interface/new/new_comprehensive.php

   1 <?php
   2 /**
   3 *
   4 * Copyright (C) 2009-2010 Rod Roark <rod@sunsetsystems.com>
   5 * Copyright (C) 2017 Brady Miller <brady.g.miller@gmail.com>
   6 *
   7 * LICENSE: This program is free software; you can redistribute it and/or
   8 * modify it under the terms of the GNU General Public License
   9 * as published by the Free Software Foundation; either version 3
  10 * of the License, or (at your option) any later version.
  11 * This program is distributed in the hope that it will be useful,
  12 * but WITHOUT ANY WARRANTY; without even the implied warranty of
  13 * MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE.  See the
  14 * GNU General Public License for more details.
  15 * You should have received a copy of the GNU General Public License
  16 * along with this program.  If not, see <http://opensource.org/licenses/gpl-license.php>.
  17 *
  18 * @package   OpenEMR
  19 * @author    Rod Roark <rod@sunsetsystems.com>
  20 * @author    Brady Miller <brady.g.miller@gmail.com>
  21 * @link      http://www.open-emr.org
  22 */
  23
  24
  25 require_once("../globals.php");
  26 require_once("$srcdir/acl.inc");
  27 require_once("$srcdir/options.inc.php");
  28 require_once("$srcdir/patient.inc");
  29 require_once("$srcdir/erx_javascript.inc.php");
  30 require_once("$srcdir/validation/LBF_Validation.php");
  31 require_once("$srcdir/patientvalidation.inc.php");
  32
  33 // Check authorization.
  34 if (!acl_check('patients', 'demo', '', array('write','addonly'))) {
  35     die("Adding demographics is not authorized.");
  36 }
  37
  38 $CPR = 4; // cells per row
  39
  40 $searchcolor = empty($GLOBALS['layout_search_color']) ?
  41   '#ffff55' : $GLOBALS['layout_search_color'];
  42
  43 $WITH_SEARCH = ($GLOBALS['full_new_patient_form'] == '1' || $GLOBALS['full_new_patient_form'] == '2' );
  44 $SHORT_FORM  = ($GLOBALS['full_new_patient_form'] == '2' || $GLOBALS['full_new_patient_form'] == '3' || $GLOBALS['full_new_patient_form'] == '4');
  45
  46 function getLayoutRes()
  47 {
  48     global $SHORT_FORM;
  49     return sqlStatement("SELECT * FROM layout_options " .
  50     "WHERE form_id = 'DEM' AND uor > 0 AND field_id != '' " .
  51     ($SHORT_FORM ? "AND ( uor > 1 OR edit_options LIKE '%N%' ) " : "") .
  52     "ORDER BY group_name, seq");
  53 }
  54
  55 // Determine layout field search treatment from its data type:
  56 // 1 = text field
  57 // 2 = select list
  58 // 0 = not searchable
  59 //
  60 function getSearchClass($data_type)
  61 {
  62     switch ($data_type) {
  63         case 1: // single-selection list
  64         case 10: // local provider list
  65         case 11: // provider list
  66         case 12: // pharmacy list
  67         case 13: // squads
  68         case 14: // address book list
  69         case 26: // single-selection list with add
  70         case 35: // facilities
  71             return 2;
  72         case 2: // text field
  73         case 3: // textarea
  74         case 4: // date
  75             return 1;
  76     }
  77
  78     return 0;
  79 }
  80
  81 $fres = getLayoutRes();
  82 ?>
  83 <html>
  84 <head>
  85 <?php html_header_show(); ?>
  86
  87 <link rel="stylesheet" href="<?php echo $css_header; ?>" type="text/css">
  88 <link rel="stylesheet" href="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-datetimepicker-2-5-4/build/jquery.datetimepicker.min.css">
  89 <link rel="stylesheet" type="text/css" href="../../library/js/fancybox/jquery.fancybox-1.2.6.css" media="screen" />
  90
  91 <style>
  92 body, td, input, select, textarea {
  93  font-family: Arial, Helvetica, sans-serif;
  94  font-size: 10pt;
  95 }
  96
  97 body {
  98  padding: 5pt 5pt 5pt 5pt;
  99 }
 100
 101 div.section {
 102  border: solid;
 103  border-width: 1px;
 104  border-color: #0000ff;
 105  margin: 0 0 0 10pt;
 106  padding: 5pt;
 107 }
 108
 109 </style>
 110
 111 <script type="text/javascript" src="../../library/dialog.js?v=<?php echo $v_js_includes; ?>"></script>
 112 <script type="text/javascript" src="../../library/textformat.js?v=<?php echo $v_js_includes; ?>"></script>
 113 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-min-1-9-1/index.js"></script>
 114 <script type="text/javascript" src="../../library/js/common.js?v=<?php echo $v_js_includes; ?>"></script>
 115 <script type="text/javascript" src="../../library/js/fancybox/jquery.fancybox-1.2.6.js"></script>
 116 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-datetimepicker-2-5-4/build/jquery.datetimepicker.full.min.js"></script>
 117
 118 <?php include_once("{$GLOBALS['srcdir']}/options.js.php"); ?>
 119
 120 <SCRIPT LANGUAGE="JavaScript"><!--
 121 //Visolve - sync the radio buttons - Start
 122 if((top.window.parent) && (parent.window)){
 123         var wname = top.window.parent.left_nav;
 124         fname = (parent.window.name)?parent.window.name:window.name;
 125         wname.syncRadios();
 126 }//Visolve - sync the radio buttons - End
 127
 128 var mypcc = '<?php echo $GLOBALS['phone_country_code'] ?>';
 129
 130 // This may be changed to true by the AJAX search script.
