interface/new/new_comprehensive.php

   1 <?php
   2 // Copyright (C) 2009-2010 Rod Roark <rod@sunsetsystems.com>
   3 //
   4 // This program is free software; you can redistribute it and/or
   5 // modify it under the terms of the GNU General Public License
   6 // as published by the Free Software Foundation; either version 2
   7 // of the License, or (at your option) any later version.
   8
   9 require_once("../globals.php");
  10 require_once("$srcdir/acl.inc");
  11 require_once("$srcdir/options.inc.php");
  12 require_once("$srcdir/patient.inc");
  13 require_once("$srcdir/erx_javascript.inc.php");
  14 require_once("$srcdir/validation/LBF_Validation.php");
  15
  16 // Check authorization.
  17 if (!acl_check('patients','demo','',array('write','addonly') ))
  18   die("Adding demographics is not authorized.");
  19
  20 $CPR = 4; // cells per row
  21
  22 $searchcolor = empty($GLOBALS['layout_search_color']) ?
  23   '#ffff55' : $GLOBALS['layout_search_color'];
  24
  25 $WITH_SEARCH = ($GLOBALS['full_new_patient_form'] == '1' || $GLOBALS['full_new_patient_form'] == '2');
  26 $SHORT_FORM  = ($GLOBALS['full_new_patient_form'] == '2' || $GLOBALS['full_new_patient_form'] == '3');
  27
  28 function getLayoutRes() {
  29   global $SHORT_FORM;
  30   return sqlStatement("SELECT * FROM layout_options " .
  31     "WHERE form_id = 'DEM' AND uor > 0 AND field_id != '' " .
  32     ($SHORT_FORM ? "AND ( uor > 1 OR edit_options LIKE '%N%' ) " : "") .
  33     "ORDER BY group_name, seq");
  34 }
  35
  36 // Determine layout field search treatment from its data type:
  37 // 1 = text field
  38 // 2 = select list
  39 // 0 = not searchable
  40 //
  41 function getSearchClass($data_type) {
  42   switch($data_type) {
  43     case  1: // single-selection list
  44     case 10: // local provider list
  45     case 11: // provider list
  46     case 12: // pharmacy list
  47     case 13: // squads
  48     case 14: // address book list
  49     case 26: // single-selection list with add
  50     case 35: // facilities
  51       return 2;
  52     case  2: // text field
  53     case  3: // textarea
  54     case  4: // date
  55       return 1;
  56   }
  57   return 0;
  58 }
  59
  60 $fres = getLayoutRes();
  61 ?>
  62 <html>
  63 <head>
  64 <?php html_header_show(); ?>
  65
  66 <link rel="stylesheet" href="<?php echo $css_header; ?>" type="text/css">
  67
  68 <style>
  69 body, td, input, select, textarea {
  70  font-family: Arial, Helvetica, sans-serif;
  71  font-size: 10pt;
  72 }
  73
  74 body {
  75  padding: 5pt 5pt 5pt 5pt;
  76 }
  77
  78 div.section {
  79  border: solid;
  80  border-width: 1px;
  81  border-color: #0000ff;
  82  margin: 0 0 0 10pt;
  83  padding: 5pt;
  84 }
  85
  86 </style>
  87
  88 <style type="text/css">@import url(../../library/dynarch_calendar.css);</style>
  89
  90 <script type="text/javascript" src="../../library/dialog.js"></script>
  91 <script type="text/javascript" src="../../library/textformat.js"></script>
  92 <script type="text/javascript" src="../../library/dynarch_calendar.js"></script>
  93 <?php include_once("{$GLOBALS['srcdir']}/dynarch_calendar_en.inc.php"); ?>
  94 <script type="text/javascript" src="../../library/dynarch_calendar_setup.js"></script>
  95 <script type="text/javascript" src="../../library/js/jquery-1.9.1.min.js"></script>
  96 <script type="text/javascript" src="../../library/js/common.js"></script>
  97 <script type="text/javascript" src="../../library/js/fancybox/jquery.fancybox-1.2.6.js"></script>
  98 <?php include_once("{$GLOBALS['srcdir']}/options.js.php"); ?>
  99 <link rel="stylesheet" type="text/css" href="../../library/js/fancybox/jquery.fancybox-1.2.6.css" media="screen" />
 100
 101 <SCRIPT LANGUAGE="JavaScript"><!--
 102 //Visolve - sync the radio buttons - Start
 103 if((top.window.parent) && (parent.window)){
 104         var wname = top.window.parent.left_nav;
 105         fname = (parent.window.name)?parent.window.name:window.name;
 106         wname.syncRadios();
 107         wname.setRadio(fname, "new");
 108 }//Visolve - sync the radio buttons - End
 109
 110 var mypcc = '<?php echo $GLOBALS['phone_country_code'] ?>';
 111
 112 // This may be changed to true by the AJAX search script.
