interface/patient_file/summary/demographics_full.php

   1 <?php
   2 // This program is free software; you can redistribute it and/or
   3 // modify it under the terms of the GNU General Public License
   4 // as published by the Free Software Foundation; either version 2
   5 // of the License, or (at your option) any later version.
   6
   7 require_once("../../globals.php");
   8 require_once("$srcdir/acl.inc");
   9 require_once("$srcdir/options.inc.php");
  10 require_once("$srcdir/formatting.inc.php");
  11 require_once("$srcdir/erx_javascript.inc.php");
  12
  13  // Session pid must be right or bad things can happen when demographics are saved!
  14  //
  15  include_once("$srcdir/pid.inc");
  16  $set_pid = $_GET["set_pid"] ? $_GET["set_pid"] : $_GET["pid"];
  17  if ($set_pid && $set_pid != $_SESSION["pid"]) {
  18   setpid($set_pid);
  19  }
  20
  21  include_once("$srcdir/patient.inc");
  22
  23  $result = getPatientData($pid, "*, DATE_FORMAT(DOB,'%Y-%m-%d') as DOB_YMD");
  24  $result2 = getEmployerData($pid);
  25
  26  // Check authorization.
  27  if ($pid) {
  28   if (!acl_check('patients', 'demo', '', 'write'))
  29    die(xl('Updating demographics is not authorized.'));
  30   if ($result['squad'] && ! acl_check('squads', $result['squad']))
  31    die(xl('You are not authorized to access this squad.'));
  32  } else {
  33   if (!acl_check('patients', 'demo', '', array('write','addonly') ))
  34    die(xl('Adding demographics is not authorized.'));
  35  }
  36
  37 $CPR = 4; // cells per row
  38
  39 // $statii = array('married','single','divorced','widowed','separated','domestic partner');
  40 // $langi = getLanguages();
  41 // $ethnoraciali = getEthnoRacials();
  42 // $provideri = getProviderInfo();
  43
  44 $insurancei = getInsuranceProviders();
  45
  46 $fres = sqlStatement("SELECT * FROM layout_options " .
  47   "WHERE form_id = 'DEM' AND uor > 0 " .
  48   "ORDER BY group_name, seq");
  49 ?>
  50 <html>
  51 <head>
  52 <?php html_header_show();?>
  53
  54 <link rel="stylesheet" href="<?php echo $css_header; ?>" type="text/css">
  55
  56 <style type="text/css">@import url(../../../library/dynarch_calendar.css);</style>
  57
  58 <script type="text/javascript" src="../../../library/dialog.js"></script>
  59 <script type="text/javascript" src="../../../library/textformat.js"></script>
  60 <script type="text/javascript" src="../../../library/dynarch_calendar.js"></script>
  61 <?php include_once("{$GLOBALS['srcdir']}/dynarch_calendar_en.inc.php"); ?>
  62 <script type="text/javascript" src="../../../library/dynarch_calendar_setup.js"></script>
  63
  64 <script type="text/javascript" src="../../../library/js/jquery.1.3.2.js"></script>
  65 <script type="text/javascript" src="../../../library/js/common.js"></script>
  66
  67 <script type="text/javascript" src="../../../library/js/fancybox/jquery.fancybox-1.2.6.js"></script>
  68 <link rel="stylesheet" type="text/css" href="../../../library/js/fancybox/jquery.fancybox-1.2.6.css" media="screen" />
  69
  70 <script type="text/javascript">
  71 $(document).ready(function(){
  72     tabbify();
  73     enable_modals();
  74
  75     // special size for
  76         $(".medium_modal").fancybox( {
  77                 'overlayOpacity' : 0.0,
  78                 'showCloseButton' : true,
  79                 'frameHeight' : 460,
  80                 'frameWidth' : 650
  81         });
  82
  83 });
  84
  85 var mypcc = '<?php echo $GLOBALS['phone_country_code'] ?>';
  86
  87 //code used from http://tech.irt.org/articles/js037/
  88 function replace(string,text,by) {
  89  // Replaces text with by in string
  90  var strLength = string.length, txtLength = text.length;