 131 var force_submit = false;
 132
 133 //code used from http://tech.irt.org/articles/js037/
 134 function replace(string,text,by) {
 135  // Replaces text with by in string
 136  var strLength = string.length, txtLength = text.length;
 137  if ((strLength == 0) || (txtLength == 0)) return string;
 138
 139  var i = string.indexOf(text);
 140  if ((!i) && (text != string.substring(0,txtLength))) return string;
 141  if (i == -1) return string;
 142
 143  var newstr = string.substring(0,i) + by;
 144
 145  if (i+txtLength < strLength)
 146   newstr += replace(string.substring(i+txtLength,strLength),text,by);
 147
 148  return newstr;
 149 }
 150
 151 <?php for ($i=1; $i<=3; $i++) { ?>
 152 function auto_populate_employer_address<?php echo $i ?>(){
 153  var f = document.demographics_form;
 154  if (f.form_i<?php echo $i?>subscriber_relationship.options[f.form_i<?php echo $i?>subscriber_relationship.selectedIndex].value == "self") {
 155   f.i<?php echo $i?>subscriber_fname.value=f.form_fname.value;
 156   f.i<?php echo $i?>subscriber_mname.value=f.form_mname.value;
 157   f.i<?php echo $i?>subscriber_lname.value=f.form_lname.value;
 158   f.i<?php echo $i?>subscriber_street.value=f.form_street.value;
 159   f.i<?php echo $i?>subscriber_city.value=f.form_city.value;
 160   f.form_i<?php echo $i?>subscriber_state.value=f.form_state.value;
 161   f.i<?php echo $i?>subscriber_postal_code.value=f.form_postal_code.value;
 162   if (f.form_country_code)
 163     f.form_i<?php echo $i?>subscriber_country.value=f.form_country_code.value;
 164   f.i<?php echo $i?>subscriber_phone.value=f.form_phone_home.value;
 165   f.i<?php echo $i?>subscriber_DOB.value=f.form_DOB.value;
 166   f.i<?php echo $i?>subscriber_ss.value=f.form_ss.value;
 167   f.form_i<?php echo $i?>subscriber_sex.value = f.form_sex.value;
 168   f.i<?php echo $i?>subscriber_employer.value=f.form_em_name.value;
 169   f.i<?php echo $i?>subscriber_employer_street.value=f.form_em_street.value;
 170   f.i<?php echo $i?>subscriber_employer_city.value=f.form_em_city.value;
 171   f.form_i<?php echo $i?>subscriber_employer_state.value=f.form_em_state.value;
 172   f.i<?php echo $i?>subscriber_employer_postal_code.value=f.form_em_postal_code.value;
 173   if (f.form_em_country)
 174     f.form_i<?php echo $i?>subscriber_employer_country.value=f.form_em_country.value;
 175  }
 176 }
 177
 178 <?php } ?>
 179
 180 function upperFirst(string,text) {
 181  return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
 182 }
 183
 184 // The ins_search.php window calls this to set the selected insurance.
 185 function set_insurance(ins_id, ins_name) {
 186  var thesel = document.forms[0]['i' + insurance_index + 'provider'];
 187  var theopts = thesel.options; // the array of Option objects
 188  var i = 0;
 189  for (; i < theopts.length; ++i) {
 190   if (theopts[i].value == ins_id) {
 191    theopts[i].selected = true;
 192    return;
 193   }
 194  }
 195  // no matching option was found so create one, append it to the
 196  // end of the list, and select it.
 197  theopts[i] = new Option(ins_name, ins_id, false, true);
 198 }
 199
 200 // Indicates which insurance slot is being updated.
 201 var insurance_index = 0;
 202
 203 // The OnClick handler for searching/adding the insurance company.
 204 function ins_search(ins) {
 205  insurance_index = ins;
 206  return false;
 207 }
 208
 209 function checkNum () {
 210  var re= new RegExp();
 211  re = /^\d*\.?\d*$/;
 212  str=document.forms[0].monthly_income.value;
 213  if(re.exec(str))
 214  {
 215  }else{
 216   alert("Please enter a dollar amount using only numbers and a decimal point.");
 217  }
 218 }
 219
 220 // This capitalizes the first letter of each word in the passed input
 221 // element.  It also strips out extraneous spaces.
 222 function capitalizeMe(elem) {
 223  var a = elem.value.split(' ');
 224  var s = '';
 225  for(var i = 0; i < a.length; ++i) {
 226   if (a[i].length > 0) {
 227    if (s.length > 0) s += ' ';
 228    s += a[i].charAt(0).toUpperCase() + a[i].substring(1);
 229   }
 230  }
 231  elem.value = s;
 232 }
 233
 234 // Onkeyup handler for policy number.  Allows only A-Z and 0-9.
