interface/patient_file/summary/demographics_full.php

   1 <?
   2  include_once("../../globals.php");
   3  include_once("$srcdir/acl.inc");
   4
   5  // Session pid must be right or bad things can happen when demographics are saved!
   6  //
   7  include_once("$srcdir/pid.inc");
   8  if ($_GET["set_pid"] && $_GET["set_pid"] != $_SESSION["pid"]) {
   9   setpid($_GET["set_pid"]);
  10  }
  11  else if ($_GET["pid"] && $_GET["pid"] != $_SESSION["pid"]) {
  12   setpid($_GET["pid"]);
  13  }
  14
  15  // Check authorization.
  16  $thisauth = acl_check('patients', 'demo');
  17  if ($pid) {
  18   if ($thisauth != 'write')
  19    die("Updating demographics is not authorized.");
  20  } else {
  21   if ($thisauth != 'write' && $thisauth != 'addonly')
  22    die("Adding demographics is not authorized.");
  23  }
  24
  25 include_once("$srcdir/patient.inc");
  26
  27 $relats = array('','self','spouse','child','other');
  28 $statii = array('married','single','divorced','widowed','separated','domestic partner');
  29
  30 $langi = getLanguages();
  31 $ethnoraciali = getEthnoRacials();
  32 $provideri = getProviderInfo();
  33 $insurancei = getInsuranceProviders();
  34 ?>
  35 <html>
  36 <head>
  37
  38 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
  39
  40 <script type="text/javascript" src="../../../library/textformat.js"></script>
  41
  42 <SCRIPT LANGUAGE="JavaScript"><!--
  43
  44 var mypcc = '<? echo $GLOBALS['phone_country_code'] ?>';
  45
  46 //code used from http://tech.irt.org/articles/js037/
  47 function replace(string,text,by) {
  48  // Replaces text with by in string
  49  var strLength = string.length, txtLength = text.length;
  50  if ((strLength == 0) || (txtLength == 0)) return string;
  51
  52  var i = string.indexOf(text);
  53  if ((!i) && (text != string.substring(0,txtLength))) return string;
  54  if (i == -1) return string;
  55
  56  var newstr = string.substring(0,i) + by;
  57
  58  if (i+txtLength < strLength)
  59   newstr += replace(string.substring(i+txtLength,strLength),text,by);
  60
  61  return newstr;
  62 }
  63
  64 function upperFirst(string,text) {
  65  return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
  66 }
  67
  68 <? for ($i=1;$i<=3;$i++) { ?>
  69 function auto_populate_employer_address<?=$i?>(){
  70  //alert(document.demographics_form.i<?=$i?>subscriber_relationship.options[document.demographics_form.i<?=$i?>subscriber_relationship.selectedIndex].value);
  71  if (document.demographics_form.i<?=$i?>subscriber_relationship.options[document.demographics_form.i<?=$i?>subscriber_relationship.selectedIndex].value == "self") {
  72   document.demographics_form.i<?=$i?>subscriber_fname.value=document.demographics_form.fname.value;
  73   document.demographics_form.i<?=$i?>subscriber_mname.value=document.demographics_form.mname.value;
  74   document.demographics_form.i<?=$i?>subscriber_lname.value=document.demographics_form.lname.value;
  75   document.demographics_form.i<?=$i?>subscriber_street.value=document.demographics_form.street.value;
  76   document.demographics_form.i<?=$i?>subscriber_city.value=document.demographics_form.city.value;
  77   document.demographics_form.i<?=$i?>subscriber_state.value=document.demographics_form.state.value;
  78   document.demographics_form.i<?=$i?>subscriber_postal_code.value=document.demographics_form.postal_code.value;
  79   document.demographics_form.i<?=$i?>subscriber_country.value=document.demographics_form.country_code.value;
  80   document.demographics_form.i<?=$i?>subscriber_phone.value=document.demographics_form.phone_home.value;
  81   document.demographics_form.i<?=$i?>subscriber_DOB.value=document.demographics_form.dob.value;
  82   document.demographics_form.i<?=$i?>subscriber_ss.value=document.demographics_form.ss.value;
  83   document.demographics_form.i<?=$i?>subscriber_sex.selectedIndex = document.demographics_form.sex.selectedIndex;
  84   document.demographics_form.i<?=$i?>subscriber_employer.value=document.demographics_form.ename.value;