  91  if ((strLength == 0) || (txtLength == 0)) return string;
  92
  93  var i = string.indexOf(text);
  94  if ((!i) && (text != string.substring(0,txtLength))) return string;
  95  if (i == -1) return string;
  96
  97  var newstr = string.substring(0,i) + by;
  98
  99  if (i+txtLength < strLength)
 100   newstr += replace(string.substring(i+txtLength,strLength),text,by);
 101
 102  return newstr;
 103 }
 104
 105 function upperFirst(string,text) {
 106  return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
 107 }
 108
 109 <?php for ($i=1;$i<=3;$i++) { ?>
 110 function auto_populate_employer_address<?php echo $i ?>(){
 111  var f = document.demographics_form;
 112  if (f.form_i<?php echo $i?>subscriber_relationship.options[f.form_i<?php echo $i?>subscriber_relationship.selectedIndex].value == "self")
 113  {
 114   f.i<?php echo $i?>subscriber_fname.value=f.form_fname.value;
 115   f.i<?php echo $i?>subscriber_mname.value=f.form_mname.value;
 116   f.i<?php echo $i?>subscriber_lname.value=f.form_lname.value;
 117   f.i<?php echo $i?>subscriber_street.value=f.form_street.value;
 118   f.i<?php echo $i?>subscriber_city.value=f.form_city.value;
 119   f.form_i<?php echo $i?>subscriber_state.value=f.form_state.value;
 120   f.i<?php echo $i?>subscriber_postal_code.value=f.form_postal_code.value;
 121   if (f.form_country_code)
 122     f.form_i<?php echo $i?>subscriber_country.value=f.form_country_code.value;
 123   f.i<?php echo $i?>subscriber_phone.value=f.form_phone_home.value;
 124   f.i<?php echo $i?>subscriber_DOB.value=f.form_DOB.value;
 125   if(typeof f.form_ss!="undefined")
 126     {
 127         f.i<?php echo $i?>subscriber_ss.value=f.form_ss.value;
 128     }
 129   f.form_i<?php echo $i?>subscriber_sex.value = f.form_sex.value;
 130   f.i<?php echo $i?>subscriber_employer.value=f.form_em_name.value;
 131   f.i<?php echo $i?>subscriber_employer_street.value=f.form_em_street.value;
 132   f.i<?php echo $i?>subscriber_employer_city.value=f.form_em_city.value;
 133   f.form_i<?php echo $i?>subscriber_employer_state.value=f.form_em_state.value;
 134   f.i<?php echo $i?>subscriber_employer_postal_code.value=f.form_em_postal_code.value;
 135   if (f.form_em_country)
 136     f.form_i<?php echo $i?>subscriber_employer_country.value=f.form_em_country.value;
 137  }
 138 }
 139
 140 <?php } ?>
 141
 142 function popUp(URL) {
 143  day = new Date();
 144  id = day.getTime();
 145  top.restoreSession();
 146  eval("page" + id + " = window.open(URL, '" + id + "', 'toolbar=0,scrollbars=1,location=0,statusbar=0,menubar=0,resizable=1,width=400,height=300,left = 440,top = 362');");
 147 }
 148
 149 function checkNum () {
 150  var re= new RegExp();
 151  re = /^\d*\.?\d*$/;
 152  str=document.demographics_form.monthly_income.value;
 153  if(re.exec(str))
 154  {
 155  }else{
 156   alert("<?php xl('Please enter a monetary amount using only numbers and a decimal point.','e'); ?>");
 157  }
 158 }
 159
 160 // Indicates which insurance slot is being updated.
 161 var insurance_index = 0;
 162
 163 // The OnClick handler for searching/adding the insurance company.
 164 function ins_search(ins) {
 165         insurance_index = ins;
 166         return false;
 167 }
 168
 169 // The ins_search.php window calls this to set the selected insurance.
 170 function set_insurance(ins_id, ins_name) {
 171  var thesel = document.forms[0]['i' + insurance_index + 'provider'];
 172  var theopts = thesel.options; // the array of Option objects
 173  var i = 0;
 174  for (; i < theopts.length; ++i) {
 175   if (theopts[i].value == ins_id) {
 176    theopts[i].selected = true;
 177    return;
 178   }
 179  }
 180  // no matching option was found so create one, append it to the
 181  // end of the list, and select it.