 235 function policykeyup(e) {
 236  var v = e.value.toUpperCase();
 237  var filteredString="";
 238  for (var i = 0; i < v.length; ++i) {
 239   var c = v.charAt(i);
 240   if ((c >= '0' && c <= '9') ||
 241      (c >= 'A' && c <= 'Z') ||
 242      (c == '*') ||
 243      (c == '-') ||
 244      (c == '_') ||
 245      (c == '(') ||
 246      (c == ')') ||
 247      (c == '#'))
 248      {
 249          filteredString+=c;
 250      }
 251  }
 252  e.value = filteredString;
 253  return;
 254 }
 255
 256 function divclick(cb, divid) {
 257  var divstyle = document.getElementById(divid).style;
 258  if (cb.checked) {
 259   divstyle.display = 'block';
 260  } else {
 261   divstyle.display = 'none';
 262  }
 263  return true;
 264 }
 265
 266 // Compute the length of a string without leading and trailing spaces.
 267 function trimlen(s) {
 268  var i = 0;
 269  var j = s.length - 1;
 270  for (; i <= j && s.charAt(i) == ' '; ++i);
 271  for (; i <= j && s.charAt(j) == ' '; --j);
 272  if (i > j) return 0;
 273  return j + 1 - i;
 274 }
 275
 276 function validate(f) {
 277   var errMsgs = new Array();
 278     <?php generate_layout_validation('DEM'); ?>
 279     <?php if ($GLOBALS['erx_enable']) { ?>
 280   alertMsg='';
 281   for(i=0;i<f.length;i++){
 282     if(f[i].type=='text' && f[i].value)
 283     {
 284       if(f[i].name == 'form_fname' || f[i].name == 'form_mname' || f[i].name == 'form_lname')
 285       {
 286         alertMsg += checkLength(f[i].name,f[i].value,35);
 287         alertMsg += checkUsername(f[i].name,f[i].value);
 288       }
 289       else if(f[i].name == 'form_street' || f[i].name == 'form_city')
 290       {
 291         alertMsg += checkLength(f[i].name,f[i].value,35);
 292         alertMsg += checkAlphaNumericExtended(f[i].name,f[i].value);
 293       }
 294       else if(f[i].name == 'form_phone_home')
 295       {
 296        alertMsg += checkPhone(f[i].name,f[i].value);
 297       }
 298     }
 299   }
 300   if(alertMsg)
 301   {
 302     alert(alertMsg);
 303     return false;
 304   }
 305     <?php } ?>
 306   var msg = "";
 307   msg += "<?php echo htmlspecialchars(xl('The following fields are required'), ENT_QUOTES); ?>:\n\n";
 308   for ( var i = 0; i < errMsgs.length; i++ ) {
 309          msg += errMsgs[i] + "\n";
 310   }
 311   msg += "\n<?php echo htmlspecialchars(xl('Please fill them in before continuing.'), ENT_QUOTES); ?>";
 312
 313
 314 //Misc  Deceased Date Validation for Future Date
 315 var dateVal = document.getElementById("form_deceased_date").value;
 316 var currentDate;
 317 var d = new Date();
 318 month = '' + (d.getMonth() + 1),
 319 day = '' + d.getDate(),
 320 year = d.getFullYear();
 321 if (month.length < 2) month = '0' + month;
 322 if (day.length < 2) day = '0' + day;
 323 currentDate = year+'-'+month+'-'+day;
 324 if(errMsgs.length > 0 || dateVal > currentDate)
 325 {
 326 if(errMsgs.length > 0)
 327     alert(msg);
 328 if(dateVal > currentDate)
 329     alert ('<?php echo xls("Deceased Date should not be greater than Today"); ?>');
 330     return false;
 331 }
 332  return true;
 333 }
 334
 335 function toggleSearch(elem) {
 336  var f = document.forms[0];
 337 <?php if ($WITH_SEARCH) { ?>
 338  // Toggle background color.
 339  if (elem.style.backgroundColor == '')
 340   elem.style.backgroundColor = '<?php echo $searchcolor; ?>';
 341  else
 342   elem.style.backgroundColor = '';
 343 <?php } ?>
 344  if (force_submit) {
 345   force_submit = false;
 346   f.create.value = '<?php xl('Create New Patient', 'e'); ?>';
 347  }
 348  return true;
 349 }
 350
 351 // If a <select> list is dropped down, this is its name.
 352 var open_sel_name = '';
 353
 354 function selClick(elem) {
 355  if (open_sel_name == elem.name) {
 356   open_sel_name = '';
 357  }
 358  else {
 359   open_sel_name = elem.name;
 360   toggleSearch(elem);
 361  }
 362  return true;
 363 }
 364
 365 function selBlur(elem) {
 366  if (open_sel_name == elem.name) {
 367   open_sel_name = '';
 368  }
 369  return true;
 370 }
 371
 372 // This invokes the patient search dialog.
