bold><?php xl('CoPay','e'); ?>: <input type=text size="6" name=i<?php echo $i?>copay value="<?php echo $result3{"copay"}?>">
 702    </span><br />
 703    <span class='required'><?php xl('Accept Assignment','e'); ?>: </span>
 704    <select name=i<?php echo $i?>accept_assignment>
 705      <option value="TRUE" <?php if (strtoupper($result3{"accept_assignment"}) == "TRUE") echo "selected"?>><?php xl('YES','e'); ?></option>
 706      <option value="FALSE" <?php if (strtoupper($result3{"accept_assignment"}) == "FALSE") echo "selected"?>><?php xl('NO','e'); ?></option>
 707    </select>
 708   </td>
 709  </tr>
 710
 711 </table>
 712 <hr />
 713 <?php
 714   }
 715   echo "</div>\n";
 716  } // end of "if not simplified_demographics"
 717 ?>
 718
 719 <?php if (!$SHORT_FORM) echo "  <center>\n"; ?>
 720 <br />
 721 <?php if ($WITH_SEARCH) { ?>
 722 <input type="button" id="search" value=<?php xl('Search','e','\'','\''); ?>
 723  style='background-color:<?php echo $searchcolor; ?>' />
 724 &nbsp;&nbsp;
 725 <?php } ?>
 726 <input type="button" name='create' id="create" value=<?php xl('Create New Patient','e','\'','\''); ?> />
 727
 728 </center>
 729
 730   </td>
 731   <td align='right' valign='top' width='1%' nowrap>
 732    <!-- Image upload stuff was here but got moved. -->
 733   </td>
 734  </tr>
 735 </table>
 736
 737 </form>
 738
 739 <!-- include support for the list-add selectbox feature -->
 740 <?php include($GLOBALS['fileroot']."/library/options_listadd.inc"); ?>
 741
 742 </body>
 743
 744 <script language="JavaScript">
 745
 746 // fix inconsistently formatted phone numbers from the database
 747 var f = document.forms[0];
 748 if (f.form_phone_contact) phonekeyup(f.form_phone_contact,mypcc);
 749 if (f.form_phone_home   ) phonekeyup(f.form_phone_home   ,mypcc);
 750 if (f.form_phone_biz    ) phonekeyup(f.form_phone_biz    ,mypcc);
 751 if (f.form_phone_cell   ) phonekeyup(f.form_phone_cell   ,mypcc);
 752
 753 <?php echo $date_init; ?>
 754
 755 // -=- jQuery makes life easier -=-
 756
 757 // var matches = 0; // number of patients that match the demographic information being entered
 758 // var override = false; // flag that overrides the duplication warning
 759
 760 $(document).ready(function() {
 761
 762     // added to integrate insurance stuff
 763     <?php for ($i=1;$i<=3;$i++) { ?>
 764     $("#form_i<?php echo $i?>subscriber_relationship").change(function() { auto_populate_employer_address<?php echo $i?>(); });
 765     <?php } ?>
 766
 767     $('#search').click(function() { searchme(); });
 768     $('#create').click(function() { submitme(); });
 769
 770     var submitme = function() {
 771       top.restoreSession();
 772       var f = document.forms[0];
 773
 774       if (validate(f)) {
 775         if (force_submit) {
 776           // In this case dups were shown already and Save should just save.
 777           f.submit();
 778           return;
 779         }
 780 <?php
 781 // D in edit_options indicates the field is used in duplication checking.
 782 // This constructs a list of the names of those fields.
 783 $mflist = "";
 784 $mfres = sqlStatement("SELECT * FROM layout_options " .
 785   "WHERE form_id = 'DEM' AND uor > 0 AND field_id != '' AND " .
 786   "edit_options LIKE '%D%' " .
 787   "ORDER BY group_name, seq");
 788 while ($mfrow = sqlFetchArray($mfres)) {
 789   $field_id  = $mfrow['field_id'];
 790   if (strpos($field_id, 'em_') === 0) continue;
 791   if (!empty($mflist)) $mflist .= ",";
 792   $mflist .= "'" . htmlentities($field_id) . "'";
 793 }
 794 ?>
 795         // Build and invoke the URL to create the dup-checker dialog.
 796         var url = 'new_search_popup.php';
 797         var flds = new Array(<?php echo $mflist; ?>);
 798         var separator = '?';
 799         for (var i = 0; i < flds.length; ++i) {
 800           var fval = $('#form_' + flds[i]).val();
 801           if (fval && fval != '') {
 802             url += separator;
 803             separator = '&';
 804             url += 'mf_' + flds[i] + '=' + encodeURIComponent(fval);
 805           }
 806         }
 807         dlgopen(url, '_blank', 700, 500);
 808
 809       } // end if validate
 810     } // end function
 811
 812 // Set onclick/onfocus handlers for toggling background color.
 813 <?php
 814 $lres = getLayoutRes();
 815 while ($lrow = sqlFetchArray($lres)) {
 816   $field_id  = $lrow['field_id'];
 817   if (strpos($field_id, 'em_') === 0) continue;
 818   switch(getSearchClass($lrow['data_type'])) {
 819     case 1:
 820       echo "    \$('#form_$field_id').click(function() { toggleSearch(this); });\n";
 821       break;
 822     case 2:
 823       echo "    \$('#form_$field_id').click(function() { selClick(this); });\n";
 824       echo "    \$('#form_$field_id').blur(function() { selBlur(this); });\n";
 825       break;
 826   }
 827 }
 828 ?>
 829
 830 }); // end document.ready
 831
 832 </script>
 833
 834 </html>
 835