 182  theopts[i] = new Option(ins_name, ins_id, false, true);
 183 }
 184
 185 // This capitalizes the first letter of each word in the passed input
 186 // element.  It also strips out extraneous spaces.
 187 function capitalizeMe(elem) {
 188  var a = elem.value.split(' ');
 189  var s = '';
 190  for(var i = 0; i < a.length; ++i) {
 191   if (a[i].length > 0) {
 192    if (s.length > 0) s += ' ';
 193    s += a[i].charAt(0).toUpperCase() + a[i].substring(1);
 194   }
 195  }
 196  elem.value = s;
 197 }
 198
 199 function divclick(cb, divid) {
 200  var divstyle = document.getElementById(divid).style;
 201  if (cb.checked) {
 202   divstyle.display = 'block';
 203  } else {
 204   divstyle.display = 'none';
 205  }
 206  return true;
 207 }
 208
 209 // Compute the length of a string without leading and trailing spaces.
 210 function trimlen(s) {
 211  var i = 0;
 212  var j = s.length - 1;
 213  for (; i <= j && s.charAt(i) == ' '; ++i);
 214  for (; i <= j && s.charAt(j) == ' '; --j);
 215  if (i > j) return 0;
 216  return j + 1 - i;
 217 }
 218
 219 function validate(f) {
 220  var errCount = 0;
 221  var errMsgs = new Array();
 222 <?php generate_layout_validation('DEM'); ?>
 223
 224  var msg = "";
 225  msg += "<?php xl('The following fields are required', 'e' ); ?>:\n\n";
 226  for ( var i = 0; i < errMsgs.length; i++ ) {
 227         msg += errMsgs[i] + "\n";
 228  }
 229  msg += "\n<?php xl('Please fill them in before continuing.', 'e'); ?>";
 230
 231  if ( errMsgs.length > 0 ) {
 232         alert(msg);
 233  }
 234
 235 //Patient Data validations
 236  <?php if($GLOBALS['erx_enable']){ ?>
 237  alertMsg='';
 238  for(i=0;i<f.length;i++){
 239   if(f[i].type=='text' && f[i].value)
 240   {
 241    if(f[i].name == 'form_fname' || f[i].name == 'form_mname' || f[i].name == 'form_lname')
 242    {
 243     alertMsg += checkLength(f[i].name,f[i].value,35);
 244     alertMsg += checkUsername(f[i].name,f[i].value);
 245    }
 246    else if(f[i].name == 'form_street' || f[i].name == 'form_city')
 247    {
 248     alertMsg += checkLength(f[i].name,f[i].value,35);
 249     alertMsg += checkAlphaNumericExtended(f[i].name,f[i].value);
 250    }
 251    else if(f[i].name == 'form_phone_home')
 252    {
 253     alertMsg += checkPhone(f[i].name,f[i].value);
 254    }
 255   }
 256  }
 257  if(alertMsg)
 258  {
 259    alert(alertMsg);
 260    return false;
 261  }
 262  <?php } ?>
 263  //return false;
 264
 265 // Some insurance validation.