  85   document.demographics_form.i<?=$i?>subscriber_employer_street.value=document.demographics_form.estreet.value;
  86   document.demographics_form.i<?=$i?>subscriber_employer_city.value=document.demographics_form.ecity.value;
  87   document.demographics_form.i<?=$i?>subscriber_employer_state.value=document.demographics_form.estate.value;
  88   document.demographics_form.i<?=$i?>subscriber_employer_postal_code.value=document.demographics_form.epostal_code.value;
  89   document.demographics_form.i<?=$i?>subscriber_employer_country.value=document.demographics_form.ecountry.value;
  90  }
  91 }
  92
  93 <? } ?>
  94
  95 function popUp(URL) {
  96  day = new Date();
  97  id = day.getTime();
  98  eval("page" + id + " = window.open(URL, '" + id + "', 'toolbar=0,scrollbars=1,location=0,statusbar=0,menubar=0,resizable=1,width=400,height=300,left = 440,top = 362');");
  99 }
 100
 101 function checkNum () {
 102  var re= new RegExp();
 103  re = /^\d*\.?\d*$/;
 104  str=document.demographics_form.monthly_income.value;
 105  if(re.exec(str))
 106  {
 107  }else{
 108   alert("Please enter a dollar amount using only numbers and a decimal point.");
 109  }
 110 }
 111
 112 //-->
 113
 114 </script>
 115 </head>
 116
 117 <body <?echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
 118 <?
 119 $result = getPatientData($pid);
 120 $result2 = getEmployerData($pid);
 121 ?>
 122
 123 <form action='demographics_save.php' name='demographics_form' method='post'>
 124 <input type=hidden name=mode value=save>
 125
 126 <a href="patient_summary.php" target=Main><font class=title>Demographics</font><font class=back><?echo $tback;?></font></a>
 127
 128 <table border="0" cellpadding="0" width='100%'>
 129  <tr>
 130   <td valign="top"><span class=required>Name: </span></td>
 131   <td colspan="6">
 132    <select name=title tabindex="1">
 133     <option value="<?echo $result{"title"}?>"><?echo $result{"title"}?></option>
 134     <option value="Mr.">Mr.</option>
 135     <option value="Mrs.">Mrs.</option>
 136     <option value="Ms.">Ms.</option>
 137     <option value="Dr.">Dr.</option>
 138    </select>
 139    <input tabindex="2" type=entry size=15 name=fname value="<?echo $result{"fname"}?>"> <input tabindex="3" type=entry size=3 name=mname value="<?echo $result{"mname"}?>"> <input tabindex="4" type=entry size=15 name=lname value="<?echo $result{"lname"}?>">
 140   </td>
 141
 142  </tr>
 143  <tr>
 144   <td valign='top'><span class='required'>DOB: </span></td>
 145   <td>
 146    <input tabindex='5' type='entry' size='11' name='dob'
 147     value='<? echo $result['DOB'] ?>' onkeyup='datekeyup(this,mypcc)'
 148     onblur='dateblur(this,mypcc)' title='yyyy-mm-dd' />
 149   </td>
 150   <td rowspan="12">&nbsp;</td>
 151   <td><span class=bold><? echo ($GLOBALS['athletic_team']) ? 'Organizational ID' : 'Patient' ?> Number: </span></td>
 152   <td rowspan="12">&nbsp;</td>
 153   <td><input type='entry' size='10' name='pubpid' value="<?echo $result{"pubpid"}?>"></td>
 154  </tr>
 155  <tr>
 156   <td><span class=required>Sex: </span></td>
 157   <td>
 158    <select name=sex tabindex="6">
 159     <option value="Male" <?if ($result{"sex"} == "Male") {echo "selected";};?>>Male</option>
 160     <option value="Female" <?if ($result{"sex"} == "Female") {echo "selected";};?>>Female</option>
 161    </select>
 162   </td>
 163   <td><span class='bold'>Emergency Contact: </span></td>
 164   <td><input type='entry' size='10' name='contact_relationship' value="<?echo $result{"contact_relationship"}?>"></td>
 165  </tr>
 166  <tr>
 167   <td><span class=bold>S.S.: </span></td>
 168   <td><input tabindex="7" type=entry size=11 name=ss value="<?echo $result{"ss"}?>"></td>
 169   <td><span class=bold>Emergency Phone:</span></td>
 170   <td><input type='text' size='20' name='phone_contact' value='<?echo $result['phone_contact'] ?>' onkeyup='phonekeyup(this,mypcc)' /></td>
 171  </tr>
