interface/patient_file/summary/demographics_full.php

   1 <?php
   2 /**
   3  * Edit demographics.
   4  *
   5  * @package   OpenEMR
   6  * @link      http://www.open-emr.org
   7  * @author    Brady Miller <brady.g.miller@gmail.com>
   8  * @copyright Copyright (c) 2017 Brady Miller <brady.g.miller@gmail.com>
   9  * @license   https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  10  */
  11
  12 require_once("../../globals.php");
  13 require_once("$srcdir/acl.inc");
  14 require_once("$srcdir/options.inc.php");
  15 require_once("$srcdir/erx_javascript.inc.php");
  16 require_once("$srcdir/validation/LBF_Validation.php");
  17 require_once("$srcdir/patientvalidation.inc.php");
  18
  19 use OpenEMR\Core\Header;
  20
  21  // Session pid must be right or bad things can happen when demographics are saved!
  22  //
  23  include_once("$srcdir/pid.inc");
  24  $set_pid = $_GET["set_pid"] ? $_GET["set_pid"] : $_GET["pid"];
  25 if ($set_pid && $set_pid != $_SESSION["pid"]) {
  26     setpid($set_pid);
  27 }
  28
  29  include_once("$srcdir/patient.inc");
  30
  31  $result = getPatientData($pid, "*, DATE_FORMAT(DOB,'%Y-%m-%d') as DOB_YMD");
  32  $result2 = getEmployerData($pid);
  33
  34  // Check authorization.
  35 if ($pid) {
  36     if (!acl_check('patients', 'demo', '', 'write')) {
  37         die(xlt('Updating demographics is not authorized.'));
  38     }
  39
  40     if ($result['squad'] && ! acl_check('squads', $result['squad'])) {
  41         die(xlt('You are not authorized to access this squad.'));
  42     }
  43 } else {
  44     if (!acl_check('patients', 'demo', '', array('write','addonly'))) {
  45         die(xlt('Adding demographics is not authorized.'));
  46     }
  47 }
  48
  49 $CPR = 4; // cells per row
  50
  51 // $statii = array('married','single','divorced','widowed','separated','domestic partner');
  52 // $langi = getLanguages();
  53 // $ethnoraciali = getEthnoRacials();
  54 // $provideri = getProviderInfo();
  55 if ($GLOBALS['insurance_information'] != '0') {
  56     $insurancei = getInsuranceProvidersExtra();
  57 } else {
  58     $insurancei = getInsuranceProviders();
  59 }
  60
  61 $fres = sqlStatement("SELECT * FROM layout_options " .
  62   "WHERE form_id = 'DEM' AND uor > 0 " .
  63   "ORDER BY group_id, seq");
  64 ?>
  65 <html>
  66 <head>
  67
  68 <title><?php echo xlt('Edit Current Patient'); ?></title>
  69
  70 <?php Header::setupHeader(['datetime-picker','common','select2']); ?>
  71
  72 <style>
  73     .form-control {
  74         width: auto;
  75         display: inline;
  76         height: auto;
  77     }
  78 </style>
  79
  80 <?php include_once("{$GLOBALS['srcdir']}/options.js.php"); ?>
  81
  82 <script type="text/javascript">
  83
  84 // Support for beforeunload handler.
  85 var somethingChanged = false;
  86
  87 $(document).ready(function(){
  88     tabbify();
  89
  90     $(".medium_modal").on('click', function(e) {
  91         e.preventDefault();e.stopPropagation();
  92         let title = '<?php echo xla('Insurance Search/Select/Add'); ?>';
  93         dlgopen('', '', 700, 460, '', title, {
  94             buttons: [
  95                 {text: '<?php echo xla('Close'); ?>', close: true, style: 'default btn-sm'}
  96             ],
  97             allowResize: true,
  98             allowDrag: true,
  99             dialogId: '',
 100             type: 'iframe',
 101             url: $(this).attr('href')
 102         });
 103     });
 104
 105   $('.datepicker').datetimepicker({
 106     <?php $datetimepicker_timepicker = false; ?>
 107     <?php $datetimepicker_showseconds = false; ?>
 108     <?php $datetimepicker_formatInput = true; ?>
 109     <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 110     <?php // can add any additional javascript settings to datetimepicker here; need to prepend first setting with a comma ?>
 111   });
 112   $('.datetimepicker').datetimepicker({
 113     <?php $datetimepicker_timepicker = true; ?>
 114     <?php $datetimepicker_showseconds = false; ?>
 115     <?php $datetimepicker_formatInput = true; ?>
 116     <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 117     <?php // can add any additional javascript settings to datetimepicker here; need to prepend first setting with a comma ?>
 118   });
 119
 120   // Support for beforeunload handler.