 373 function searchme() {
 374  var f = document.forms[0];
 375  var url = '../main/finder/patient_select.php?popup=1';
 376
 377 <?php
 378 $lres = getLayoutRes();
 379
 380 while ($lrow = sqlFetchArray($lres)) {
 381     $field_id  = $lrow['field_id'];
 382     if (strpos($field_id, 'em_') === 0) {
 383         continue;
 384     }
 385
 386     $data_type = $lrow['data_type'];
 387     $fldname = "form_$field_id";
 388     switch (getSearchClass($data_type)) {
 389         case 1:
 390             echo
 391             " if (f.$fldname.style.backgroundColor != '' && trimlen(f.$fldname.value) > 0) {\n" .
 392             "  url += '&$field_id=' + encodeURIComponent(f.$fldname.value);\n" .
 393             " }\n";
 394             break;
 395         case 2:
 396             echo
 397             " if (f.$fldname.style.backgroundColor != '' && f.$fldname.selectedIndex > 0) {\n" .
 398             "  url += '&$field_id=' + encodeURIComponent(f.$fldname.options[f.$fldname.selectedIndex].value);\n" .
 399             " }\n";
 400             break;
 401     }
 402 }
 403 ?>
 404
 405  dlgopen(url, '_blank', 700, 500);
 406 }
 407
 408 //-->
 409
 410 </script>
 411 </head>
 412
 413 <body class="body_top">
 414
 415 <?php
 416 /*Get the constraint from the DB-> LBF forms accordinf the form_id*/
 417 $constraints = LBF_Validation::generate_validate_constraints("DEM");
 418 ?>
 419 <script> var constraints = <?php echo $constraints;?>; </script>
 420
 421 <form action='new_comprehensive_save.php' name='demographics_form' id="DEM"  method='post' onsubmit='return submitme(<?php echo $GLOBALS['new_validate'] ? 1 : 0;?>,event,"DEM",constraints)'>
 422
 423 <span class='title'><?php xl('Search or Add Patient', 'e'); ?></span>
 424
 425 <table width='100%' cellpadding='0' cellspacing='8'>
 426  <tr>
 427   <td align='left' valign='top'>
 428 <?php if ($SHORT_FORM) {
 429     echo "  <center>\n";
 430 } ?>
 431 <?php
 432
 433 function end_cell()
 434 {
 435     global $item_count, $cell_count;
 436     if ($item_count > 0) {
 437         echo "</td>";
 438         $item_count = 0;
 439     }
 440 }
 441
 442 function end_row()
 443 {
 444     global $cell_count, $CPR;
 445     end_cell();
 446     if ($cell_count > 0) {
 447         for (; $cell_count < $CPR;
 448         ++$cell_count) {
 449             echo "<td></td>";
 450         }
 451
 452         echo "</tr>\n";
 453         $cell_count = 0;
 454     }
 455 }
 456
 457 function end_group()
 458 {
 459     global $last_group, $SHORT_FORM;
 460     if (strlen($last_group) > 0) {
 461         end_row();
 462         echo " </table>\n";
 463         if (!$SHORT_FORM) {
 464             echo "</div>\n";
 465         }
 466     }
 467 }
 468
 469 $last_group    = '';
 470 $cell_count    = 0;
 471 $item_count    = 0;
 472 $display_style = 'block';
 473 $group_seq     = 0; // this gives the DIV blocks unique IDs
 474
 475 while ($frow = sqlFetchArray($fres)) {
 476     $this_group = $frow['group_name'];
 477     $titlecols  = $frow['titlecols'];
 478     $datacols   = $frow['datacols'];
 479     $data_type  = $frow['data_type'];
 480     $field_id   = $frow['field_id'];
 481     $list_id    = $frow['list_id'];
 482     $currvalue  = '';
 483     $condition_str = get_conditions_str($condition_str, $group_fields);
 484
 485     if (strpos($field_id, 'em_') === 0) {
 486         $tmp = substr($field_id, 3);
 487         if (isset($result2[$tmp])) {
 488             $currvalue = $result2[$tmp];
 489         }
 490     } else {
 491         if (isset($result[$field_id])) {
 492             $currvalue = $result[$field_id];
 493         }
 494     }
 495
 496   // Handle a data category (group) change.
 497     if (strcmp($this_group, $last_group) != 0) {
 498         if (!$SHORT_FORM) {
 499             end_group();
 500             $group_seq++;    // ID for DIV tags
 501             $group_name = substr($this_group, 1);
 502             if (strlen($last_group) > 0) {
 503                 echo "<br />";
 504             }
 505
 506             echo "<span class='bold'><input type='checkbox' name='form_cb_$group_seq' id='form_cb_$group_seq' value='1' " .
 507             "onclick='return divclick(this,\"div_$group_seq\");'";
 508             if ($display_style == 'block') {
 509                 echo " checked";
 510             }
 511
 512             // Modified 6-09 by BM - Translate if applicable
 513             echo " /><b>" . xl_layout_label($group_name) . "</b></span>\n";
 514
 515             echo "<div id='div_$group_seq' class='section' style='display:$display_style;'>\n";
 516             echo " <table border='0' cellpadding='0'>\n";
 517             $display_style = 'none';
 518         } else if (strlen($last_group) == 0) {
 519             echo " <table border='0' cellpadding='0'>\n";
 520         }
 521
 522         $last_group = $this_group;
 523     }
 524
 525   // Handle starting of a new row.