 113 var force_submit = false;
 114
 115 //code used from http://tech.irt.org/articles/js037/
 116 function replace(string,text,by) {
 117  // Replaces text with by in string
 118  var strLength = string.length, txtLength = text.length;
 119  if ((strLength == 0) || (txtLength == 0)) return string;
 120
 121  var i = string.indexOf(text);
 122  if ((!i) && (text != string.substring(0,txtLength))) return string;
 123  if (i == -1) return string;
 124
 125  var newstr = string.substring(0,i) + by;
 126
 127  if (i+txtLength < strLength)
 128   newstr += replace(string.substring(i+txtLength,strLength),text,by);
 129
 130  return newstr;
 131 }
 132
 133 <?php for ($i=1;$i<=3;$i++) { ?>
 134 function auto_populate_employer_address<?php echo $i ?>(){
 135  var f = document.demographics_form;
 136  if (f.form_i<?php echo $i?>subscriber_relationship.options[f.form_i<?php echo $i?>subscriber_relationship.selectedIndex].value == "self") {
 137   f.i<?php echo $i?>subscriber_fname.value=f.form_fname.value;
 138   f.i<?php echo $i?>subscriber_mname.value=f.form_mname.value;
 139   f.i<?php echo $i?>subscriber_lname.value=f.form_lname.value;
 140   f.i<?php echo $i?>subscriber_street.value=f.form_street.value;
 141   f.i<?php echo $i?>subscriber_city.value=f.form_city.value;
 142   f.form_i<?php echo $i?>subscriber_state.value=f.form_state.value;
 143   f.i<?php echo $i?>subscriber_postal_code.value=f.form_postal_code.value;
 144   if (f.form_country_code)
 145     f.form_i<?php echo $i?>subscriber_country.value=f.form_country_code.value;
 146   f.i<?php echo $i?>subscriber_phone.value=f.form_phone_home.value;
 147   f.i<?php echo $i?>subscriber_DOB.value=f.form_DOB.value;
 148   f.i<?php echo $i?>subscriber_ss.value=f.form_ss.value;
 149   f.form_i<?php echo $i?>subscriber_sex.value = f.form_sex.value;
 150   f.i<?php echo $i?>subscriber_employer.value=f.form_em_name.value;
 151   f.i<?php echo $i?>subscriber_employer_street.value=f.form_em_street.value;
 152   f.i<?php echo $i?>subscriber_employer_city.value=f.form_em_city.value;
 153   f.form_i<?php echo $i?>subscriber_employer_state.value=f.form_em_state.value;
 154   f.i<?php echo $i?>subscriber_employer_postal_code.value=f.form_em_postal_code.value;
 155   if (f.form_em_country)
 156     f.form_i<?php echo $i?>subscriber_employer_country.value=f.form_em_country.value;
 157  }
 158 }
 159
 160 <?php } ?>
 161
 162 function upperFirst(string,text) {
 163  return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
 164 }
 165
 166 // The ins_search.php window calls this to set the selected insurance.
 167 function set_insurance(ins_id, ins_name) {
 168  var thesel = document.forms[0]['i' + insurance_index + 'provider'];
 169  var theopts = thesel.options; // the array of Option objects
 170  var i = 0;
 171  for (; i < theopts.length; ++i) {
 172   if (theopts[i].value == ins_id) {
 173    theopts[i].selected = true;
 174    return;
 175   }
 176  }
 177  // no matching option was found so create one, append it to the
 178  // end of the list, and select it.
 179  theopts[i] = new Option(ins_name, ins_id, false, true);
 180 }
 181
 182 // Indicates which insurance slot is being updated.
 183 var insurance_index = 0;
 184
 185 // The OnClick handler for searching/adding the insurance company.
 186 function ins_search(ins) {
 187  insurance_index = ins;
 188  return false;
 189 }
 190
 191 function checkNum () {
 192  var re= new RegExp();
 193  re = /^\d*\.?\d*$/;
 194  str=document.forms[0].monthly_income.value;
 195  if(re.exec(str))
 196  {
 197  }else{
 198   alert("Please enter a dollar amount using only numbers and a decimal point.");
 199  }
 200 }
 201
 202 // This capitalizes the first letter of each word in the passed input
 203 // element.  It also strips out extraneous spaces.
 204 function capitalizeMe(elem) {
 205  var a = elem.value.split(' ');
 206  var s = '';
 207  for(var i = 0; i < a.length; ++i) {
 208   if (a[i].length > 0) {
 209    if (s.length > 0) s += ' ';
 210    s += a[i].charAt(0).toUpperCase() + a[i].substring(1);
 211   }
 212  }
 213  elem.value = s;
 214 }
 215
 216 // Onkeyup handler for policy number.  Allows only A-Z and 0-9.