 172  <tr>
 173   <td><span class=required>Address: </span></td>
 174   <td><input tabindex="8" type=entry size=25 name=street value="<?echo $result{"street"}?>"></td>
 175   <td><span class='bold'>Home Phone: </span></td>
 176   <td><input type='text' size='20' name='phone_home' value='<?echo $result['phone_home'] ?>' onkeyup='phonekeyup(this,mypcc)' /></td>
 177  </tr>
 178  <tr>
 179   <td><span class=required>City: </span></td>
 180   <td><input tabindex="9" type=entry size=15 name=city value="<?echo $result{"city"}?>"></td>
 181   <td><span class=bold>Work Phone:</span></td>
 182   <td><input type='text' size='20' name='phone_biz' value='<?echo $result['phone_biz'] ?>' onkeyup='phonekeyup(this,mypcc)' /></td>
 183  </tr>
 184  <tr>
 185   <td><span class=required><? echo ($GLOBALS['phone_country_code'] == '1') ? 'State' : 'Locality' ?>: </span></td>
 186   <td><input tabindex="10" type=entry size=15 name=state value="<?echo $result{"state"}?>"></td>
 187   <td><span class=bold>Mobile Phone: </span></td>
 188   <td><input type='text' size='20' name='phone_cell' value='<?echo $result['phone_cell'] ?>' onkeyup='phonekeyup(this,mypcc)' /></td>
 189  </tr>
 190  <tr>
 191   <td><span class=required><? echo ($GLOBALS['phone_country_code'] == '1') ? 'Zip' : 'Postal' ?> Code: </span></td><td><input tabindex="11" type=entry size=6 name=postal_code value="<?echo $result{"postal_code"}?>"></td>
 192   <td><span class=bold>Contact Email: </span></td><td><input type=entry size=30 name=email value="<?echo $result{"email"}?>"></td>
 193  </tr>
 194  <tr>
 195   <td><span class=required>Country: </span></td><td><input tabindex="12" type=entry size=10 name=country_code value="<?echo $result{"country_code"}?>"></td>
 196   <td><span class=bold>User Defined Fields</span></td>
 197  </tr>
 198  <tr>
 199   <td><span class=required>Marital Status: </span></td>
 200   <td>
 201    <select name=status tabindex="13">
 202 <?php
 203  print "<!-- ".$result["status"]." -->\n";
 204  foreach ($statii as $s) {
 205   if ($s == "unassigned") {
 206    echo "<option value=''";
 207   } else {
 208    echo "<option value='".$s."'";
 209   }
 210
 211   if ($s == $result["status"])
 212    echo " selected";
 213
 214   echo ">".ucwords($s)."</option>\n";
 215  }
 216 ?>
 217    </select>
 218   </td>
 219   <td><input name="genericname1" size=20 value="<? echo $result{"genericname1"} ?>" /></td><td><input name="genericval1" size='20' value="<? echo $result{"genericval1"} ?>" /></td>
 220  </tr>
 221  <tr>
 222   <td><span class=required>Provider: </span></td>
 223   <td>
 224    <select tabindex="14" name="providerID" onchange="javascript:document.demographics_form.referrer.value=upperFirst(this.options[this.selectedIndex].text,this.options[this.selectedIndex].text);">
 225     <option value=''>Unassigned</option>
 226 <?php
 227  foreach ($provideri as $s) {
 228   //echo "defined provider is: " .trim($s['fname']." ".$s['lname']). " compared to : " .$result["referrer"] . "<br />";
 229
 230   echo "<option value='".$s['id']."'";
 231
 232   if ($s['id'] == $result["providerID"])
 233    echo " selected";
 234    echo ">".ucwords($s['fname']." ".$s['lname'])."</option>\n";
 235  }
 236 ?>
 237    </select>
 238   </td>
 239   <td><input name="genericname2" size='20' value="<?echo $result{"genericname2"};?>" /></td>
 240   <td><input name="genericval2" size='20' value="<?echo $result{"genericval2"};?>" /></td>
 241  </tr>
 242  <tr>
 243   <td colspan='6'>
 244    <a href="javascript:document.demographics_form.submit();" target='Main' class='link_submit'>[Save Patient Demographics]</a>
 245    <hr>
 246   </td>
 247  </tr>
 248 </table>
 249
 250 <? if (! $GLOBALS['athletic_team']) { ?>
 251
 252 <table width='100%'>
 253  <tr>
 254   <th colspan='4' align='left' class='bold'>HIPAA Choices:</th>
 255  </tr>
 256  <tr>
 257   <td class='bold' width='10%' nowrap>Allow Mail:</td>
 258   <td class='bold'>
 259    <select name="hipaa_mail">
 260     <?