 526     if (($titlecols > 0 && $cell_count >= $CPR) || $cell_count == 0) {
 527         end_row();
 528         echo "  <tr>";
 529     }
 530
 531     if ($item_count == 0 && $titlecols == 0) {
 532         $titlecols = 1;
 533     }
 534
 535     $field_id_label='label_'.$frow['field_id'];
 536   // Handle starting of a new label cell.
 537     if ($titlecols > 0) {
 538         end_cell();
 539         echo "<td colspan='$titlecols' id='$field_id_label'";
 540         echo ($frow['uor'] == 2) ? " class='required'" : " class='bold'";
 541         if ($cell_count == 2) {
 542             echo " style='padding-left:10pt'";
 543         }
 544
 545         echo ">";
 546         $cell_count += $titlecols;
 547     }
 548
 549     ++$item_count;
 550
 551     echo "<b>";
 552
 553   // Modified 6-09 by BM - Translate if applicable
 554     if ($frow['title']) {
 555         echo (xl_layout_label($frow['title']).":");
 556     } else {
 557         echo "&nbsp;";
 558     }
 559
 560     echo "</b>";
 561
 562   // Handle starting of a new data cell.
 563     if ($datacols > 0) {
 564         $id_field_text = "text_".$frow['field_id'];
 565         end_cell();
 566         echo "<td colspan='$datacols' class='text data'";
 567         if ($cell_count > 0) {
 568             echo " style='padding-left:5pt'". " id='".$id_field_text."'";
 569         }
 570
 571         echo ">";
 572         $cell_count += $datacols;
 573     }
 574
 575     ++$item_count;
 576     generate_form_field($frow, $currvalue);
 577 }
 578
 579 end_group();
 580 ?>
 581
 582 <?php
 583 if (! $GLOBALS['simplified_demographics']) {
 584     $insurancei = getInsuranceProviders();
 585     $pid = 0;
 586     $insurance_headings = array(xl("Primary Insurance Provider"), xl("Secondary Insurance Provider"), xl("Tertiary Insurance provider"));
 587     $insurance_info = array();
 588     $insurance_info[1] = getInsuranceData($pid, "primary");
 589     $insurance_info[2] = getInsuranceData($pid, "secondary");
 590     $insurance_info[3] = getInsuranceData($pid, "tertiary");
 591
 592     echo "<br /><span class='bold'><input type='checkbox' name='form_cb_ins' value='1' " .
 593     "onclick='return divclick(this,\"div_ins\");'";
 594     if ($display_style == 'block') {
 595         echo " checked";
 596     }
 597
 598     echo " /><b>" . xl('Insurance') . "</b></span>\n";
 599     echo "<div id='div_ins' class='section' style='display:$display_style;'>\n";
 600
 601     for ($i=1; $i<=3; $i++) {
 602         $result3 = $insurance_info[$i];
 603     ?>
 604   <table border="0">
 605    <tr>
 606     <td valign='top' colspan='2'>
 607      <span class='required'><?php echo $insurance_headings[$i -1].":"?></span>
 608      <select name="i<?php echo $i?>provider">
 609     <option value=""><?php xl('Unassigned', 'e'); ?></option>
 610 <?php
 611 foreach ($insurancei as $iid => $iname) {
 612     echo "<option value='" . $iid . "'";
 613     if (strtolower($iid) == strtolower($result3{"provider"})) {
 614         echo " selected";
 615     }
 616
 617     echo ">" . $iname . "</option>\n";
 618 }
 619 ?>
 620      </select>&nbsp;<a class='iframe medium_modal' href='../practice/ins_search.php' onclick='ins_search(<?php echo $i?>)'>
 621   <span> <?php xl('Search/Add Insurer', 'e'); ?></span></a>
 622   </td>
 623  </tr>
 624  <tr>
 625   <td valign=top>
 626    <table border="0">
 627
 628     <tr>
 629      <td>
 630       <span class='required'><?php xl('Plan Name', 'e'); ?>: </span>
 631      </td>
 632      <td>
 633       <input type='entry' size='20' name='i<?php echo $i?>plan_name' value="<?php echo $result3{"plan_name"} ?>"
 634        onchange="capitalizeMe(this);" />&nbsp;&nbsp;
 635      </td>
 636     </tr>
 637
 638     <tr>
 639      <td>
 640       <span class='required'><?php xl('Effective Date', 'e'); ?>: </span>
 641      </td>
 642      <td>
 643       <input type='entry' size='11' class='datepicker' name='i<?php echo $i ?>effective_date'
 644        id='i<?php echo $i ?>effective_date'
 645        value='<?php echo $result3['date'] ?>'
 646        title='yyyy-mm-dd' />
 647      </td>
 648     </tr>
 649
 650     <tr>
 651      <td><span class=required><?php xl('Policy Number', 'e'); ?>: </span></td>
 652      <td><input type='entry' size='16' name='i<?php echo $i?>policy_number' value="<?php echo $result3{"policy_number"}?>"
 653       onkeyup='policykeyup(this)'></td>
 654     </tr>
 655
 656     <tr>
 657      <td><span class=required><?php xl('Group Number', 'e'); ?>: </span></td><td><input type=entry size=16 name=i<?php echo $i?>group_number value="<?php echo $result3{"group_number"}?>" onkeyup='policykeyup(this)'></td>
 658     </tr>
 659
 660     <tr<?php if ($GLOBALS['omit_employers']) {
 661         echo " style='display:none'";
 662 } ?>>
 663      <td class='required'><?php xl('Subscriber Employer (SE)', 'e'); ?><br><span style='font-weight:normal'>