 121   $('.tab input, .tab select, .tab textarea').change(function() {
 122     somethingChanged = true;
 123   });
 124   window.addEventListener("beforeunload", function (e) {
 125     if (somethingChanged && !top.timed_out) {
 126       var msg = "<?php echo xls('You have unsaved changes.'); ?>";
 127       e.returnValue = msg;     // Gecko, Trident, Chrome 34+
 128       return msg;              // Gecko, WebKit, Chrome <34
 129     }
 130   });
 131
 132   if (window.checkSkipConditions) {
 133     checkSkipConditions();
 134   }
 135 });
 136
 137 var mypcc = '<?php echo $GLOBALS['phone_country_code'] ?>';
 138
 139 //code used from http://tech.irt.org/articles/js037/
 140 function replace(string,text,by) {
 141  // Replaces text with by in string
 142  var strLength = string.length, txtLength = text.length;
 143  if ((strLength == 0) || (txtLength == 0)) return string;
 144
 145  var i = string.indexOf(text);
 146  if ((!i) && (text != string.substring(0,txtLength))) return string;
 147  if (i == -1) return string;
 148
 149  var newstr = string.substring(0,i) + by;
 150
 151  if (i+txtLength < strLength)
 152   newstr += replace(string.substring(i+txtLength,strLength),text,by);
 153
 154  return newstr;
 155 }
 156
 157 function upperFirst(string,text) {
 158  return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
 159 }
 160
 161 <?php for ($i=1; $i<=3; $i++) { ?>
 162 function auto_populate_employer_address<?php echo $i ?>(){
 163  var f = document.demographics_form;
 164  if (f.form_i<?php echo $i?>subscriber_relationship.options[f.form_i<?php echo $i?>subscriber_relationship.selectedIndex].value == "self")
 165  {
 166   f.i<?php echo $i?>subscriber_fname.value=f.form_fname.value;
 167   f.i<?php echo $i?>subscriber_mname.value=f.form_mname.value;
 168   f.i<?php echo $i?>subscriber_lname.value=f.form_lname.value;
 169   f.i<?php echo $i?>subscriber_street.value=f.form_street.value;
 170   f.i<?php echo $i?>subscriber_city.value=f.form_city.value;
 171   f.form_i<?php echo $i?>subscriber_state.value=f.form_state.value;
 172   f.i<?php echo $i?>subscriber_postal_code.value=f.form_postal_code.value;
 173   if (f.form_country_code)
 174     f.form_i<?php echo $i?>subscriber_country.value=f.form_country_code.value;
 175   f.i<?php echo $i?>subscriber_phone.value=f.form_phone_home.value;
 176   f.i<?php echo $i?>subscriber_DOB.value=f.form_DOB.value;
 177   if(typeof f.form_ss!="undefined")
 178     {
 179         f.i<?php echo $i?>subscriber_ss.value=f.form_ss.value;
 180     }
 181   f.form_i<?php echo $i?>subscriber_sex.value = f.form_sex.value;
 182   f.i<?php echo $i?>subscriber_employer.value=f.form_em_name.value;
 183   f.i<?php echo $i?>subscriber_employer_street.value=f.form_em_street.value;
 184   f.i<?php echo $i?>subscriber_employer_city.value=f.form_em_city.value;
 185   f.form_i<?php echo $i?>subscriber_employer_state.value=f.form_em_state.value;
 186   f.i<?php echo $i?>subscriber_employer_postal_code.value=f.form_em_postal_code.value;
 187   if (f.form_em_country)
 188     f.form_i<?php echo $i?>subscriber_employer_country.value=f.form_em_country.value;
 189  }
 190 }
 191
 192 <?php } ?>
 193
 194 function popUp(URL) {
 195  day = new Date();
 196  id = day.getTime();
 197  top.restoreSession();
 198  eval("page" + id + " = window.open(URL, '" + id + "', 'toolbar=0,scrollbars=1,location=0,statusbar=0,menubar=0,resizable=1,width=400,height=300,left = 440,top = 362');");
 199 }
 200
 201 function checkNum () {
 202  var re= new RegExp();
 203  re = /^\d*\.?\d*$/;
 204  str=document.demographics_form.monthly_income.value;
 205  if(re.exec(str))
 206  {
 207  }else{
 208   alert("<?php echo xls('Please enter a monetary amount using only numbers and a decimal point.'); ?>");
 209  }
 210 }
 211
 212 // Indicates which insurance slot is being updated.
