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 // $provideri = getProviderInfo();
  43 if ($GLOBALS['insurance_information'] != '0') {
  44     $insurancei = getInsuranceProvidersExtra();
  45 }else{
  46         $insurancei = getInsuranceProviders();
  47 }
  48
  49 $fres = sqlStatement("SELECT * FROM layout_options " .
  50   "WHERE form_id = 'DEM' AND uor > 0 " .
  51   "ORDER BY group_name, seq");
  52 ?>
  53 <html>
  54 <head>
  55 <?php html_header_show();?>
  56
  57 <link rel="stylesheet" href="<?php echo $css_header; ?>" type="text/css">
  58
  59 <style type="text/css">@import url(../../../library/dynarch_calendar.css);</style>
  60
  61 <script type="text/javascript" src="../../../library/dialog.js"></script>
  62 <script type="text/javascript" src="../../../library/textformat.js"></script>
  63 <script type="text/javascript" src="../../../library/dynarch_calendar.js"></script>
  64 <?php include_once("{$GLOBALS['srcdir']}/dynarch_calendar_en.inc.php"); ?>
  65 <script type="text/javascript" src="../../../library/dynarch_calendar_setup.js"></script>
  66 <script type="text/javascript" src="../../../library/js/jquery.1.3.2.js"></script>
  67 <script type="text/javascript" src="../../../library/js/common.js"></script>
  68 <script type="text/javascript" src="../../../library/js/fancybox/jquery.fancybox-1.2.6.js"></script>
  69 <?php include_once("{$GLOBALS['srcdir']}/options.js.php"); ?>
  70
  71 <link rel="stylesheet" type="text/css" href="../../../library/js/fancybox/jquery.fancybox-1.2.6.css" media="screen" />
  72
  73 <script type="text/javascript">
  74 $(document).ready(function(){
  75     tabbify();
  76     enable_modals();
  77
  78     // special size for
  79         $(".medium_modal").fancybox( {
  80                 'overlayOpacity' : 0.0,
  81                 'showCloseButton' : true,
  82                 'frameHeight' : 460,
  83                 'frameWidth' : 650
  84         });
  85
  86 });
  87
  88 var mypcc = '<?php echo $GLOBALS['phone_country_code'] ?>';
  89
  90 //code used from http://tech.irt.org/articles/js037/
  91 function replace(string,text,by) {
  92  // Replaces text with by in string
  93  var strLength = string.length, txtLength = text.length;
  94  if ((strLength == 0) || (txtLength == 0)) return string;
  95
  96  var i = string.indexOf(text);
  97  if ((!i) && (text != string.substring(0,txtLength))) return string;
  98  if (i == -1) return string;
  99
 100  var newstr = string.substring(0,i) + by;
 101
 102  if (i+txtLength < strLength)
 103   newstr += replace(string.substring(i+txtLength,strLength),text,by);
 104
 105  return newstr;
 106 }
 107
 108 function upperFirst(string,text) {
 109  return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
 110 }
 111
 112 <?php for ($i=1;$i<=3;$i++) { ?>
 113 function auto_populate_employer_address<?php echo $i ?>(){
 114  var f = document.demographics_form;
 115  if (f.form_i<?php echo $i?>subscriber_relationship.options[f.form_i<?php echo $i?>subscriber_relationship.selectedIndex].value == "self")
 116  {
 117   f.i<?php echo $i?>subscriber_fname.value=f.form_fname.value;
 118   f.i<?php echo $i?>subscriber_mname.value=f.form_mname.value;
 119   f.i<?php echo $i?>subscriber_lname.value=f.form_lname.value;
 120   f.i<?php echo $i?>subscriber_street.value=f.form_street.value;
 121   f.i<?php echo $i?>subscriber_city.value=f.form_city.value;