 266  for (var i = 1; i <= 3; ++i) {
 267   subprov = 'i' + i + 'provider';
 268   if (!f[subprov] || f[subprov].selectedIndex <= 0) continue;
 269   var subpfx = 'i' + i + 'subscriber_';
 270   var subrelat = f['form_' + subpfx + 'relationship'];
 271   var samename =
 272    f[subpfx + 'fname'].value == f.form_fname.value &&
 273    f[subpfx + 'mname'].value == f.form_mname.value &&
 274    f[subpfx + 'lname'].value == f.form_lname.value;
 275   var ss_regexp=/[0-9][0-9][0-9]-?[0-9][0-9]-?[0-9][0-9][0-9][0-9]/;
 276   var samess=true;
 277   var ss_valid=false;
 278   if(typeof f.form_ss!="undefined")
 279       {
 280         samess = f[subpfx + 'ss'].value == f.form_ss.value;
 281         ss_valid=ss_regexp.test(f[subpfx + 'ss'].value) && ss_regexp.test(f.form_ss.value);
 282       }
 283   if (subrelat.options[subrelat.selectedIndex].value == "self") {
 284    if (!samename) {
 285     if (!confirm("<?php echo xls('Subscriber relationship is self but name is different! Is this really OK?'); ?>"))
 286      return false;
 287    }
 288    if (!samess && ss_valid) {
 289     if(!confirm("<?php echo xls('Subscriber relationship is self but SS number is different!')." ". xls("Is this really OK?"); ?>"))
 290     return false;
 291    }
 292   } // end self
 293   else {
 294    if (samename) {
 295     if (!confirm("<?php echo xls('Subscriber relationship is not self but name is the same! Is this really OK?'); ?>"))
 296      return false;
 297    }
 298    if (samess && ss_valid)  {
 299     if(!confirm("<?php echo xls('Subscriber relationship is not self but SS number is the same!') ." ". xls("Is this really OK?"); ?>"))
 300     return false;
 301    }
 302   } // end not self
 303  } // end for
 304
 305  return errMsgs.length < 1;
 306 }
 307
 308 function submitme() {
 309  var f = document.forms[0];
 310  if (validate(f)) {
 311   top.restoreSession();
 312   f.submit();
 313  }
 314 }
 315
 316 // Onkeyup handler for policy number.  Allows only A-Z and 0-9.
 317 function policykeyup(e) {
 318  var v = e.value.toUpperCase();
 319  for (var i = 0; i < v.length; ++i) {
 320   var c = v.charAt(i);
 321   if (c >= '0' && c <= '9') continue;
 322   if (c >= 'A' && c <= 'Z') continue;
 323   if (c == '*') continue;
 324   if (c == '-') continue;
 325   if (c == '_') continue;
 326   if (c == '(') continue;
 327   if (c == ')') continue;
 328   if (c == '#') continue;
 329   v = v.substring(0, i) + v.substring(i + i);
 330   --i;
 331  }
 332  e.value = v;
 333  return;
 334 }
 335
 336 // Added 06/2009 by BM to make compatible with list_options table and functions - using jquery
 337 $(document).ready(function() {
 338
 339  <?php for ($i=1;$i<=3;$i++) { ?>
 340   $("#form_i<?php echo $i?>subscriber_relationship").change(function() { auto_populate_employer_address<?php echo $i?>(); });
 341  <?php } ?>
 342
 343 });
 344
 345 </script>
 346 </head>
 347
 348 <body class="body_top">
 349 <form action='demographics_save.php' name='demographics_form' method='post' onsubmit='return validate(this)'>
 350 <input type='hidden' name='mode' value='save' />
 351 <input type='hidden' name='db_id' value="<?php echo $result['id']?>" />
 352 <table cellpadding='0' cellspacing='0' border='0'>
 353         <tr>
 354                 <td>
 355                         <?php if ($GLOBALS['concurrent_layout']) { ?>
 356                         <a href="demographics.php" onclick="top.restoreSession()">
 357                         <?php } else { ?>
 358                         <a href="patient_summary.php" target="Main" onclick="top.restoreSession()">
 359                         <?php } ?>
 360                         <font class=title><?php xl('Current Patient','e'); ?></font>
 361                         </a>
 362                         &nbsp;&nbsp;
 363                 </td>
 364                 <td>
 365                         <a href="javascript:submitme();" class='css_button'>
 366                                 <span><?php xl('Save','e'); ?></span>
 367                         </a>
 368                 </td>
 369                 <td>
 370                         <?php if ($GLOBALS['concurrent_layout']) { ?>
 371                         <a class="css_button" href="demographics.php" onclick="top.restoreSession()">
 372                         <?php } else { ?>
 373                         <a href="patient_summary.php" target="Main" onclick="top.restoreSession()">
 374                         <?php } ?>
 375                         <span><?php xl('Cancel','e'); ?></span>
 376                         </a>
 377                 </td>
 378         </tr>
 379 </table>
 380 <?php
 381
 382 function end_cell() {
 383   global $item_count, $cell_count;
 384   if ($item_count > 0) {
 385     echo "</td>";
 386     $item_count = 0;
 387   }
 388 }
 389
 390 function end_row() {