 213 var insurance_index = 0;
 214
 215 // The OnClick handler for searching/adding the insurance company.
 216 function ins_search(ins) {
 217     insurance_index = ins;
 218     return false;
 219 }
 220 function InsSaveClose() {
 221     top.restoreSession();
 222     document.location.reload();
 223 }
 224 // The ins_search.php window calls this to set the selected insurance.
 225 function set_insurance(ins_id, ins_name) {
 226  var thesel = document.forms[0]['i' + insurance_index + 'provider'];
 227  var theopts = thesel.options; // the array of Option objects
 228  var i = 0;
 229  for (; i < theopts.length; ++i) {
 230   if (theopts[i].value == ins_id) {
 231    theopts[i].selected = true;
 232    return;
 233   }
 234  }
 235  // no matching option was found so create one, append it to the
 236  // end of the list, and select it.
 237  theopts[i] = new Option(ins_name, ins_id, false, true);
 238 }
 239
 240 // This capitalizes the first letter of each word in the passed input
 241 // element.  It also strips out extraneous spaces.
 242 function capitalizeMe(elem) {
 243  var a = elem.value.split(' ');
 244  var s = '';
 245  for(var i = 0; i < a.length; ++i) {
 246   if (a[i].length > 0) {
 247    if (s.length > 0) s += ' ';
 248    s += a[i].charAt(0).toUpperCase() + a[i].substring(1);
 249   }
 250  }
 251  elem.value = s;
 252 }
 253
 254 function divclick(cb, divid) {
 255  var divstyle = document.getElementById(divid).style;
 256  if (cb.checked) {
 257   divstyle.display = 'block';
 258  } else {
 259   divstyle.display = 'none';
 260  }
 261  return true;
 262 }
 263
 264 // Compute the length of a string without leading and trailing spaces.