 217 function policykeyup(e) {
 218  var v = e.value.toUpperCase();
 219  var filteredString="";
 220  for (var i = 0; i < v.length; ++i) {
 221   var c = v.charAt(i);
 222   if ((c >= '0' && c <= '9') ||
 223      (c >= 'A' && c <= 'Z') ||
 224      (c == '*') ||
 225      (c == '-') ||
 226      (c == '_') ||
 227      (c == '(') ||
 228      (c == ')') ||
 229      (c == '#'))
 230      {
 231          filteredString+=c;
 232      }
 233  }
 234  e.value = filteredString;
 235  return;
 236 }
 237
 238 function divclick(cb, divid) {
 239  var divstyle = document.getElementById(divid).style;
 240  if (cb.checked) {
 241   divstyle.display = 'block';
 242  } else {
 243   divstyle.display = 'none';
 244  }
 245  return true;
 246 }
 247
 248 // Compute the length of a string without leading and trailing spaces.
 249 function trimlen(s) {
 250  var i = 0;
 251  var j = s.length - 1;
 252  for (; i <= j && s.charAt(i) == ' '; ++i);
 253  for (; i <= j && s.charAt(j) == ' '; --j);
 254  if (i > j) return 0;
 255  return j + 1 - i;
 256 }
 257
 258 function validate(f) {
 259   var errMsgs = new Array();
 260   <?php generate_layout_validation('DEM'); ?>
 261   <?php if($GLOBALS['erx_enable']){ ?>
 262   alertMsg='';
 263   for(i=0;i<f.length;i++){
 264     if(f[i].type=='text' && f[i].value)
 265     {
 266       if(f[i].name == 'form_fname' || f[i].name == 'form_mname' || f[i].name == 'form_lname')
 267       {
 268         alertMsg += checkLength(f[i].name,f[i].value,35);
 269         alertMsg += checkUsername(f[i].name,f[i].value);
 270       }
 271       else if(f[i].name == 'form_street' || f[i].name == 'form_city')
 272       {
 273         alertMsg += checkLength(f[i].name,f[i].value,35);
 274         alertMsg += checkAlphaNumericExtended(f[i].name,f[i].value);
 275       }
 276       else if(f[i].name == 'form_phone_home')
 277       {
 278        alertMsg += checkPhone(f[i].name,f[i].value);
 279       }
 280     }
 281   }
 282   if(alertMsg)
 283   {
 284     alert(alertMsg);
 285     return false;
 286   }
 287   <?php } ?>
 288   var msg = "";
 289   msg += "<?php echo htmlspecialchars(xl('The following fields are required'),ENT_QUOTES); ?>:\n\n";
 290   for ( var i = 0; i < errMsgs.length; i++ ) {
 291          msg += errMsgs[i] + "\n";
 292   }
 293   msg += "\n<?php echo htmlspecialchars(xl('Please fill them in before continuing.'),ENT_QUOTES); ?>";
 294
 295
 296 //Misc  Deceased Date Validation for Future Date
 297 var dateVal = document.getElementById("form_deceased_date").value;
 298 var currentDate;
 299 var d = new Date();
 300 month = '' + (d.getMonth() + 1),
 301 day = '' + d.getDate(),
 302 year = d.getFullYear();
 303 if (month.length < 2) month = '0' + month;
 304 if (day.length < 2) day = '0' + day;
 305 currentDate = year+'-'+month+'-'+day;
 306 if(errMsgs.length > 0 || dateVal > currentDate)
 307 {
 308 if(errMsgs.length > 0)
 309         alert(msg);
 310 if(dateVal > currentDate)
 311         alert ('<?php echo xls("Deceased Date should not be greater than Today"); ?>');
 312         return false;
 313 }
 314  return true;
 315 }
 316
 317 function toggleSearch(elem) {
 318  var f = document.forms[0];
 319 <?php if ($WITH_SEARCH) { ?>
 320  // Toggle background color.
 321  if (elem.style.backgroundColor == '')
 322   elem.style.backgroundColor = '<?php echo $searchcolor; ?>';
 323  else
 324   elem.style.backgroundColor = '';
 325 <?php } ?>
 326  if (force_submit) {
 327   force_submit = false;
 328   f.create.value = '<?php xl('Create New Patient','e'); ?>';
 329  }
 330  return true;
 331 }
 332
 333 // If a <select> list is dropped down, this is its name.