 391   global $cell_count, $CPR;
 392   end_cell();
 393   if ($cell_count > 0) {
 394     for (; $cell_count < $CPR; ++$cell_count) echo "<td></td>";
 395     echo "</tr>\n";
 396     $cell_count = 0;
 397   }
 398 }
 399
 400 function end_group() {
 401   global $last_group;
 402   if (strlen($last_group) > 0) {
 403     end_row();
 404     echo " </table>\n";
 405     echo "</div>\n";
 406   }
 407 }
 408
 409 $last_group = '';
 410 $cell_count = 0;
 411 $item_count = 0;
 412 $display_style = 'block';
 413
 414 $group_seq=0; // this gives the DIV blocks unique IDs
 415
 416 ?>
 417 <br>
 418   <div class="section-header">
 419    <span class="text"><b> <?php xl("Demographics", "e" )?></b></span>
 420 </div>
 421
 422 <div id="DEM" >
 423
 424         <ul class="tabNav">
 425            <?php display_layout_tabs('DEM', $result, $result2); ?>
 426         </ul>
 427
 428         <div class="tabContainer">
 429                 <?php display_layout_tabs_data_editable('DEM', $result, $result2); ?>
 430         </div>
 431 </div>
 432 <br>
 433   <div class="section-header">
 434     <span class="text"><b><?php xl("Insurance", "e" )?></b></span>
 435 </div>
 436 <div id="DEM" >
 437
 438
 439 <?php
 440  if (! $GLOBALS['simplified_demographics']) {
 441
 442           $insurance_headings = array(xl("Primary Insurance Provider"), xl("Secondary Insurance Provider"), xl("Tertiary Insurance provider"));
 443           $insurance_info = array();
 444           $insurance_info[1] = getInsuranceData($pid,"primary");
 445           $insurance_info[2] = getInsuranceData($pid,"secondary");
 446           $insurance_info[3] = getInsuranceData($pid,"tertiary");
 447
 448         ?>
 449         <div id="INSURANCE" >
 450                 <ul class="tabNav">
 451                 <?php
 452                 foreach (array('primary','secondary','tertiary') as $instype) {
 453                         ?><li <?php echo $instype == 'primary' ? 'class="current"' : '' ?>><a href="/play/javascript-tabbed-navigation/"><?php $CapInstype=ucfirst($instype); xl($CapInstype,'e'); ?></a></li><?php
 454                 }
 455                 ?>
 456                 </ul>
 457
 458         <div class="tabContainer">
 459
 460         <?php
 461           for($i=1;$i<=3;$i++) {
 462            $result3 = $insurance_info[$i];
 463         ?>
 464
 465                 <div class="tab <?php echo $i == 1 ? 'current': '' ?>" style='height:auto;width:auto'>          <!---display icky, fix to auto-->
 466
 467                 <table border="0">
 468
 469                  <tr>
 470                   <td valign=top width="430">
 471                    <table border="0">
 472
 473                          <tr>
 474                           <td valign='top'>
 475                            <span class='required'><?php echo $insurance_headings[$i -1]."&nbsp;"?></span>
 476                           </td>
 477                           <td class='required'>:</td>
 478                           <td>
 479                            <a href="../../practice/ins_search.php" class="iframe medium_modal css_button" onclick="ins_search(<?php echo $i?>)">
 480                                 <span><?php echo xl('Search/Add') ?></span>
 481                                 </a>
 482                                 <select name="i<?php echo $i?>provider">
 483                                 <option value=""><?php xl('Unassigned','e'); ?></option>
 484                                 <?php
 485                                  foreach ($insurancei as $iid => $iname) {
 486                                   echo "<option value='" . $iid . "'";
 487                                   if (strtolower($iid) == strtolower($result3{"provider"}))
 488                                    echo " selected";
 489                                   echo ">" . $iname . "</option>\n";
 490                                  }
 491                                 ?>
 492                            </select>
 493
 494                           </td>
 495                          </tr>
 496
 497                         <tr>
 498                          <td>
 499                           <span class='required'><?php xl('Plan Name','e'); ?> </span>
 500                          </td>
 501                          <td class='required'>:</td>
 502                          <td>
 503                           <input type='entry' size='20' name='i<?php echo $i?>plan_name' value="<?php echo $result3{"plan_name"} ?>"
 504                            onchange="capitalizeMe(this);" />&nbsp;&nbsp;
 505                          </td>
 506                         </tr>
 507
 508                         <tr>
 509                          <td>
 510                           <span class='required'><?php xl('Effective Date','e'); ?></span>