 122   f.form_i<?php echo $i?>subscriber_state.value=f.form_state.value;
 123   f.i<?php echo $i?>subscriber_postal_code.value=f.form_postal_code.value;
 124   if (f.form_country_code)
 125     f.form_i<?php echo $i?>subscriber_country.value=f.form_country_code.value;
 126   f.i<?php echo $i?>subscriber_phone.value=f.form_phone_home.value;
 127   f.i<?php echo $i?>subscriber_DOB.value=f.form_DOB.value;
 128   if(typeof f.form_ss!="undefined")
 129     {
 130         f.i<?php echo $i?>subscriber_ss.value=f.form_ss.value;
 131     }
 132   f.form_i<?php echo $i?>subscriber_sex.value = f.form_sex.value;
 133   f.i<?php echo $i?>subscriber_employer.value=f.form_em_name.value;
 134   f.i<?php echo $i?>subscriber_employer_street.value=f.form_em_street.value;
 135   f.i<?php echo $i?>subscriber_employer_city.value=f.form_em_city.value;
 136   f.form_i<?php echo $i?>subscriber_employer_state.value=f.form_em_state.value;
 137   f.i<?php echo $i?>subscriber_employer_postal_code.value=f.form_em_postal_code.value;
 138   if (f.form_em_country)
 139     f.form_i<?php echo $i?>subscriber_employer_country.value=f.form_em_country.value;
 140  }
 141 }
 142
 143 <?php } ?>
 144
 145 function popUp(URL) {
 146  day = new Date();
 147  id = day.getTime();
 148  top.restoreSession();
 149  eval("page" + id + " = window.open(URL, '" + id + "', 'toolbar=0,scrollbars=1,location=0,statusbar=0,menubar=0,resizable=1,width=400,height=300,left = 440,top = 362');");
 150 }
 151
 152 function checkNum () {
 153  var re= new RegExp();
 154  re = /^\d*\.?\d*$/;
 155  str=document.demographics_form.monthly_income.value;
 156  if(re.exec(str))
 157  {
 158  }else{
 159   alert("<?php xl('Please enter a monetary amount using only numbers and a decimal point.','e'); ?>");
 160  }
 161 }
 162
 163 // Indicates which insurance slot is being updated.
 164 var insurance_index = 0;
 165
 166 // The OnClick handler for searching/adding the insurance company.
 167 function ins_search(ins) {
 168         insurance_index = ins;
 169         return false;
 170 }
 171
 172 // The ins_search.php window calls this to set the selected insurance.
 173 function set_insurance(ins_id, ins_name) {
 174  var thesel = document.forms[0]['i' + insurance_index + 'provider'];
 175  var theopts = thesel.options; // the array of Option objects
 176  var i = 0;
 177  for (; i < theopts.length; ++i) {
 178   if (theopts[i].value == ins_id) {
 179    theopts[i].selected = true;
 180    return;
 181   }
 182  }
 183  // no matching option was found so create one, append it to the
 184  // end of the list, and select it.
 185  theopts[i] = new Option(ins_name, ins_id, false, true);
 186 }
 187
 188 // This capitalizes the first letter of each word in the passed input
 189 // element.  It also strips out extraneous spaces.
 190 function capitalizeMe(elem) {
 191  var a = elem.value.split(' ');
 192  var s = '';
 193  for(var i = 0; i < a.length; ++i) {
 194   if (a[i].length > 0) {
 195    if (s.length > 0) s += ' ';
 196    s += a[i].charAt(0).toUpperCase() + a[i].substring(1);
 197   }
 198  }
 199  elem.value = s;
 200 }
 201
 202 function divclick(cb, divid) {
 203  var divstyle = document.getElementById(divid).style;
 204  if (cb.checked) {
 205   divstyle.display = 'block';
 206  } else {
 207   divstyle.display = 'none';
 208  }
 209  return true;
 210 }
 211
 212 // Compute the length of a string without leading and trailing spaces.