 334 var open_sel_name = '';
 335
 336 function selClick(elem) {
 337  if (open_sel_name == elem.name) {
 338   open_sel_name = '';
 339  }
 340  else {
 341   open_sel_name = elem.name;
 342   toggleSearch(elem);
 343  }
 344  return true;
 345 }
 346
 347 function selBlur(elem) {
 348  if (open_sel_name == elem.name) {
 349   open_sel_name = '';
 350  }
 351  return true;
 352 }
 353
 354 // This invokes the patient search dialog.
 355 function searchme() {
 356  var f = document.forms[0];
 357  var url = '../main/finder/patient_select.php?popup=1';
 358
 359 <?php
 360 $lres = getLayoutRes();
 361
 362 while ($lrow = sqlFetchArray($lres)) {
 363   $field_id  = $lrow['field_id'];
 364   if (strpos($field_id, 'em_') === 0) continue;
 365   $data_type = $lrow['data_type'];
 366   $fldname = "form_$field_id";
 367   switch(getSearchClass($data_type)) {
 368     case  1:
 369       echo
 370       " if (f.$fldname.style.backgroundColor != '' && trimlen(f.$fldname.value) > 0) {\n" .
 371       "  url += '&$field_id=' + encodeURIComponent(f.$fldname.value);\n" .
 372       " }\n";
 373       break;
 374     case 2:
 375       echo
 376       " if (f.$fldname.style.backgroundColor != '' && f.$fldname.selectedIndex > 0) {\n" .
 377       "  url += '&$field_id=' + encodeURIComponent(f.$fldname.options[f.$fldname.selectedIndex].value);\n" .
 378       " }\n";
 379       break;
 380   }
 381 }
 382 ?>
 383
 384  dlgopen(url, '_blank', 700, 500);
 385 }
 386
 387 //-->
 388
 389 </script>
 390 </head>
 391
 392 <body class="body_top">
 393
 394 <form action='new_comprehensive_save.php' name='demographics_form' id="DEM"  method='post' onsubmit='return submitme(<?php echo $GLOBALS['new_validate'] ? 1 : 0;?>,event,"DEM")'>
 395
 396 <span class='title'><?php xl('Search or Add Patient','e'); ?></span>
 397
 398 <table width='100%' cellpadding='0' cellspacing='8'>
 399  <tr>
 400   <td align='left' valign='top'>
 401 <?php if ($SHORT_FORM) echo "  <center>\n"; ?>
 402 <?php
 403
 404 function end_cell() {
 405   global $item_count, $cell_count;
 406   if ($item_count > 0) {
 407     echo "</td>";
 408     $item_count = 0;
 409   }
 410 }
 411
 412 function end_row() {
 413   global $cell_count, $CPR;
 414   end_cell();
 415   if ($cell_count > 0) {
 416     for (; $cell_count < $CPR; ++$cell_count) echo "<td></td>";
 417     echo "</tr>\n";
 418     $cell_count = 0;
 419   }
 420 }
 421
 422 function end_group() {
 423   global $last_group, $SHORT_FORM;
 424   if (strlen($last_group) > 0) {
 425     end_row();
 426     echo " </table>\n";
 427     if (!$SHORT_FORM) echo "</div>\n";
 428   }
 429 }
 430
 431 $last_group    = '';
 432 $cell_count    = 0;
 433 $item_count    = 0;
 434 $display_style = 'block';
 435 $group_seq     = 0; // this gives the DIV blocks unique IDs
 436
 437 while ($frow = sqlFetchArray($fres)) {
 438   $this_group = $frow['group_name'];
 439   $titlecols  = $frow['titlecols'];
 440   $datacols   = $frow['datacols'];
 441   $data_type  = $frow['data_type'];
 442   $field_id   = $frow['field_id'];
 443   $list_id    = $frow['list_id'];
 444   $currvalue  = '';
 445   $condition_str = get_conditions_str($condition_str,$group_fields);
 446
 447   if (strpos($field_id, 'em_') === 0) {
 448     $tmp = substr($field_id, 3);
 449     if (isset($result2[$tmp])) $currvalue = $result2[$tmp];
 450   }
 451   else {
 452     if (isset($result[$field_id])) $currvalue = $result[$field_id];
 453   }
 454
 455   // Handle a data category (group) change.
 456   if (strcmp($this_group, $last_group) != 0) {
 457     if (!$SHORT_FORM) {
 458       end_group();
 459       $group_seq++;    // ID for DIV tags
 460       $group_name = substr($this_group, 1);
 461       if (strlen($last_group) > 0) echo "<br />";
 462       echo "<span class='bold'><input type='checkbox' name='form_cb_$group_seq' id='form_cb_$group_seq' value='1' " .