 265 function trimlen(s) {
 266  var i = 0;
 267  var j = s.length - 1;
 268  for (; i <= j && s.charAt(i) == ' '; ++i);
 269  for (; i <= j && s.charAt(j) == ' '; --j);
 270  if (i > j) return 0;
 271  return j + 1 - i;
 272 }
 273
 274 function validate(f) {
 275  var errCount = 0;
 276  var errMsgs = new Array();
 277 <?php generate_layout_validation('DEM'); ?>
 278
 279  var msg = "";
 280  msg += "<?php echo xla('The following fields are required'); ?>:\n\n";
 281  for ( var i = 0; i < errMsgs.length; i++ ) {
 282     msg += errMsgs[i] + "\n";
 283  }
 284  msg += "\n<?php echo xla('Please fill them in before continuing.'); ?>";
 285
 286  if ( errMsgs.length > 0 ) {
 287     alert(msg);
 288  }
 289
 290  //Misc  Deceased Date Validation for Future Date
 291 var dateVal = document.getElementById("form_deceased_date").value;
 292 var currentDate;
 293 var d = new Date();
 294 month = '' + (d.getMonth() + 1),
 295 day = '' + d.getDate(),
 296 year = d.getFullYear();
 297 if (month.length < 2) month = '0' + month;
 298 if (day.length < 2) day = '0' + day;
 299 currentDate = year+'-'+month+'-'+day;
 300 if(dateVal > currentDate)
 301 {
 302     alert ('<?php echo xls("Deceased Date should not be greater than Today"); ?>');
 303     return false;
 304 }
 305
 306 //Patient Data validations
 307     <?php if ($GLOBALS['erx_enable']) { ?>
 308  alertMsg='';
 309  for(i=0;i<f.length;i++){
 310   if(f[i].type=='text' && f[i].value)
 311   {
 312    if(f[i].name == 'form_fname' || f[i].name == 'form_mname' || f[i].name == 'form_lname')
 313    {
 314     alertMsg += checkLength(f[i].name,f[i].value,35);
 315     alertMsg += checkUsername(f[i].name,f[i].value);
 316    }
 317    else if(f[i].name == 'form_street' || f[i].name == 'form_city')
 318    {
 319     alertMsg += checkLength(f[i].name,f[i].value,35);
 320     alertMsg += checkAlphaNumericExtended(f[i].name,f[i].value);
 321    }
 322    else if(f[i].name == 'form_phone_home')
 323    {
 324     alertMsg += checkPhone(f[i].name,f[i].value);
 325    }
 326   }
 327  }
 328  if(alertMsg)
 329  {
 330    alert(alertMsg);
 331    return false;
 332  }
 333     <?php } ?>
 334  //return false;
 335
 336 // Some insurance validation.
 337  for (var i = 1; i <= 3; ++i) {
 338   subprov = 'i' + i + 'provider';
 339   if (!f[subprov] || f[subprov].selectedIndex <= 0) continue;
 340   var subpfx = 'i' + i + 'subscriber_';
 341   var subrelat = f['form_' + subpfx + 'relationship'];
 342   var samename =
 343    f[subpfx + 'fname'].value == f.form_fname.value &&
 344    f[subpfx + 'mname'].value == f.form_mname.value &&
 345    f[subpfx + 'lname'].value == f.form_lname.value;
 346   var ss_regexp=/[0-9][0-9][0-9]-?[0-9][0-9]-?[0-9][0-9][0-9][0-9]/;
 347   var samess=true;
 348   var ss_valid=false;
 349   if(typeof f.form_ss!="undefined")
 350       {
 351         samess = f[subpfx + 'ss'].value == f.form_ss.value;
 352         ss_valid=ss_regexp.test(f[subpfx + 'ss'].value) && ss_regexp.test(f.form_ss.value);
 353       }
 354   if (subrelat.options[subrelat.selectedIndex].value == "self") {
 355    if (!samename) {
 356     if (!confirm("<?php echo xls('Subscriber relationship is self but name is different! Is this really OK?'); ?>"))
 357      return false;
 358    }
 359    if (!samess && ss_valid) {
 360     if(!confirm("<?php echo xls('Subscriber relationship is self but SS number is different!')." ". xls("Is this really OK?"); ?>"))
 361     return false;
 362    }
 363   } // end self
 364   else {
 365    if (samename) {
 366     if (!confirm("<?php echo xls('Subscriber relationship is not self but name is the same! Is this really OK?'); ?>"))
 367      return false;
 368    }
 369    if (samess && ss_valid)  {
 370     if(!confirm("<?php echo xls('Subscriber relationship is not self but SS number is the same!') ." ". xls("Is this really OK?"); ?>"))
 371     return false;
 372    }
 373   } // end not self
 374  } // end for
 375
 376  return errMsgs.length < 1;
 377 }
 378
 379
 380
 381 // Onkeyup handler for policy number.  Allows only A-Z and 0-9.