 261      echo ('<option>NO</option>');
 262      $result{"hipaa_mail"}=='YES' ? $opt_out='<option selected>YES</option>' : $opt_out='<option>YES</option>' ;
 263      echo $opt_out;
 264     ?>
 265    </select>
 266   </td>
 267   <td class='bold' width='10%' nowrap>Allow Voice Msg:</td>
 268   <td class='bold'>
 269    <select name="hipaa_voice">
 270     <?
 271      echo ('<option>NO</option>');
 272      $result{"hipaa_voice"}=='YES' ? $opt_out='<option selected>YES</option>' : $opt_out='<option>YES</option>' ;
 273      echo $opt_out;
 274     ?>
 275    </select>
 276   </td>
 277  </tr>
 278  <tr>
 279   <td colspan='4'>
 280    <a href="javascript:document.demographics_form.submit();" target=Main class=link_submit>[Save Patient Demographics]</a>
 281    <br><hr>
 282   </td>
 283  </tr>
 284 </table>
 285
 286 <? } ?>
 287
 288 <table width='100%'>
 289  <tr>
 290   <td valign=top>
 291    <input type=hidden size=30 name=referrer value="<?echo ucfirst($result{"referrer"});?>">
 292    <input type=hidden size=20 name=referrerID value="<?echo $result{"referrerID"}?>">
 293    <input type=hidden size=20 name=db_id value="<?echo $result{"id"}?>">
 294    <table>
 295     <tr>
 296      <td><span class=bold>Occupation: </span></td>
 297      <td><input type=entry size=20 name=occupation value="<?echo $result{"occupation"}?>"></td>
 298     </tr>
 299     <tr>
 300      <td class='bold'>Employer:</td>
 301      <td><input type=entry size=20 name=ename value="<?echo $result2{"name"}?>"></td>
 302     </tr>
 303     <tr>
 304      <td colspan='2' class='bold' style='font-weight:normal'>(if unemployed enter Student, PT Student, or leave blank)</td>
 305     </tr>
 306 <? if ($GLOBALS['athletic_team']) { ?>
 307     <tr>
 308      <td colspan='2' class='bold' style='font-weight:normal'>&nbsp;</td>
 309     </tr>
 310     <tr>
 311      <td><span class='bold'>Squad: </span></td>
 312      <td>
 313       <select name='squad'>
 314        <option value='0'>&nbsp;</option>
 315        <option value='1'<? if ($result['squad'] == '1') echo ' selected' ?>>Senior</option>
 316        <option value='2'<? if ($result['squad'] == '2') echo ' selected' ?>>Academy</option>
 317        <option value='3'<? if ($result['squad'] == '3') echo ' selected' ?>>Ladies</option>
 318       </select>
 319      </td>
 320     </tr>
 321 <? } ?>
 322    </table>
 323   </td>
 324   <td valign=top>
 325    <table>
 326     <tr>
 327      <td><span class=bold>Employer Address</span></td><td><span class=bold></span><input type=entry size=25 name=estreet value="<?echo $result2{"street"}?>"></td>
 328     </tr>
 329     <tr>
 330      <td><span class=bold>City: </span></td><td><input type=entry size=15 name=ecity value="<?echo $result2{"city"}?>"></td>
 331     </tr>
 332     <tr>
 333      <td><span class=bold><? echo ($GLOBALS['phone_country_code'] == '1') ? 'State' : 'Locality' ?>: </span></td><td><input type=entry size=15 name=estate value="<?echo $result2{"state"}?>"></td>
 334     </tr>
 335     <tr>
 336      <td><span class=bold><? echo ($GLOBALS['phone_country_code'] == '1') ? 'Zip' : 'Postal' ?> Code: </span></td><td><input type=entry size=10 name=epostal_code value="<?echo $result2{"postal_code"}?>"></td>
 337     </tr>
 338     <tr>
 339      <td><span class=bold>Country: </span></td><td><input type=entry size=10 name=ecountry value="<?echo $result2{"country"}?>"></td>