 213 function trimlen(s) {
 214  var i = 0;
 215  var j = s.length - 1;
 216  for (; i <= j && s.charAt(i) == ' '; ++i);
 217  for (; i <= j && s.charAt(j) == ' '; --j);
 218  if (i > j) return 0;
 219  return j + 1 - i;
 220 }
 221
 222 function validate(f) {
 223  var errCount = 0;
 224  var errMsgs = new Array();
 225 <?php generate_layout_validation('DEM'); ?>
 226
 227  var msg = "";
 228  msg += "<?php xl('The following fields are required', 'e' ); ?>:\n\n";
 229  for ( var i = 0; i < errMsgs.length; i++ ) {
 230         msg += errMsgs[i] + "\n";
 231  }
 232  msg += "\n<?php xl('Please fill them in before continuing.', 'e'); ?>";
 233
 234  if ( errMsgs.length > 0 ) {
 235         alert(msg);
 236  }
 237
 238 //Patient Data validations
 239  <?php if($GLOBALS['erx_enable']){ ?>
 240  alertMsg='';
 241  for(i=0;i<f.length;i++){
 242   if(f[i].type=='text' && f[i].value)
 243   {
 244    if(f[i].name == 'form_fname' || f[i].name == 'form_mname' || f[i].name == 'form_lname')
 245    {
 246     alertMsg += checkLength(f[i].name,f[i].value,35);
 247     alertMsg += checkUsername(f[i].name,f[i].value);
 248    }
 249    else if(f[i].name == 'form_street' || f[i].name == 'form_city')
 250    {
 251     alertMsg += checkLength(f[i].name,f[i].value,35);
 252     alertMsg += checkAlphaNumericExtended(f[i].name,f[i].value);
 253    }
 254    else if(f[i].name == 'form_phone_home')
 255    {
 256     alertMsg += checkPhone(f[i].name,f[i].value);
 257    }
 258   }
 259  }
 260  if(alertMsg)
 261  {
 262    alert(alertMsg);
 263    return false;
 264  }
 265  <?php } ?>
 266  //return false;
 267
 268 // Some insurance validation.
 269  for (var i = 1; i <= 3; ++i) {
 270   subprov = 'i' + i + 'provider';
 271   if (!f[subprov] || f[subprov].selectedIndex <= 0) continue;
 272   var subpfx = 'i' + i + 'subscriber_';
 273   var subrelat = f['form_' + subpfx + 'relationship'];
 274   var samename =
 275    f[subpfx + 'fname'].value == f.form_fname.value &&
 276    f[subpfx + 'mname'].value == f.form_mname.value &&
 277    f[subpfx + 'lname'].value == f.form_lname.value;
 278   var ss_regexp=/[0-9][0-9][0-9]-?[0-9][0-9]-?[0-9][0-9][0-9][0-9]/;
 279   var samess=true;
 280   var ss_valid=false;
 281   if(typeof f.form_ss!="undefined")
 282       {
 283         samess = f[subpfx + 'ss'].value == f.form_ss.value;
 284         ss_valid=ss_regexp.test(f[subpfx + 'ss'].value) && ss_regexp.test(f.form_ss.value);
 285       }
 286   if (subrelat.options[subrelat.selectedIndex].value == "self") {
 287    if (!samename) {
 288     if (!confirm("<?php echo xls('Subscriber relationship is self but name is different! Is this really OK?'); ?>"))
 289      return false;
 290    }
 291    if (!samess && ss_valid) {
 292     if(!confirm("<?php echo xls('Subscriber relationship is self but SS number is different!')." ". xls("Is this really OK?"); ?>"))
 293     return false;
 294    }
 295   } // end self
 296   else {
 297    if (samename) {
 298     if (!confirm("<?php echo xls('Subscriber relationship is not self but name is the same! Is this really OK?'); ?>"))
 299      return false;
 300    }
 301    if (samess && ss_valid)  {
 302     if(!confirm("<?php echo xls('Subscriber relationship is not self but SS number is the same!') ." ". xls("Is this really OK?"); ?>"))
 303     return false;
 304    }
 305   } // end not self
 306  } // end for
 307
 308  return errMsgs.length < 1;
 309 }
 310
 311 function submitme() {
 312  var f = document.forms[0];
 313  if (validate(f)) {
 314   top.restoreSession();
 315   f.submit();
 316  }
 317 }
 318
 319 // Onkeyup handler for policy number.  Allows only A-Z and 0-9.