 463         "onclick='return divclick(this,\"div_$group_seq\");'";
 464       if ($display_style == 'block') echo " checked";
 465
 466       // Modified 6-09 by BM - Translate if applicable
 467       echo " /><b>" . xl_layout_label($group_name) . "</b></span>\n";
 468
 469       echo "<div id='div_$group_seq' class='section' style='display:$display_style;'>\n";
 470       echo " <table border='0' cellpadding='0'>\n";
 471       $display_style = 'none';
 472     }
 473     else if (strlen($last_group) == 0) {
 474       echo " <table border='0' cellpadding='0'>\n";
 475     }
 476     $last_group = $this_group;
 477   }
 478
 479   // Handle starting of a new row.
 480   if (($titlecols > 0 && $cell_count >= $CPR) || $cell_count == 0) {
 481     end_row();
 482     echo "  <tr>";
 483   }
 484
 485   if ($item_count == 0 && $titlecols == 0) $titlecols = 1;
 486   $field_id_label='label_'.$frow['field_id'];
 487   // Handle starting of a new label cell.
 488   if ($titlecols > 0) {
 489     end_cell();
 490     echo "<td colspan='$titlecols' id='$field_id_label'";
 491     echo ($frow['uor'] == 2) ? " class='required'" : " class='bold'";
 492     if ($cell_count == 2) echo " style='padding-left:10pt'";
 493     echo ">";
 494     $cell_count += $titlecols;
 495   }
 496   ++$item_count;
 497
 498   echo "<b>";
 499
 500   // Modified 6-09 by BM - Translate if applicable
 501   if ($frow['title']) echo (xl_layout_label($frow['title']).":"); else echo "&nbsp;";
 502
 503   echo "</b>";
 504
 505   // Handle starting of a new data cell.
 506   if ($datacols > 0) {
 507       $id_field_text = "text_".$frow['field_id'];
 508     end_cell();
 509     echo "<td colspan='$datacols' class='text data'";
 510     if ($cell_count > 0) echo " style='padding-left:5pt'". " id='".$id_field_text."'";
 511     echo ">";
 512     $cell_count += $datacols;
 513   }
 514
 515   ++$item_count;
 516   generate_form_field($frow, $currvalue);
 517 }
 518
 519 end_group();
 520 ?>
 521
 522 <?php
 523 if (! $GLOBALS['simplified_demographics']) {
 524   $insurancei = getInsuranceProviders();
 525   $pid = 0;
 526   $insurance_headings = array(xl("Primary Insurance Provider"), xl("Secondary Insurance Provider"), xl("Tertiary Insurance provider"));
 527   $insurance_info = array();
 528   $insurance_info[1] = getInsuranceData($pid,"primary");
 529   $insurance_info[2] = getInsuranceData($pid,"secondary");
 530   $insurance_info[3] = getInsuranceData($pid,"tertiary");
 531
 532   echo "<br /><span class='bold'><input type='checkbox' name='form_cb_ins' value='1' " .
 533     "onclick='return divclick(this,\"div_ins\");'";
 534   if ($display_style == 'block') echo " checked";
 535   echo " /><b>" . xl('Insurance') . "</b></span>\n";
 536   echo "<div id='div_ins' class='section' style='display:$display_style;'>\n";
 537
 538   for($i=1;$i<=3;$i++) {
 539    $result3 = $insurance_info[$i];
 540 ?>
 541 <table border="0">
 542  <tr>
 543   <td valign='top' colspan='2'>
 544    <span class='required'><?php echo $insurance_headings[$i -1].":"?></span>
 545    <select name="i<?php echo $i?>provider">
 546     <option value=""><?php xl('Unassigned','e'); ?></option>
 547 <?php
 548  foreach ($insurancei as $iid => $iname) {
 549   echo "<option value='" . $iid . "'";
 550   if (strtolower($iid) == strtolower($result3{"provider"}))
 551    echo " selected";
 552   echo ">" . $iname . "</option>\n";
 553  }
 554 ?>
 555    </select>&nbsp;<a class='iframe medium_modal' href='../practice/ins_search.php' onclick='ins_search(<?php echo $i?>)'>
 556   <span> <?php xl('Search/Add Insurer','e'); ?></span></a>
 557   </td>
 558  </tr>
 559  <tr>
 560   <td valign=top>
 561    <table border="0">
 562
 563     <tr>
 564      <td>
 565       <span class='required'><?php xl('Plan Name','e'); ?>: </span>
 566      </td>
 567      <td>
 568       <input type='entry' size='20' name='i<?php echo $i?>plan_name' value="<?php echo $result3{"plan_name"} ?>"
 569        onchange="capitalizeMe(this);" />&nbsp;&nbsp;
 570      </td>
 571     </tr>
 572
 573     <tr>
 574      <td>
 575       <span class='required'><?php xl('Effective Date','e'); ?>: </span>
 576      </td>
 577      <td>
 578       <input type='entry' size='11' name='i<?php echo $i ?>effective_date'
 579        id='i<?php echo $i ?>effective_date'
 580        value='<?php echo $result3['date'] ?>'
 581        onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)'
 582        title='yyyy-mm-dd' />
 583