 664       (<?php xl('if unemployed enter Student', 'e'); ?>,<br><?php xl('PT Student, or leave blank', 'e'); ?>): </span></td>
 665      <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer
 666       value="<?php echo $result3{"subscriber_employer"}?>"
 667        onchange="capitalizeMe(this);" /></td>
 668     </tr>
 669
 670     <tr<?php if ($GLOBALS['omit_employers']) {
 671         echo " style='display:none'";
 672 } ?>>
 673      <td><span class=required><?php xl('SE Address', 'e'); ?>: </span></td>
 674      <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer_street
 675       value="<?php echo $result3{"subscriber_employer_street"}?>"
 676        onchange="capitalizeMe(this);" /></td>
 677     </tr>
 678
 679     <tr<?php if ($GLOBALS['omit_employers']) {
 680         echo " style='display:none'";
 681 } ?>>
 682      <td colspan="2">
 683       <table>
 684        <tr>
 685         <td><span class=required><?php xl('SE City', 'e'); ?>: </span></td>
 686         <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_city
 687          value="<?php echo $result3{"subscriber_employer_city"}?>"
 688           onchange="capitalizeMe(this);" /></td>
 689         <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE State', 'e') : xl('SE Locality', 'e') ?>: </span></td>
 690     <td>
 691             <?php
 692             // Modified 7/2009 by BM to incorporate data types
 693             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'), $result3['subscriber_employer_state']);
 694                 ?>
 695           </td>
 696          </tr>
 697          <tr>
 698             <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE Zip Code', 'e') : xl('SE Postal Code', 'e') ?>: </span></td>
 699             <td><input type=entry size=10 name=i<?php echo $i?>subscriber_employer_postal_code value="<?php echo $result3{"subscriber_employer_postal_code"}?>"></td>
 700             <td><span class=required><?php xl('SE Country', 'e'); ?>: </span></td>
 701       <td>
 702                 <?php
 703               // Modified 7/2009 by BM to incorporate data types
 704                 generate_form_field(array('data_type'=>$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']);
 705                 ?>
 706       </td>
 707          </tr>
 708         </table>
 709        </td>
 710       </tr>
 711
 712      </table>
 713     </td>
 714
 715     <td valign=top>
 716        <span class=required><?php xl('Subscriber', 'e'); ?>: </span>
 717        <input type=entry size=10 name=i<?php echo $i?>subscriber_fname
 718         value="<?php echo $result3{"subscriber_fname"}?>"
 719       onchange="capitalizeMe(this);" />
 720        <input type=entry size=3 name=i<?php echo $i?>subscriber_mname
 721         value="<?php echo $result3{"subscriber_mname"}?>"
 722       onchange="capitalizeMe(this);" />
 723        <input type=entry size=10 name=i<?php echo $i?>subscriber_lname
 724         value="<?php echo $result3{"subscriber_lname"}?>"
 725       onchange="capitalizeMe(this);" />
 726      <br>
 727        <span class=required><?php xl('Relationship', 'e'); ?>: </span>
 728         <?php
 729       // Modified 6/2009 by BM to use list_options and function
 730         generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_relationship'),'list_id'=>'sub_relation','empty_title'=>' '), $result3['subscriber_relationship']);
 731         ?>
 732        <a href="javascript:popUp('../../interface/patient_file/summary/browse.php?browsenum=<?php echo $i?>')" class=text>(<?php xl('Browse', 'e'); ?>)</a><br />
 733
 734        <span class=bold><?php xl('D.O.B.', 'e'); ?>: </span>
 735        <input type='entry' size='11' class='datepicker' name='i<?php echo $i?>subscriber_DOB'
 736       id='i<?php echo $i?>subscriber_DOB'
 737       value='<?php echo $result3['subscriber_DOB'] ?>'
 738     title='yyyy-mm-dd' />
 739
 740        <span class=bold><?php xl('S.S.', 'e'); ?>: </span><input type=entry size=11 name=i<?php echo $i?>subscriber_ss value="<?php echo $result3{"subscriber_ss"}?>">&nbsp;
 741        <span class=bold><?php xl('Sex', 'e'); ?>: </span>
 742         <?php
 743       // Modified 6/2009 by BM to use list_options and function
 744         generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_sex'),'list_id'=>'sex'), $result3['subscriber_sex']);
 745         ?>
 746      <br>
 747        <span class=required><?php xl('Subscriber Address', 'e'); ?>: </span>
 748        <input type=entry size=25 name=i<?php echo $i?>subscriber_street
 749       value="<?php echo $result3{"subscriber_street"}?>"
 750     onchange="capitalizeMe(this);" /><br>
 751        <span class=required><?php xl('City', 'e'); ?>: </span>
 752        <input type=entry size=15 name=i<?php echo $i?>subscriber_city
 753       value="<?php echo $result3{"subscriber_city"}?>"
 754     onchange="capitalizeMe(this);" />