 320 function policykeyup(e) {
 321  var v = e.value.toUpperCase();
 322  var filteredString="";
 323  for (var i = 0; i < v.length; ++i) {
 324   var c = v.charAt(i);
 325   if ((c >= '0' && c <= '9') ||
 326      (c >= 'A' && c <= 'Z') ||
 327      (c == '*') ||
 328      (c == '-') ||
 329      (c == '_') ||
 330      (c == '(') ||
 331      (c == ')') ||
 332      (c == '#'))
 333      {
 334          filteredString+=c;
 335      }
 336  }
 337  e.value = filteredString;
 338  return;
 339 }
 340
 341 // Added 06/2009 by BM to make compatible with list_options table and functions - using jquery
 342 $(document).ready(function() {
 343
 344  <?php for ($i=1;$i<=3;$i++) { ?>
 345   $("#form_i<?php echo $i?>subscriber_relationship").change(function() { auto_populate_employer_address<?php echo $i?>(); });
 346  <?php } ?>
 347
 348 });
 349
 350 </script>
 351 </head>
 352
 353 <body class="body_top">
 354 <form action='demographics_save.php' name='demographics_form' method='post' onsubmit='return validate(this)'>
 355 <input type='hidden' name='mode' value='save' />
 356 <input type='hidden' name='db_id' value="<?php echo $result['id']?>" />
 357 <table cellpadding='0' cellspacing='0' border='0'>
 358         <tr>
 359                 <td>
 360                         <?php if ($GLOBALS['concurrent_layout']) { ?>
 361                         <a href="demographics.php" onclick="top.restoreSession()">
 362                         <?php } else { ?>
 363                         <a href="patient_summary.php" target="Main" onclick="top.restoreSession()">
 364                         <?php } ?>
 365                         <font class=title><?php xl('Current Patient','e'); ?></font>
 366                         </a>
 367                         &nbsp;&nbsp;
 368                 </td>
 369                 <td>
 370                         <a href="javascript:submitme();" class='css_button'>
 371                                 <span><?php xl('Save','e'); ?></span>
 372                         </a>
 373                 </td>
 374                 <td>
 375                         <?php if ($GLOBALS['concurrent_layout']) { ?>
 376                         <a class="css_button" href="demographics.php" onclick="top.restoreSession()">
 377                         <?php } else { ?>
 378                         <a href="patient_summary.php" target="Main" onclick="top.restoreSession()">
 379                         <?php } ?>
 380                         <span><?php xl('Cancel','e'); ?></span>
 381                         </a>
 382                 </td>
 383         </tr>
 384 </table>
 385 <?php
 386
 387 function end_cell() {
 388   global $item_count, $cell_count;
 389   if ($item_count > 0) {
 390     echo "</td>";
 391     $item_count = 0;
 392   }
 393 }
 394
 395 function end_row() {
 396   global $cell_count, $CPR;
 397   end_cell();
 398   if ($cell_count > 0) {
 399     for (; $cell_count < $CPR; ++$cell_count) echo "<td></td>";
 400     echo "</tr>\n";
 401     $cell_count = 0;
 402   }
 403 }
 404
 405 function end_group() {
 406   global $last_group;
 407   if (strlen($last_group) > 0) {
 408     end_row();
 409     echo " </table>\n";
 410     echo "</div>\n";
 411   }
 412 }
 413
 414 $last_group = '';
 415 $cell_count = 0;
 416 $item_count = 0;
 417 $display_style = 'block';
 418
 419 $group_seq=0; // this gives the DIV blocks unique IDs
 420
 421 ?>
 422 <br>
 423   <div class="section-header">
 424    <span class="text"><b> <?php xl("Demographics", "e" )?></b></span>
 425 </div>
 426
 427 <div id="DEM" >
 428
 429         <ul class="tabNav">
 430            <?php display_layout_tabs('DEM', $result, $result2); ?>
 431         </ul>
 432
 433         <div class="tabContainer">
 434                 <?php display_layout_tabs_data_editable('DEM', $result, $result2); ?>
 435         </div>
 436 </div>
 437 <br>
 438
 439 <div id="DEM" >
 440
 441
 442 <?php
 443  if (! $GLOBALS['simplified_demographics']) {
 444
 445           $insurance_headings = array(xl("Primary Insurance Provider"), xl("Secondary Insurance Provider"), xl("Tertiary Insurance provider"));
 446           $insurance_info = array();
 447           $insurance_info[1] = getInsuranceData($pid,"primary");
 448           $insurance_info[2] = getInsuranceData($pid,"secondary");
 449           $insurance_info[3] = getInsuranceData($pid,"tertiary");
 450
 451         ?>
 452      <div class="section-header">
 453          <span class="text"><b><?php xl("Insurance", "e" )?></b></span>