 511                          </td>
 512                          <td class='required'>:</td>
 513                          <td>
 514                           <input type='entry' size='16' id='i<?php echo $i ?>effective_date' name='i<?php echo $i ?>effective_date'
 515                            value='<?php echo $result3['date'] ?>'
 516                            onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)'
 517                            title='yyyy-mm-dd' />
 518                           <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'); ?>'>
 519                          </td>
 520                         </tr>
 521
 522                         <tr>
 523                          <td><span class=required><?php xl('Policy Number','e'); ?></span></td>
 524                          <td class='required'>:</td>
 525                          <td><input type='entry' size='16' name='i<?php echo $i?>policy_number' value="<?php echo $result3{"policy_number"}?>"
 526                           onkeyup='policykeyup(this)'></td>
 527                         </tr>
 528
 529                         <tr>
 530                          <td><span class=required><?php xl('Group Number','e'); ?></span></td>
 531                          <td class='required'>:</td>
 532                          <td><input type=entry size=16 name=i<?php echo $i?>group_number value="<?php echo $result3{"group_number"}?>" onkeyup='policykeyup(this)'></td>
 533                         </tr>
 534
 535                         <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 536                          <td class='required'><?php xl('Subscriber Employer (SE)','e'); ?><br><span style='font-weight:normal'>
 537                           (<?php xl('if unemployed enter Student','e'); ?>,<br><?php xl('PT Student, or leave blank','e'); ?>) </span></td>
 538                           <td class='required'>:</td>
 539                          <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer
 540                           value="<?php echo $result3{"subscriber_employer"}?>"
 541                            onchange="capitalizeMe(this);" /></td>
 542                         </tr>
 543
 544                         <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 545                          <td><span class=required><?php xl('SE Address','e'); ?></span></td>
 546                          <td class='required'>:</td>
 547                          <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer_street
 548                           value="<?php echo $result3{"subscriber_employer_street"}?>"
 549                            onchange="capitalizeMe(this);" /></td>
 550                         </tr>
 551
 552                         <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 553                          <td colspan="3">
 554                           <table>
 555                            <tr>
 556                                 <td><span class=required><?php xl('SE City','e'); ?>: </span></td>
 557                                 <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_city
 558                                  value="<?php echo $result3{"subscriber_employer_city"}?>"
 559                                   onchange="capitalizeMe(this);" /></td>
 560                                 <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE State','e') : xl('SE Locality','e') ?>: </span></td>
 561                         <td>
 562                                  <?php
 563                                   // Modified 7/2009 by BM to incorporate data types
 564                           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'), $result3['subscriber_employer_state']);
 565                                  ?>
 566                                 </td>
 567                            </tr>
 568                            <tr>
 569                                 <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE Zip Code','e') : xl('SE Postal Code','e') ?>: </span></td>
 570                                 <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_postal_code value="<?php echo $result3{"subscriber_employer_postal_code"}?>"></td>
 571                                 <td><span class=required><?php xl('SE Country','e'); ?>: </span></td>
 572                         <td>
 573                                  <?php
 574                                   // Modified 7/2009 by BM to incorporate data types
 575                           generate_form_field(array('data_type'=>$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'), $result3['subscriber_employer_country']);
 576                                  ?>
 577                         </td>
 578                            </tr>
 579                           </table>