 340     </tr>
 341    </table>
 342   </td>
 343   <td valign=top></td>
 344  </tr>
 345
 346  <tr>
 347   <td colspan=4>
 348    <a href="javascript:document.demographics_form.submit();" target=Main class=link_submit>[Save Patient Demographics]</a><hr></td>
 349  </tr>
 350
 351 <? if (! $GLOBALS['athletic_team']) { ?>
 352
 353  <tr>
 354   <td valign='top'>
 355    <span class='bold'>Language: </span><br>
 356    <select onchange="javascript:document.demographics_form.language.value=upperFirst(this.options[this.selectedIndex].value,this.options[this.selectedIndex].value);">
 357 <?php
 358  foreach ($langi as $s) {
 359   if ($s == "unassigned") {
 360    echo "<option value=''";
 361   } else {
 362    echo "<option value='".$s."'";
 363   }
 364   if ($s == strtolower($result["language"]))
 365    echo " selected";
 366   echo ">".ucwords($s)."</option>\n";
 367  }
 368 ?>
 369    </select><br>
 370    <input type=entry size=30 name=language value="<?echo ucfirst($result{"language"});?>"><br><br />
 371    <span class=bold>Race/Ethnicity: </span><br>
 372    <select onchange="javascript:document.demographics_form.ethnoracial.value=upperFirst(this.options[this.selectedIndex].value,this.options[this.selectedIndex].value);">
 373 <?php
 374  foreach ($ethnoraciali as $s) {
 375   if ($s == "unassigned") {
 376    echo "<option value=''";
 377   } else {
 378    echo "<option value='".$s."'";
 379   }
 380   if ($s == strtolower($result["ethnoracial"]))
 381    echo " selected";
 382   echo ">".ucwords($s)."</option>\n";
 383  }
 384 ?>
 385    </select>
 386    <br>
 387    <input type=entry size=30 name=ethnoracial value="<?echo ucfirst($result{"ethnoracial"});?>"><br>
 388   </td>
 389   <td valign=top>
 390    <table>
 391     <tr>
 392      <td><span class=bold>Financial Review Date: </span></td><td><input type=entry size=11 name=financial_review value="<?if ($result{"financial_review"} != "0000-00-00 00:00:00") {echo date("m/d/Y",strtotime($result{"financial_review"}));} else {echo "MM/DD/YYYY";}?>"></td>
 393     </tr>
 394     <tr>
 395      <td><span class=bold>Family Size: </span></td><td><input type=entry size=20 name=family_size value="<?echo $result{"family_size"}?>"></td>
 396     </tr>
 397     <tr>
 398      <td><span class=bold>Monthly Income: </span></td><td><input type=entry size=20 name=monthly_income onblur="javascript:checkNum();" value="<?echo $result{"monthly_income"}?>"><span class=small>(Numbers only)</span></td>
 399     </tr>
 400     <tr>
 401      <td><span class=bold>Homeless, etc.: </span></td><td><input type=entry size=20 name=homeless value="<?echo $result{"homeless"}?>"></td>
 402     </tr>
 403     <tr>
 404      <td><span class=bold>Interpreter: </span></td><td><input type=entry size=20 name=interpretter value="<?echo $result{"interpretter"}?>"></td>
 405     </tr>
 406     <tr>
 407      <td><span class=bold>Migrant/Seasonal: </span></td><td><input type=entry size=20 name=migrantseasonal value="<?echo $result{"migrantseasonal"}?>"></td>
 408     </tr>
 409    </table>
 410   </td>
 411   <td valign=top></td>
 412  </tr>
 413
 414  <tr>
 415   <td colspan=4>
 416    <a href="javascript:document.demographics_form.submit();" target=Main class=link_submit>[Save Patient Demographics]</a>
 417    <hr>
 418   </td>
 419  </tr>
 420
 421 <? } ?>
 422
 423 </table>
 424
 425 <?