 454      </div>
 455         <div id="INSURANCE" >
 456                 <ul class="tabNav">
 457                 <?php
 458                 foreach (array('primary','secondary','tertiary') as $instype) {
 459                         ?><li <?php echo $instype == 'primary' ? 'class="current"' : '' ?>><a href="/play/javascript-tabbed-navigation/"><?php $CapInstype=ucfirst($instype); xl($CapInstype,'e'); ?></a></li><?php
 460                 }
 461                 ?>
 462                 </ul>
 463
 464         <div class="tabContainer">
 465
 466         <?php
 467           for($i=1;$i<=3;$i++) {
 468            $result3 = $insurance_info[$i];
 469         ?>
 470
 471                 <div class="tab <?php echo $i == 1 ? 'current': '' ?>" style='height:auto;width:auto'>          <!---display icky, fix to auto-->
 472
 473                 <table border="0">
 474
 475                  <tr>
 476                   <td valign=top width="430">
 477                    <table border="0">
 478
 479                          <tr>
 480                           <td valign='top'>
 481                            <span class='required'><?php echo $insurance_headings[$i -1]."&nbsp;"?></span>
 482                           </td>
 483                           <td class='required'>:</td>
 484                           <td>
 485                            <a href="../../practice/ins_search.php" class="iframe medium_modal css_button" onclick="ins_search(<?php echo $i?>)">
 486                                 <span><?php echo xl('Search/Add') ?></span>
 487                                 </a>
 488                                 <select name="i<?php echo $i?>provider">
 489                                 <option value=""><?php xl('Unassigned','e'); ?></option>
 490                                 <?php
 491                                  foreach ($insurancei as $iid => $iname) {
 492                                   echo "<option value='" . $iid . "'";
 493                                   if (strtolower($iid) == strtolower($result3{"provider"}))
 494                                    echo " selected";
 495                                   echo ">" . $iname . "</option>\n";
 496                                  }
 497                                 ?>
 498                            </select>
 499
 500                           </td>
 501                          </tr>
 502
 503                         <tr>
 504                          <td>
 505                           <span class='required'><?php xl('Plan Name','e'); ?> </span>
 506                          </td>
 507                          <td class='required'>:</td>
 508                          <td>
 509                           <input type='entry' size='20' name='i<?php echo $i?>plan_name' value="<?php echo $result3{"plan_name"} ?>"
 510                            onchange="capitalizeMe(this);" />&nbsp;&nbsp;
 511                          </td>
 512                         </tr>
 513
 514                         <tr>
 515                          <td>
 516                           <span class='required'><?php xl('Effective Date','e'); ?></span>
 517                          </td>
 518                          <td class='required'>:</td>
 519                          <td>
 520                           <input type='entry' size='16' id='i<?php echo $i ?>effective_date' name='i<?php echo $i ?>effective_date'
 521                            value='<?php echo $result3['date'] ?>'
 522                            onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)'
 523                            title='yyyy-mm-dd' />
 524                           <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'); ?>'>
 525                          </td>
 526                         </tr>
 527
 528                         <tr>
 529                          <td><span class=required><?php xl('Policy Number','e'); ?></span></td>
 530                          <td class='required'>:</td>
 531                          <td><input type='entry' size='16' name='i<?php echo $i?>policy_number' value="<?php echo $result3{"policy_number"}?>"
 532                           onkeyup='policykeyup(this)'></td>
 533                         </tr>
 534
 535                         <tr>
 536                          <td><span class=required><?php xl('Group Number','e'); ?></span></td>
 537                          <td class='required'>:</td>
 538                          <td><input type=entry size=16 name=i<?php echo $i?>group_number value="<?php echo $result3{"group_number"}?>" onkeyup='policykeyup(this)'></td>