 580                          </td>
 581                         </tr>
 582
 583                    </table>
 584                   </td>
 585
 586                   <td valign=top>
 587                 <table border="0">
 588                         <tr>
 589                                 <td><span class=required><?php xl('Relationship','e'); ?></span></td>
 590                                 <td class=required>:</td>
 591                                 <td colspan=3><?php
 592                                         // Modified 6/2009 by BM to use list_options and function
 593                                         generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_relationship'),'list_id'=>'sub_relation','empty_title'=>' '), $result3['subscriber_relationship']);
 594                                         ?>
 595
 596                                 <a href="javascript:popUp('browse.php?browsenum=<?php echo $i?>')" class=text>(<?php xl('Browse','e'); ?>)</a></td>
 597                                 <td></td><td></td><td></td><td></td>
 598                         </tr>
 599                         <tr>
 600                                 <td width=120><span class=required><?php xl('Subscriber','e'); ?> </span></td>
 601                                 <td class=required>:</td>
 602                                 <td colspan=3><input type=entry size=10 name=i<?php echo $i?>subscriber_fname   value="<?php echo $result3{"subscriber_fname"}?>" onchange="capitalizeMe(this);" />
 603                                 <input type=entry size=3 name=i<?php echo $i?>subscriber_mname value="<?php echo $result3{"subscriber_mname"}?>" onchange="capitalizeMe(this);" />
 604                                 <input type=entry size=10 name=i<?php echo $i?>subscriber_lname value="<?php echo $result3{"subscriber_lname"}?>" onchange="capitalizeMe(this);" /></td>
 605                                 <td></td><td></td><td></td><td></td>
 606                         </tr>
 607                         <tr>
 608                                 <td><span class=bold><?php xl('D.O.B.','e'); ?> </span></td>
 609                                 <td class=required>:</td>
 610                                 <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 $i; ?>dob_date' border='0' alt='[?]' style='cursor:pointer' title='<?php xl('Click here to choose a date','e'); ?>'></td>
 611
 612                                 <td><span class=bold><?php xl('Sex','e'); ?>: </span></td>
 613                                 <td><?php
 614                                         // Modified 6/2009 by BM to use list_options and function
 615                                         generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_sex'),'list_id'=>'sex'), $result3['subscriber_sex']);
 616                                         ?>
 617                                 </td>
 618                                 <td></td><td></td> <td></td><td></td>
 619                         </tr>
 620                         <tr>
 621                                 <td class=leftborder><span class=bold><?php xl('S.S.','e'); ?> </span></td>
 622                                 <td class=required>:</td>
 623                                 <td><input type=entry size=11 name=i<?php echo $i?>subscriber_ss value="<?php echo trim($result3{"subscriber_ss"})?>"></td>
 624                         </tr>
 625
 626                         <tr>
 627                                 <td><span class=required><?php xl('Subscriber Address','e'); ?> </span></td>
 628                                 <td class=required>:</td>
 629                                 <td><input type=entry size=20 name=i<?php echo $i?>subscriber_street value="<?php echo $result3{"subscriber_street"}?>" onchange="capitalizeMe(this);" /></td>
 630
 631                                 <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('State','e') : xl('Locality','e') ?>: </span></td>
 632                                 <td>
 633                                         <?php
 634                                         // Modified 7/2009 by BM to incorporate data types
 635                                         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']);
 636                                 ?>
 637                                 </td>
 638                         </tr>
 639                         <tr>
 640                                 <td class=leftborder><span class=required><?php xl('City','e'); ?></span></td>
 641                                 <td class=required>:</td>
 642                                 <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>
 643                                         <?php
 644                                         // Modified 7/2009 by BM to incorporate data types