 584       <img src='../../interface/pic/show_calendar.gif' align='absbottom' width='24' height='22'
 585       id='img_i<?php echo $i ?>effective_date' border='0' alt='[?]' style='cursor:pointer'
 586       title='<?php xl('Click here to choose a date','e'); ?>'>
 587
 588       <script LANGUAGE="JavaScript">
 589       Calendar.setup({inputField:"i<?php echo $i ?>effective_date", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i; ?>effective_date"});
 590       </script>
 591
 592
 593      </td>
 594     </tr>
 595
 596     <tr>
 597      <td><span class=required><?php xl('Policy Number','e'); ?>: </span></td>
 598      <td><input type='entry' size='16' name='i<?php echo $i?>policy_number' value="<?php echo $result3{"policy_number"}?>"
 599       onkeyup='policykeyup(this)'></td>
 600     </tr>
 601
 602     <tr>
 603      <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 $result3{"group_number"}?>" onkeyup='policykeyup(this)'></td>
 604     </tr>
 605
 606     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 607      <td class='required'><?php xl('Subscriber Employer (SE)','e'); ?><br><span style='font-weight:normal'>
 608       (<?php xl('if unemployed enter Student','e'); ?>,<br><?php xl('PT Student, or leave blank','e'); ?>): </span></td>
 609      <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer
 610       value="<?php echo $result3{"subscriber_employer"}?>"
 611        onchange="capitalizeMe(this);" /></td>
 612     </tr>
 613
 614     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 615      <td><span class=required><?php xl('SE Address','e'); ?>: </span></td>
 616      <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer_street
 617       value="<?php echo $result3{"subscriber_employer_street"}?>"
 618        onchange="capitalizeMe(this);" /></td>
 619     </tr>
 620
 621     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 622      <td colspan="2">
 623       <table>
 624        <tr>
 625         <td><span class=required><?php xl('SE City','e'); ?>: </span></td>
 626         <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_city
 627          value="<?php echo $result3{"subscriber_employer_city"}?>"
 628           onchange="capitalizeMe(this);" /></td>
 629         <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE State','e') : xl('SE Locality','e') ?>: </span></td>
 630         <td>
 631          <?php
 632           // Modified 7/2009 by BM to incorporate data types
 633           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'), $result3['subscriber_employer_state']);
 634          ?>
 635         </td>
 636        </tr>
 637        <tr>
 638         <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE Zip Code','e') : xl('SE Postal Code','e') ?>: </span></td>
 639         <td><input type=entry size=10 name=i<?php echo $i?>subscriber_employer_postal_code value="<?php echo $result3{"subscriber_employer_postal_code"}?>"></td>
 640         <td><span class=required><?php xl('SE Country','e'); ?>: </span></td>
 641         <td>
 642          <?php
 643           // Modified 7/2009 by BM to incorporate data types
 644           generate_form_field(array('data_type'=>$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']);
 645          ?>
 646         </td>
 647        </tr>
 648       </table>
 649      </td>
 650     </tr>
 651
 652    </table>
 653   </td>
 654
 655   <td valign=top>
 656    <span class=required><?php xl('Subscriber','e'); ?>: </span>
 657    <input type=entry size=10 name=i<?php echo $i?>subscriber_fname
 658     value="<?php echo $result3{"subscriber_fname"}?>"
 659     onchange="capitalizeMe(this);" />
 660    <input type=entry size=3 name=i<?php echo $i?>subscriber_mname
 661     value="<?php echo $result3{"subscriber_mname"}?>"
 662     onchange="capitalizeMe(this);" />
 663    <input type=entry size=10 name=i<?php echo $i?>subscriber_lname
 664     value="<?php echo $result3{"subscriber_lname"}?>"
 665     onchange="capitalizeMe(this);" />
 666    <br>
 667    <span class=required><?php xl('Relationship','e'); ?>: </span>
 668    <?php
 669     // Modified 6/2009 by BM to use list_options and function
 670     generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_relationship'),'list_id'=>'sub_relation','empty_title'=>' '), $result3['subscriber_relationship']);
 671    ?>
 672    <a href="javascript:popUp('../../interface/patient_file/summary/browse.php?browsenum=<?php echo $i?>')" class=text>(<?php xl('Browse','e'); ?>)</a><br />
 673
 674    <span class=bold><?php xl('D.O.B.','e'); ?>: </span>