 539                         </tr>
 540
 541                         <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 542                          <td class='required'><?php xl('Subscriber Employer (SE)','e'); ?><br><span style='font-weight:normal'>
 543                           (<?php xl('if unemployed enter Student','e'); ?>,<br><?php xl('PT Student, or leave blank','e'); ?>) </span></td>
 544                           <td class='required'>:</td>
 545                          <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer
 546                           value="<?php echo $result3{"subscriber_employer"}?>"
 547                            onchange="capitalizeMe(this);" /></td>
 548                         </tr>
 549
 550                         <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 551                          <td><span class=required><?php xl('SE Address','e'); ?></span></td>
 552                          <td class='required'>:</td>
 553                          <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer_street
 554                           value="<?php echo $result3{"subscriber_employer_street"}?>"
 555                            onchange="capitalizeMe(this);" /></td>
 556                         </tr>
 557
 558                         <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 559                          <td colspan="3">
 560                           <table>
 561                            <tr>
 562                                 <td><span class=required><?php xl('SE City','e'); ?>: </span></td>
 563                                 <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_city
 564                                  value="<?php echo $result3{"subscriber_employer_city"}?>"
 565                                   onchange="capitalizeMe(this);" /></td>
 566                                 <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE State','e') : xl('SE Locality','e') ?>: </span></td>
 567                         <td>
 568                                  <?php
 569                                   // Modified 7/2009 by BM to incorporate data types
 570                           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'), $result3['subscriber_employer_state']);
 571                                  ?>
 572                                 </td>
 573                            </tr>
 574                            <tr>
 575                                 <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE Zip Code','e') : xl('SE Postal Code','e') ?>: </span></td>
 576                                 <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_postal_code value="<?php echo $result3{"subscriber_employer_postal_code"}?>"></td>
 577                                 <td><span class=required><?php xl('SE Country','e'); ?>: </span></td>
 578                         <td>
 579                                  <?php
 580                                   // Modified 7/2009 by BM to incorporate data types
 581                           generate_form_field(array('data_type'=>$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'), $result3['subscriber_employer_country']);
 582                                  ?>
 583                         </td>
 584                            </tr>
 585                           </table>
 586                          </td>
 587                         </tr>
 588
 589                    </table>
 590                   </td>
 591
 592                   <td valign=top>
 593                 <table border="0">
 594                         <tr>
 595                                 <td><span class=required><?php xl('Relationship','e'); ?></span></td>
 596                                 <td class=required>:</td>
 597                                 <td colspan=3><?php
 598                                         // Modified 6/2009 by BM to use list_options and function
 599                                         generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_relationship'),'list_id'=>'sub_relation','empty_title'=>' '), $result3['subscriber_relationship']);
 600                                         ?>
 601
 602                                 <a href="javascript:popUp('browse.php?browsenum=<?php echo $i?>')" class=text>(<?php xl('Browse','e'); ?>)</a></td>
 603                                 <td></td><td></td><td></td><td></td>