 645                                         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'), $result3['subscriber_country']);
 646                                         ?>
 647                                 </td>
 648 </tr>
 649                         <tr>
 650                                 <td><span class=required><?php echo ($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>
 651
 652                                 <td colspan=2>
 653                                 </td><td></td>
 654                         </tr>
 655                         <tr>
 656                                 <td><span class=bold><?php xl('Subscriber Phone','e'); ?></span></td>
 657                                 <td class=required>:</td>
 658                                 <td><input type='text' size='20' name='i<?php echo $i?>subscriber_phone' value='<?php echo $result3["subscriber_phone"] ?>' onkeyup='phonekeyup(this,mypcc)' /></td>
 659                                 <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>
 660                                 <td colspan=2>
 661                                 </td><td></td><td></td>
 662                         </tr>
 663                         <tr>
 664                                 <td colspan=0><span class='required'><?php xl('Accept Assignment','e'); ?></span></td>
 665                                 <td class=required>:</td>
 666                                 <td colspan=2>
 667                                         <select name=i<?php echo $i?>accept_assignment>
 668                                                 <option value="TRUE" <?php if (strtoupper($result3{"accept_assignment"}) == "TRUE") echo "selected"?>><?php xl('YES','e'); ?></option>
 669                                                 <option value="FALSE" <?php if (strtoupper($result3{"accept_assignment"}) == "FALSE") echo "selected"?>><?php xl('NO','e'); ?></option>
 670                                         </select>
 671                                 </td>
 672                                 <td></td><td></td>
 673                                 <td colspan=2>
 674                                 </td><td></td>
 675                         </tr>
 676       <tr>
 677         <td><span class='bold'><?php xl('Secondary Medicare Type','e'); ?></span></td>
 678         <td class='bold'>:</td>
 679         <td colspan='6'>
 680           <select name=i<?php echo $i?>policy_type>
 681 <?php
 682   foreach ($policy_types AS $key => $value) {
 683     echo "            <option value ='$key'";
 684     if ($key == $result3['policy_type']) echo " selected";
 685     echo ">" . htmlspecialchars($value) . "</option>\n";
 686   }
 687 ?>
 688           </select>
 689         </td>
 690       </tr>
 691                 </table>
 692
 693                   </td>
 694                  </tr>
 695                 </table>
 696
 697                 </div>
 698
 699         <?php } //end insurer for loop ?>
 700
 701         </div>
 702 </div>
 703
 704 <?php } // end of "if not simplified_demographics" ?>
 705 </div></div>
 706
 707 </form>
 708
 709 <br>
 710
 711 <script language="JavaScript">
 712
 713  // fix inconsistently formatted phone numbers from the database
 714  var f = document.forms[0];
 715  if (f.form_phone_contact) phonekeyup(f.form_phone_contact,mypcc);
 716  if (f.form_phone_home   ) phonekeyup(f.form_phone_home   ,mypcc);
 717  if (f.form_phone_biz    ) phonekeyup(f.form_phone_biz    ,mypcc);
 718  if (f.form_phone_cell   ) phonekeyup(f.form_phone_cell   ,mypcc);
 719
 720 <?php if (! $GLOBALS['simplified_demographics']) { ?>
 721  phonekeyup(f.i1subscriber_phone,mypcc);
 722  phonekeyup(f.i2subscriber_phone,mypcc);
 723  phonekeyup(f.i3subscriber_phone,mypcc);
 724 <?php } ?>
 725
 726 <?php if ($GLOBALS['concurrent_layout'] && $set_pid) { ?>
 727  parent.left_nav.setPatient(<?php echo "'" . addslashes($result['fname']) . " " . addslashes($result['lname']) . "',$pid,'" . addslashes($result['pubpid']) . "','', ' " . xl('DOB') . ": " . oeFormatShortDate($result['DOB_YMD']) . " " . xl('Age') . ": " . getPatientAgeDisplay($result['DOB_YMD']) . "'"; ?>);
 728  parent.left_nav.setRadio(window.name, 'dem');
 729 <?php } ?>
 730
 731 <?php echo $date_init; ?>
 732 <?php if (! $GLOBALS['simplified_demographics']) { for ($i=1; $i<=3; $i++): ?>
 733  Calendar.setup({inputField:"i<?php echo $i?>effective_date", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i?>effective_date"});
 734  Calendar.setup({inputField:"i<?php echo $i?>subscriber_DOB", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i?>dob_date"});
 735 <?php endfor; } ?>
 736 </script>
 737
 738 <!-- include support for the list-add selectbox feature -->
 739 <?php include $GLOBALS['fileroot']."/library/options_listadd.inc"; ?>
 740
 741 </body>
 742
 743 </html>