 382 function policykeyup(e) {
 383  var v = e.value.toUpperCase();
 384  var filteredString="";
 385  for (var i = 0; i < v.length; ++i) {
 386   var c = v.charAt(i);
 387   if ((c >= '0' && c <= '9') ||
 388      (c >= 'A' && c <= 'Z') ||
 389      (c == '*') ||
 390      (c == '-') ||
 391      (c == '_') ||
 392      (c == '(') ||
 393      (c == ')') ||
 394      (c == '#'))
 395      {
 396          filteredString+=c;
 397      }
 398  }
 399  e.value = filteredString;
 400  return;
 401 }
 402
 403 // Added 06/2009 by BM to make compatible with list_options table and functions - using jquery
 404 $(document).ready(function() {
 405
 406     <?php for ($i=1; $i<=3; $i++) { ?>
 407   $("#form_i<?php echo $i?>subscriber_relationship").change(function() { auto_populate_employer_address<?php echo $i?>(); });
 408     <?php } ?>
 409
 410 });
 411
 412 </script>
 413 </head>
 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 <body class="body_top">
 422
 423 <form action='demographics_save.php' name='demographics_form' id="DEM" method='post' onsubmit="submitme(<?php echo $GLOBALS['new_validate'] ? 1 : 0;?>,event,'DEM',constraints)">
 424 <input type='hidden' name='mode' value='save' />
 425 <input type='hidden' name='db_id' value="<?php echo attr($result['id']); ?>" />
 426
 427     <div class="container-fluid">
 428         <div class="row">
 429             <div class="col-xs-12">
 430                 <div class="page-header">
 431                     <h2><?php echo xlt('Edit Current Patient');?></h2>
 432                 </div>
 433             </div>
 434             <div class="col-xs-12">
 435                 <div class="btn-group">
 436                     <button type="submit" class="btn btn-default btn-save" id="submit_btn" disabled="disabled" value="<?php echo xla('Save'); ?>">
 437                         <?php echo xlt('Save'); ?>
 438                     </button>
 439                     <a class="btn btn-link btn-cancel" href="demographics.php" onclick="top.restoreSession()">
 440                         <?php echo xlt('Cancel'); ?>
 441                     </a>
 442                 </div>
 443                 <hr>
 444             </div>
 445         </div>
 446     </div>
 447 <?php
 448
 449 function end_cell()
 450 {
 451     global $item_count, $cell_count;
 452     if ($item_count > 0) {
 453         echo "</td>";
 454         $item_count = 0;
 455     }
 456 }
 457
 458 function end_row()
 459 {
 460     global $cell_count, $CPR;
 461     end_cell();
 462     if ($cell_count > 0) {
 463         for (; $cell_count < $CPR;
 464         ++$cell_count) {
 465             echo "<td></td>";
 466         }
 467
 468         echo "</tr>\n";
 469         $cell_count = 0;
 470     }
 471 }
 472
 473 function end_group()
 474 {
 475     global $last_group;
 476     if (strlen($last_group) > 0) {
 477         end_row();
 478         echo " </table>\n";
 479         echo "</div>\n";
 480     }
 481 }
 482
 483 $last_group = '';
 484 $cell_count = 0;
 485 $item_count = 0;
 486 $display_style = 'block';
 487
 488 $group_seq=0; // this gives the DIV blocks unique IDs
 489
 490 $condition_str = '';
 491 ?>
 492 <br>
 493   <div class="section-header">
 494    <span class="text"><b> <?php echo xlt("Demographics")?></b></span>
 495 </div>
 496
 497 <div id="DEM" >
 498
 499     <ul class="tabNav">
 500         <?php display_layout_tabs('DEM', $result, $result2); ?>
 501     </ul>
 502
 503     <div class="tabContainer">
 504         <?php display_layout_tabs_data_editable('DEM', $result, $result2); ?>
 505     </div>
 506 </div>
 507 <br>
 508
 509 <div id="DEM" >
 510
 511
 512 <?php
 513 if (! $GLOBALS['simplified_demographics']) {
 514     $insurance_headings = array(xl("Primary Insurance Provider"), xl("Secondary Insurance Provider"), xl("Tertiary Insurance provider"));
 515     $insurance_info = array();
 516     $insurance_info[1] = getInsuranceData($pid, "primary");
 517     $insurance_info[2] = getInsuranceData($pid, "secondary");