 604                         </tr>
 605                         <tr>
 606                                 <td width=120><span class=required><?php xl('Subscriber','e'); ?> </span></td>
 607                                 <td class=required>:</td>
 608                                 <td colspan=3><input type=entry size=10 name=i<?php echo $i?>subscriber_fname   value="<?php echo $result3{"subscriber_fname"}?>" onchange="capitalizeMe(this);" />
 609                                 <input type=entry size=3 name=i<?php echo $i?>subscriber_mname value="<?php echo $result3{"subscriber_mname"}?>" onchange="capitalizeMe(this);" />
 610                                 <input type=entry size=10 name=i<?php echo $i?>subscriber_lname value="<?php echo $result3{"subscriber_lname"}?>" onchange="capitalizeMe(this);" /></td>
 611                                 <td></td><td></td><td></td><td></td>
 612                         </tr>
 613                         <tr>
 614                                 <td><span class=bold><?php xl('D.O.B.','e'); ?> </span></td>
 615                                 <td class=required>:</td>
 616                                 <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 $i; ?>dob_date' border='0' alt='[?]' style='cursor:pointer' title='<?php xl('Click here to choose a date','e'); ?>'></td>
 617
 618                                 <td><span class=bold><?php xl('Sex','e'); ?>: </span></td>
 619                                 <td><?php
 620                                         // Modified 6/2009 by BM to use list_options and function
 621                                         generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_sex'),'list_id'=>'sex'), $result3['subscriber_sex']);
 622                                         ?>
 623                                 </td>
 624                                 <td></td><td></td> <td></td><td></td>
 625                         </tr>
 626                         <tr>
 627                                 <td class=leftborder><span class=bold><?php xl('S.S.','e'); ?> </span></td>
 628                                 <td class=required>:</td>
 629                                 <td><input type=entry size=11 name=i<?php echo $i?>subscriber_ss value="<?php echo trim($result3{"subscriber_ss"})?>"></td>
 630                         </tr>
 631
 632                         <tr>
 633                                 <td><span class=required><?php xl('Subscriber Address','e'); ?> </span></td>
 634                                 <td class=required>:</td>
 635                                 <td><input type=entry size=20 name=i<?php echo $i?>subscriber_street value="<?php echo $result3{"subscriber_street"}?>" onchange="capitalizeMe(this);" /></td>
 636
 637                                 <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('State','e') : xl('Locality','e') ?>: </span></td>
 638                                 <td>
 639                                         <?php
 640                                         // Modified 7/2009 by BM to incorporate data types
 641                                         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']);
 642                                 ?>
 643                                 </td>
 644                         </tr>
 645                         <tr>
 646                                 <td class=leftborder><span class=required><?php xl('City','e'); ?></span></td>
 647                                 <td class=required>:</td>
 648                                 <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>
 649                                         <?php
 650                                         // Modified 7/2009 by BM to incorporate data types
 651                                         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'), $result3['subscriber_country']);
 652                                         ?>
 653                                 </td>
 654 </tr>
 655                         <tr>
 656                                 <td><span class=required><?php echo ($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>
 657
 658                                 <td colspan=2>
 659                                 </td><td></td>
 660                         </tr>
 661                         <tr>
 662                                 <td><span class=bold><?php xl('Subscriber Phone','e'); ?></span></td>
 663                                 <td class=required>:</td>