 755        <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('State', 'e') : xl('Locality', 'e') ?>: </span>
 756         <?php
 757       // Modified 7/2009 by BM to incorporate data types
 758         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'), $result3['subscriber_state']);
 759         ?>
 760      <br />
 761        <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('Zip Code', 'e') : xl('Postal Code', 'e') ?>: </span><input type=entry size=10 name=i<?php echo $i?>subscriber_postal_code value="<?php echo $result3{"subscriber_postal_code"}?>">
 762        <span class='required'<?php if ($GLOBALS['omit_employers']) {
 763             echo " style='display:none'";
 764 } ?>>
 765         <?php xl('Country', 'e'); ?>: </span>
 766         <?php
 767       // Modified 7/2009 by BM to incorporate data types
 768         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']);
 769         ?>
 770      <br />
 771        <span class=bold><?php xl('Subscriber Phone', 'e'); ?>:
 772        <input type='text' size='20' name='i<?php echo $i?>subscriber_phone' value='<?php echo $result3["subscriber_phone"] ?>' onkeyup='phonekeyup(this,mypcc)' />
 773      </span><br />
 774        <span class=bold><?php xl('CoPay', 'e'); ?>: <input type=text size="6" name=i<?php echo $i?>copay value="<?php echo $result3{"copay"}?>">
 775      </span><br />
 776        <span class='required'><?php xl('Accept Assignment', 'e'); ?>: </span>
 777        <select name=i<?php echo $i?>accept_assignment>
 778        <option value="TRUE" <?php if (strtoupper($result3{"accept_assignment"}) == "TRUE") {
 779             echo "selected";
 780 }?>><?php xl('YES', 'e'); ?></option>
 781        <option value="FALSE" <?php if (strtoupper($result3{"accept_assignment"}) == "FALSE") {
 782             echo "selected";
 783 }?>><?php xl('NO', 'e'); ?></option>
 784      </select>
 785     </td>
 786    </tr>
 787
 788   </table>
 789   <hr />
 790     <?php
 791     }
 792
 793     echo "</div>\n";
 794 } // end of "if not simplified_demographics"
 795 ?>
 796
 797 <?php if (!$SHORT_FORM) {
 798     echo "  <center>\n";
 799 } ?>
 800 <br />
 801 <?php if ($WITH_SEARCH) { ?>
 802 <input type="button" id="search" value=<?php xl('Search', 'e', '\'', '\''); ?>
 803  style='background-color:<?php echo $searchcolor; ?>' />
 804 &nbsp;&nbsp;
 805 <?php } ?>
 806 <input type="button" name='create' id="create" value=<?php xl('Create New Patient', 'e', '\'', '\''); ?> />
 807
 808 </center>
 809
 810   </td>
 811   <td align='right' valign='top' width='1%' nowrap>
 812    <!-- Image upload stuff was here but got moved. -->
 813   </td>
 814  </tr>
 815 </table>
 816
 817 </form>
 818
 819 <!-- include support for the list-add selectbox feature -->
 820 <?php include($GLOBALS['fileroot']."/library/options_listadd.inc"); ?>
 821
 822 </body>
 823
 824 <script language="JavaScript">
 825
 826 // hard code validation for old validation, in the new validation possible to add match rules
 827 <?php if ($GLOBALS['new_validate'] == 0) { ?>
 828
 829 // fix inconsistently formatted phone numbers from the database
 830 var f = document.forms[0];
 831 if (f.form_phone_contact) phonekeyup(f.form_phone_contact,mypcc);
 832 if (f.form_phone_home   ) phonekeyup(f.form_phone_home   ,mypcc);
 833 if (f.form_phone_biz    ) phonekeyup(f.form_phone_biz    ,mypcc);
 834 if (f.form_phone_cell   ) phonekeyup(f.form_phone_cell   ,mypcc);
 835
 836 <?php }?>
 837
 838 <?php echo $date_init; ?>
 839
 840 // -=- jQuery makes life easier -=-
 841
 842 // var matches = 0; // number of patients that match the demographic information being entered
 843 // var override = false; // flag that overrides the duplication warning
 844
 845 $(document).ready(function() {
 846 enable_modals();
 847  $(".medium_modal").fancybox( {
 848                 'overlayOpacity' : 0.0,
 849                 'showCloseButton' : true,
 850                 'frameHeight' : 460,
 851                 'frameWidth' : 650
 852         });
 853     // added to integrate insurance stuff
 854     <?php for ($i=1; $i<=3; $i++) { ?>
 855     $("#form_i<?php echo $i?>subscriber_relationship").change(function() { auto_populate_employer_address<?php echo $i?>(); });
 856     <?php } ?>
 857
 858     $('#search').click(function() { searchme(); });
 859     $('#create').click(function() { check()});
 860
 861     var check = function(e) {
 862         <?php if ($GLOBALS['new_validate']) {?>
 863             var valid = submitme(<?php echo $GLOBALS['new_validate'] ? 1 : 0;?>,e,"DEM",constraints);
 864         <?php } else {?>
 865             top.restoreSession();
 866             var f = document.forms[0];
 867             var valid = validate(f);
 868         <?php }?>
 869         if (valid) {
 870             if (force_submit) {
 871                 // In this case dups were shown already and Save should just save.