 675    <input type='entry' size='11' name='i<?php echo $i?>subscriber_DOB'
 676     id='i<?php echo $i?>subscriber_DOB'
 677     value='<?php echo $result3['subscriber_DOB'] ?>'
 678     onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)'
 679     title='yyyy-mm-dd' />
 680
 681    <img src='../../interface/pic/show_calendar.gif' align='absbottom' width='24' height='22'
 682     id='img_i<?php echo $i; ?>dob_date' border='0' alt='[?]' style='cursor:pointer'
 683     title='<?php xl('Click here to choose a date','e'); ?>'>
 684
 685     <script LANGUAGE="JavaScript">
 686     Calendar.setup({inputField:"i<?php echo $i?>subscriber_DOB", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i; ?>dob_date"});
 687     </script>
 688
 689
 690    <span class=bold><?php xl('S.S.','e'); ?>: </span><input type=entry size=11 name=i<?php echo $i?>subscriber_ss value="<?php echo $result3{"subscriber_ss"}?>">&nbsp;
 691    <span class=bold><?php xl('Sex','e'); ?>: </span>
 692    <?php
 693     // Modified 6/2009 by BM to use list_options and function
 694     generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_sex'),'list_id'=>'sex'), $result3['subscriber_sex']);
 695    ?>
 696    <br>
 697    <span class=required><?php xl('Subscriber Address','e'); ?>: </span>
 698    <input type=entry size=25 name=i<?php echo $i?>subscriber_street
 699     value="<?php echo $result3{"subscriber_street"}?>"
 700     onchange="capitalizeMe(this);" /><br>
 701    <span class=required><?php xl('City','e'); ?>: </span>
 702    <input type=entry size=15 name=i<?php echo $i?>subscriber_city
 703     value="<?php echo $result3{"subscriber_city"}?>"
 704     onchange="capitalizeMe(this);" />
 705    <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('State','e') : xl('Locality','e') ?>: </span>
 706    <?php
 707     // Modified 7/2009 by BM to incorporate data types
 708     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'), $result3['subscriber_state']);
 709    ?>
 710    <br />
 711    <span class=required><?php echo ($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 $result3{"subscriber_postal_code"}?>">
 712    <span class='required'<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 713    <?php xl('Country','e'); ?>: </span>
 714    <?php
 715     // Modified 7/2009 by BM to incorporate data types
 716     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']);
 717    ?>
 718    <br />
 719    <span class=bold><?php xl('Subscriber Phone','e'); ?>:
 720    <input type='text' size='20' name='i<?php echo $i?>subscriber_phone' value='<?php echo $result3["subscriber_phone"] ?>' onkeyup='phonekeyup(this,mypcc)' />
 721    </span><br />
 722    <span class=bold><?php xl('CoPay','e'); ?>: <input type=text size="6" name=i<?php echo $i?>copay value="<?php echo $result3{"copay"}?>">
 723    </span><br />
 724    <span class='required'><?php xl('Accept Assignment','e'); ?>: </span>
 725    <select name=i<?php echo $i?>accept_assignment>
 726      <option value="TRUE" <?php if (strtoupper($result3{"accept_assignment"}) == "TRUE") echo "selected"?>><?php xl('YES','e'); ?></option>
 727      <option value="FALSE" <?php if (strtoupper($result3{"accept_assignment"}) == "FALSE") echo "selected"?>><?php xl('NO','e'); ?></option>
 728    </select>
 729   </td>
 730  </tr>
 731
 732 </table>
 733 <hr />
 734 <?php
 735   }
 736   echo "</div>\n";
 737  } // end of "if not simplified_demographics"
 738 ?>
 739
 740 <?php if (!$SHORT_FORM) echo "  <center>\n"; ?>
 741 <br />
 742 <?php if ($WITH_SEARCH) { ?>
 743 <input type="button" id="search" value=<?php xl('Search','e','\'','\''); ?>
 744  style='background-color:<?php echo $searchcolor; ?>' />
 745 &nbsp;&nbsp;
 746 <?php } ?>
 747 <input type="button" name='create' id="create" value=<?php xl('Create New Patient','e','\'','\''); ?> />
 748
 749 </center>
 750
 751   </td>
 752   <td align='right' valign='top' width='1%' nowrap>
 753    <!-- Image upload stuff was here but got moved. -->
 754   </td>
 755  </tr>
 756 </table>
 757
 758 </form>
 759
 760 <!-- include support for the list-add selectbox feature -->
 761 <?php include($GLOBALS['fileroot']."/library/options_listadd.inc"); ?>
 762
 763 </body>
 764
 765 <script language="JavaScript">
 766
 767 // hard code validation for old validation, in the new validation possible to add match rules
 768 <?php if($GLOBALS['new_validate'] == 0) { ?>
 769
 770 // fix inconsistently formatted phone numbers from the database
 771 var f = document.forms[0];