 426  // if (! $GLOBALS['athletic_team']) {
 427   $insurance_headings = array("Primary Insurance Provider:", "Secondary Insurance Provider", "Tertiary Insurance provider");
 428   $insurance_info = array();
 429   $insurance_info[1] = getInsuranceData($pid,"primary");
 430   $insurance_info[2] = getInsuranceData($pid,"secondary");
 431   $insurance_info[3] = getInsuranceData($pid,"tertiary");
 432   for($i=1;$i<=3;$i++) {
 433    $result3 = $insurance_info[$i];
 434 ?>
 435 <table border="0">
 436  <tr>
 437   <td valign=top>
 438    <table border="0">
 439     <tr>
 440      <td colspan="5"><span class='required'><?=$insurance_headings[$i -1]?></span></td>
 441     </tr>
 442     <tr>
 443      <td colspan="5">
 444       <select name="i<?=$i?>provider">
 445        <option value="">Unassigned</option>
 446 <?php
 447  foreach ($insurancei as $iid => $iname) {
 448   echo "<option value='".$iid."'";
 449   if (strtolower($iid) == strtolower($result3{"provider"}))
 450    echo " selected";
 451   echo ">".$iname."</option>\n";
 452  }
 453 ?>
 454       </select>&nbsp;<a href="<? echo  $GLOBALS['webroot'] ?>/controller.php?practice_settings&insurance_company&action=edit">Add New Insurer</a>
 455      </td>
 456     </tr>
 457     <tr>
 458      <td><span class=required>Plan Name: </span></td><td><input type=entry size=20 name=i<?=$i?>plan_name value="<?echo $result3{"plan_name"}?>"></td>
 459     </tr>
 460     <tr>
 461      <td><span class=required>Policy Number: </span></td><td><input type=entry size=16 name=i<?=$i?>policy_number value="<?echo $result3{"policy_number"}?>"></td>
 462     </tr>
 463     <tr>
 464      <td><span class=required>Group Number: </span></td><td><input type=entry size=16 name=i<?=$i?>group_number value="<?echo $result3{"group_number"}?>"></td>
 465     </tr>
 466     <tr>
 467      <td class='required'>Subscriber Employer (SE) <br><span style='font-weight:normal'>
 468       (if unemployed enter Student,<br>PT Student, or leave blank): </span></td>
 469      <td><input type=entry size=25 name=i<?=$i?>subscriber_employer value="<?echo $result3{"subscriber_employer"}?>"></td>
 470     </tr>
 471     <tr>
 472      <td><span class=required>SE Address: </span></td><td><input type=entry size=25 name=i<?=$i?>subscriber_employer_street value="<?echo $result3{"subscriber_employer_street"}?>"></td>
 473     </tr>
 474     <tr>
 475      <td colspan="2">
 476       <table>
 477        <tr>
 478         <td><span class=required>SE City: </span></td>
 479         <td><input type=entry size=15 name=i<?=$i?>subscriber_employer_city value="<?echo $result3{"subscriber_employer_city"}?>"></td>
 480         <td><span class=required>SE <? echo ($GLOBALS['phone_country_code'] == '1') ? 'State' : 'Locality' ?>: </span></td>
 481         <td><input type=entry size=15 name=i<?=$i?>subscriber_employer_state value="<?echo $result3{"subscriber_employer_state"}?>"></td>
 482        </tr>
 483        <tr>
 484         <td><span class=required>SE <? echo ($GLOBALS['phone_country_code'] == '1') ? 'Zip' : 'Postal' ?> Code: </span></td>
 485         <td><input type=entry size=10 name=i<?=$i?>subscriber_employer_postal_code value="<?echo $result3{"subscriber_employer_postal_code"}?>"></td>
 486         <td><span class=required>SE Country: </span></td>
 487         <td><input type=entry size=25 name=i<?=$i?>subscriber_employer_country value="<?echo $result3{"subscriber_employer_country"}?>"></td>
 488        </tr>
 489       </table>
 490      </td>
 491     </tr>
 492    </table>
 493   </td>
 494
 495   <td valign=top>