 872                 top.restoreSession();
 873                 f.submit();
 874                 return;
 875             }
 876
 877         <?php
 878         // D in edit_options indicates the field is used in duplication checking.
 879         // This constructs a list of the names of those fields.
 880         $mflist = "";
 881         $mfres = sqlStatement("SELECT * FROM layout_options " .
 882             "WHERE form_id = 'DEM' AND uor > 0 AND field_id != '' AND " .
 883             "(edit_options LIKE '%D%' OR  edit_options LIKE '%W%' )" .
 884             "ORDER BY group_name, seq");
 885         while ($mfrow = sqlFetchArray($mfres)) {
 886             $field_id  = $mfrow['field_id'];
 887             if (strpos($field_id, 'em_') === 0) {
 888                 continue;
 889             }
 890
 891             if (!empty($mflist)) {
 892                 $mflist .= ",";
 893             }
 894
 895             $mflist .= "'" . htmlentities($field_id) . "'";
 896         }
 897 ?>
 898         <?php if (($GLOBALS['full_new_patient_form'] == '4') && (checkIfPatientValidationHookIsActive())) :?>
 899             // Use zend module patient validation hook to open the controller and send the dup-checker fields.
 900             var url ='<?php echo  $GLOBALS['web_root']."/interface/modules/zend_modules/public/patientvalidation";?>';
 901         <?php else :?>
 902             // Build and invoke the URL to create the dup-checker dialog.
 903             var url = 'new_search_popup.php';
 904         <?php endif;?>
 905
 906         var flds = new Array(<?php echo $mflist; ?>);
 907         var separator = '?';
 908         for (var i = 0; i < flds.length; ++i) {
 909             var fval = $('#form_' + flds[i]).val();
 910             if (fval && fval != '') {
 911                 url += separator;
 912                 separator = '&';
 913                 url += 'mf_' + flds[i] + '=' + encodeURIComponent(fval);
 914             }
 915         }
 916         url+="&close"
 917         dlgopen(url, '_blank', 700, 500);
 918         } // end function
 919     } // end function
 920
 921
 922 // Set onclick/onfocus handlers for toggling background color.
 923 <?php
 924 $lres = getLayoutRes();
 925 while ($lrow = sqlFetchArray($lres)) {
 926     $field_id  = $lrow['field_id'];
 927     if (strpos($field_id, 'em_') === 0) {
 928         continue;
 929     }
 930
 931     switch (getSearchClass($lrow['data_type'])) {
 932         case 1:
 933             echo "    \$('#form_$field_id').click(function() { toggleSearch(this); });\n";
 934             break;
 935         case 2:
 936             echo "    \$('#form_$field_id').click(function() { selClick(this); });\n";
 937             echo "    \$('#form_$field_id').blur(function() { selBlur(this); });\n";
 938             break;
 939     }
 940 }
 941 ?>
 942
 943   $('.datepicker').datetimepicker({
 944     <?php $datetimepicker_timepicker = false; ?>
 945     <?php $datetimepicker_showseconds = false; ?>
 946     <?php $datetimepicker_formatInput = false; ?>
 947     <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 948     <?php // can add any additional javascript settings to datetimepicker here; need to prepend first setting with a comma ?>
 949   });
 950   $('.datetimepicker').datetimepicker({
 951     <?php $datetimepicker_timepicker = true; ?>
 952     <?php $datetimepicker_showseconds = false; ?>
 953     <?php $datetimepicker_formatInput = false; ?>
 954     <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 955     <?php // can add any additional javascript settings to datetimepicker here; need to prepend first setting with a comma ?>
 956   });
 957
 958 }); // end document.ready
 959
 960 </script>
 961 <?php /*Include the validation script and rules for this form*/
 962 $form_id="DEM";
 963 ?>
 964
 965 <?php
 966 //LBF forms use the new validation depending on the global value
 967 $use_validate_js=$GLOBALS['new_validate'];
 968 include_once("$srcdir/validation/validation_script.js.php");?>
 969 <script language='JavaScript'>
 970     // Array of skip conditions for the checkSkipConditions() function.
 971     var skipArray = [
 972         <?php echo $condition_str; ?>
 973     ];
 974     checkSkipConditions();
 975     $("input").change(function() {
 976         checkSkipConditions();
 977     });
 978     $("select").change(function() {
 979         checkSkipConditions();
 980     });
 981 </script>
 982
 983 </html>
 984