 772 if (f.form_phone_contact) phonekeyup(f.form_phone_contact,mypcc);
 773 if (f.form_phone_home   ) phonekeyup(f.form_phone_home   ,mypcc);
 774 if (f.form_phone_biz    ) phonekeyup(f.form_phone_biz    ,mypcc);
 775 if (f.form_phone_cell   ) phonekeyup(f.form_phone_cell   ,mypcc);
 776
 777 <?php }?>
 778
 779 <?php echo $date_init; ?>
 780
 781 // -=- jQuery makes life easier -=-
 782
 783 // var matches = 0; // number of patients that match the demographic information being entered
 784 // var override = false; // flag that overrides the duplication warning
 785
 786 $(document).ready(function() {
 787 enable_modals();
 788  $(".medium_modal").fancybox( {
 789                 'overlayOpacity' : 0.0,
 790                 'showCloseButton' : true,
 791                 'frameHeight' : 460,
 792                 'frameWidth' : 650
 793         });
 794     // added to integrate insurance stuff
 795     <?php for ($i=1;$i<=3;$i++) { ?>
 796     $("#form_i<?php echo $i?>subscriber_relationship").change(function() { auto_populate_employer_address<?php echo $i?>(); });
 797     <?php } ?>
 798
 799     $('#search').click(function() { searchme(); });
 800     $('#create').click(function() { check()});
 801
 802     var check = function(e) {
 803       <?php if($GLOBALS['new_validate']){?>
 804             var valid = submitme(<?php echo $GLOBALS['new_validate'] ? 1 : 0;?>,e,"DEM");
 805       <?php }else{?>
 806             top.restoreSession();
 807             var f = document.forms[0];
 808             var valid = validate(f);
 809       <?php }?>
 810         if (valid) {
 811             if (force_submit) {
 812                 // In this case dups were shown already and Save should just save.
 813                 f.submit();
 814                 return;
 815             }
 816
 817       <?php
 818         // D in edit_options indicates the field is used in duplication checking.
 819         // This constructs a list of the names of those fields.
 820         $mflist = "";
 821         $mfres = sqlStatement("SELECT * FROM layout_options " .
 822             "WHERE form_id = 'DEM' AND uor > 0 AND field_id != '' AND " .
 823             "edit_options LIKE '%D%' " .
 824             "ORDER BY group_name, seq");
 825         while ($mfrow = sqlFetchArray($mfres)) {
 826             $field_id  = $mfrow['field_id'];
 827             if (strpos($field_id, 'em_') === 0) continue;
 828             if (!empty($mflist)) $mflist .= ",";
 829             $mflist .= "'" . htmlentities($field_id) . "'";
 830         }
 831 ?>
 832         // Build and invoke the URL to create the dup-checker dialog.
 833         var url = 'new_search_popup.php';
 834         var flds = new Array(<?php echo $mflist; ?>);
 835         var separator = '?';
 836         for (var i = 0; i < flds.length; ++i) {
 837             var fval = $('#form_' + flds[i]).val();
 838             if (fval && fval != '') {
 839                 url += separator;
 840                 separator = '&';
 841                 url += 'mf_' + flds[i] + '=' + encodeURIComponent(fval);
 842             }
 843         }
 844         dlgopen(url, '_blank', 700, 500);
 845         } // end function
 846     } // end function
 847
 848
 849 // Set onclick/onfocus handlers for toggling background color.
 850 <?php
 851 $lres = getLayoutRes();
 852 while ($lrow = sqlFetchArray($lres)) {
 853   $field_id  = $lrow['field_id'];
 854   if (strpos($field_id, 'em_') === 0) continue;
 855   switch(getSearchClass($lrow['data_type'])) {
 856     case 1:
 857       echo "    \$('#form_$field_id').click(function() { toggleSearch(this); });\n";
 858       break;
 859     case 2:
 860       echo "    \$('#form_$field_id').click(function() { selClick(this); });\n";
 861       echo "    \$('#form_$field_id').blur(function() { selBlur(this); });\n";
 862       break;
 863   }
 864 }
 865 ?>
 866
 867 }); // end document.ready
 868
 869 </script>
 870 <?php /*Include the validation script and rules for this form*/
 871 $form_id="DEM";
 872 ?>
 873
 874 <?php include_once("$srcdir/validation/validation_script.js.php");?>
 875 <script language='JavaScript'>
 876     // Array of skip conditions for the checkSkipConditions() function.
 877     var skipArray = [
 878         <?php echo $condition_str; ?>
 879     ];
 880     checkSkipConditions();
 881     $("input").change(function() {
 882         checkSkipConditions();
 883     });
 884     $("select").change(function() {
 885         checkSkipConditions();
 886     });
 887 </script>
 888
 889 </html>
 890