 664                                 <td><input type='text' size='20' name='i<?php echo $i?>subscriber_phone' value='<?php echo $result3["subscriber_phone"] ?>' onkeyup='phonekeyup(this,mypcc)' /></td>
 665                                 <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>
 666                                 <td colspan=2>
 667                                 </td><td></td><td></td>
 668                         </tr>
 669                         <tr>
 670                                 <td colspan=0><span class='required'><?php xl('Accept Assignment','e'); ?></span></td>
 671                                 <td class=required>:</td>
 672                                 <td colspan=2>
 673                                         <select name=i<?php echo $i?>accept_assignment>
 674                                                 <option value="TRUE" <?php if (strtoupper($result3{"accept_assignment"}) == "TRUE") echo "selected"?>><?php xl('YES','e'); ?></option>
 675                                                 <option value="FALSE" <?php if (strtoupper($result3{"accept_assignment"}) == "FALSE") echo "selected"?>><?php xl('NO','e'); ?></option>
 676                                         </select>
 677                                 </td>
 678                                 <td></td><td></td>
 679                                 <td colspan=2>
 680                                 </td><td></td>
 681                         </tr>
 682       <tr>
 683         <td><span class='bold'><?php xl('Secondary Medicare Type','e'); ?></span></td>
 684         <td class='bold'>:</td>
 685         <td colspan='6'>
 686           <select name=i<?php echo $i?>policy_type>
 687 <?php
 688   foreach ($policy_types AS $key => $value) {
 689     echo "            <option value ='$key'";
 690     if ($key == $result3['policy_type']) echo " selected";
 691     echo ">" . htmlspecialchars($value) . "</option>\n";
 692   }
 693 ?>
 694           </select>
 695         </td>
 696       </tr>
 697                 </table>
 698
 699                   </td>
 700                  </tr>
 701                 </table>
 702
 703                 </div>
 704
 705         <?php } //end insurer for loop ?>
 706
 707         </div>
 708 </div>
 709
 710 <?php } // end of "if not simplified_demographics" ?>
 711 </div></div>
 712
 713 </form>
 714
 715 <br>
 716
 717 <script language="JavaScript">
 718
 719  // fix inconsistently formatted phone numbers from the database
 720  var f = document.forms[0];
 721  if (f.form_phone_contact) phonekeyup(f.form_phone_contact,mypcc);
 722  if (f.form_phone_home   ) phonekeyup(f.form_phone_home   ,mypcc);
 723  if (f.form_phone_biz    ) phonekeyup(f.form_phone_biz    ,mypcc);
 724  if (f.form_phone_cell   ) phonekeyup(f.form_phone_cell   ,mypcc);
 725
 726 <?php if (! $GLOBALS['simplified_demographics']) { ?>
 727  phonekeyup(f.i1subscriber_phone,mypcc);
 728  phonekeyup(f.i2subscriber_phone,mypcc);
 729  phonekeyup(f.i3subscriber_phone,mypcc);
 730 <?php } ?>
 731
 732 <?php if ($GLOBALS['concurrent_layout'] && $set_pid) { ?>
 733  parent.left_nav.setPatient(<?php echo "'" . addslashes($result['fname']) . " " . addslashes($result['lname']) . "',$pid,'" . addslashes($result['pubpid']) . "','', ' " . xl('DOB') . ": " . oeFormatShortDate($result['DOB_YMD']) . " " . xl('Age') . ": " . getPatientAgeDisplay($result['DOB_YMD']) . "'"; ?>);
 734  parent.left_nav.setRadio(window.name, 'dem');
 735 <?php } ?>
 736
 737 <?php echo $date_init; ?>
 738 <?php if (! $GLOBALS['simplified_demographics']) { for ($i=1; $i<=3; $i++): ?>
 739  Calendar.setup({inputField:"i<?php echo $i?>effective_date", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i?>effective_date"});
 740  Calendar.setup({inputField:"i<?php echo $i?>subscriber_DOB", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i?>dob_date"});
 741 <?php endfor; } ?>
 742 </script>
 743
 744 <!-- include support for the list-add selectbox feature -->
 745 <?php include $GLOBALS['fileroot']."/library/options_listadd.inc"; ?>
 746
 747 </body>
 748 <script language='JavaScript'>
 749     // Array of skip conditions for the checkSkipConditions() function.
 750     var skipArray = [
 751         <?php echo $condition_str; ?>
 752     ];
 753     checkSkipConditions();
 754     $("input").change(function() {
 755         checkSkipConditions();
 756     });
 757     $("select").change(function() {
 758         checkSkipConditions();
 759     });
 760 </script>
 761
 762
 763 </html>