 496    <span class=required>Subscriber: </span><input type=entry size=10 name=i<?=$i?>subscriber_fname value="<?echo $result3{"subscriber_fname"}?>"><input type=entry size=3 name=i<?=$i?>subscriber_mname value="<?echo $result3{"subscriber_mname"}?>"><input type=entry size=10 name=i<?=$i?>subscriber_lname value="<?echo $result3{"subscriber_lname"}?>">
 497    <br>
 498    <span class=required>Relationship: </span>
 499    <select name=i<?=$i?>subscriber_relationship onchange="javascript:auto_populate_employer_address<?=$i?>();">
 500 <?php
 501  foreach ($relats as $s) {
 502   if ($s == "unassigned") {
 503    echo "<option value=''";
 504   } else {
 505    echo "<option value='".$s."'";
 506   }
 507   if ($s == $result3{"subscriber_relationship"})
 508    echo " selected";
 509   echo ">".ucfirst($s)."</option>\n";
 510 }
 511 ?>
 512    </select>
 513    <a href="javascript:popUp('browse.php?browsenum=<?=$i?>')" class=text>(Browse)</a><br />
 514    <span class=bold>D.O.B.: </span>
 515    <input type='entry' size='11' name='i<?=$i?>subscriber_DOB'
 516     value='<? echo $result3['subscriber_DOB'] ?>'
 517     onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)'
 518     title='yyyy-mm-dd' />
 519    <span class=bold>S.S.: </span><input type=entry size=11 name=i<?=$i?>subscriber_ss value="<?echo $result3{"subscriber_ss"}?> ">&nbsp;
 520    <span class=bold>Sex: </span>
 521    <select name=i<?=$i?>subscriber_sex>
 522     <option value="Male" <? if (strtolower($result3{"subscriber_sex"}) == "male") echo "selected"?>>Male</option>
 523     <option value="Female" <? if (strtolower($result3{"subscriber_sex"}) == "female") echo "selected"?>>Female</option>
 524    </select>
 525    <br>
 526    <span class=required>Subscriber Address: </span><input type=entry size=25 name=i<?=$i?>subscriber_street value="<?echo $result3{"subscriber_street"}?>"><br>
 527    <span class=required>City: </span><input type=entry size=15 name=i<?=$i?>subscriber_city value="<?echo $result3{"subscriber_city"}?>">
 528    <span class=required><? echo ($GLOBALS['phone_country_code'] == '1') ? 'State' : 'Locality' ?>: </span><input type=entry size=15 name=i<?=$i?>subscriber_state value="<?echo $result3{"subscriber_state"}?>"><br>
 529    <span class=required><? echo ($GLOBALS['phone_country_code'] == '1') ? 'Zip' : 'Postal' ?> Code: </span><input type=entry size=10 name=i<?=$i?>subscriber_postal_code value="<?echo $result3{"subscriber_postal_code"}?>">
 530    <span class=required>Country: </span><input type=entry size=10 name=i<?=$i?>subscriber_country value="<?echo $result3{"subscriber_country"}?>"><br>
 531    <span class=bold>Subscriber Phone:
 532    <input type='text' size='20' name='i<?=$i?>subscriber_phone' value='<?echo $result3["subscriber_phone"] ?>' onkeyup='phonekeyup(this,mypcc)' />
 533    </span><br />
 534    <span class=bold>CoPay: <input type=text size="6" name=i<?=$i?>copay value="<?echo $result3{"copay"}?>">
 535   </td>
 536  </tr>
 537 </table>
 538 <a href="javascript:document.demographics_form.submit();" target=Main class=link_submit>[Save Patient Demographics]</a>
 539 <hr>
 540
 541 <?
 542   } //end insurer for loop
 543  // } // end of "if not athletic team"
 544 ?>
 545
 546 </form>
 547
 548 <br>
 549
 550 <script language="JavaScript">
 551  // fix inconsistently formatted phone numbers from the database
 552  var f = document.forms[0];
 553  phonekeyup(f.phone_contact,mypcc);
 554  phonekeyup(f.phone_home,mypcc);
 555  phonekeyup(f.phone_biz,mypcc);
 556  phonekeyup(f.phone_cell,mypcc);
 557  phonekeyup(f.i1subscriber_phone,mypcc);
 558  phonekeyup(f.i2subscriber_phone,mypcc);
 559  phonekeyup(f.i3subscriber_phone,mypcc);
 560 </script>
 561
 562 </body>
 563 </html>