 518     $insurance_info[3] = getInsuranceData($pid, "tertiary");
 519
 520     ?>
 521     <div class="section-header">
 522        <span class="text"><b><?php echo xlt("Insurance")?></b></span>
 523     </div>
 524     <div id="INSURANCE" >
 525        <ul class="tabNav">
 526         <?php
 527         foreach (array('primary','secondary','tertiary') as $instype) {
 528             ?><li <?php echo $instype == 'primary' ? 'class="current"' : '' ?>><a href="#"><?php $CapInstype=ucfirst($instype);
 529 echo xlt($CapInstype); ?></a></li><?php
 530         }
 531         ?>
 532         </ul>
 533
 534     <div class="tabContainer">
 535
 536     <?php
 537     for ($i=1; $i<=3; $i++) {
 538         $result3 = $insurance_info[$i];
 539     ?>
 540
 541      <div class="tab <?php echo $i == 1 ? 'current': '' ?>" style='height:auto;width:auto'>     <!---display icky, fix to auto-->
 542
 543       <div class="row">
 544         <div class="col-md-6">
 545          <table border="0">
 546
 547            <tr>
 548             <td valign='top'>
 549             <label class='required'><?php echo text($insurance_headings[$i -1])."&nbsp;"?></label>
 550             </td>
 551             <td class='required'>:</td>
 552             <td>
 553              <a href="../../practice/ins_search.php" class="medium_modal css_button" onclick="ins_search(<?php echo $i?>)">
 554              <span><?php echo xlt('Search/Add') ?></span>
 555                   </a>
 556              <select name="i<?php echo $i?>provider" class="form-control sel2" style="width: 300;">
 557              <option value=""><?php echo xlt('Unassigned'); ?></option>
 558                 <?php
 559                 foreach ($insurancei as $iid => $iname) {
 560                     echo "<option value='" . attr($iid) . "'";
 561                     if (strtolower($iid) == strtolower($result3{"provider"})) {
 562                         echo " selected";
 563                     }
 564
 565                     echo ">" . text($iname) . "</option>\n";
 566                 }
 567                 ?>
 568                </select>
 569
 570               </td>
 571              </tr>
 572
 573             <tr>
 574              <td>
 575               <label class='required'><?php echo xlt('Plan Name'); ?> </label>
 576              </td>
 577              <td class='required'>:</td>
 578              <td>
 579               <input type='entry' class='form-control' size='20' name='i<?php echo $i?>plan_name' value="<?php echo attr($result3{"plan_name"}); ?>"
 580                onchange="capitalizeMe(this);" />&nbsp;&nbsp;
 581              </td>
 582             </tr>
 583
 584             <tr>
 585              <td>
 586               <label class='required'><?php echo xlt('Effective Date'); ?></label>
 587              </td>
 588              <td class='required'>:</td>
 589              <td>
 590               <input type='entry' size='16' class='datepicker form-control' id='i<?php echo $i ?>effective_date' name='i<?php echo $i ?>effective_date'
 591                value='<?php echo attr(oeFormatShortDate($result3['date'])); ?>'
 592                 />
 593              </td>
 594             </tr>
 595
 596             <tr>
 597              <td><label class=required><?php echo xlt('Policy Number'); ?></label></td>
 598              <td class='required'>:</td>
 599              <td><input type='entry' class='form-control' size='16' name='i<?php echo $i?>policy_number' value="<?php echo attr($result3{"policy_number"}); ?>"
 600               onkeyup='policykeyup(this)'></td>
 601             </tr>
 602
 603             <tr>
 604              <td><label class=required><?php echo xlt('Group Number'); ?></label></td>
 605              <td class='required'>:</td>
 606              <td><input type=entry class='form-control' size=16 name=i<?php echo $i?>group_number value="<?php echo attr($result3{"group_number"}); ?>" onkeyup='policykeyup(this)'></td>
 607             </tr>
 608
 609             <tr<?php if ($GLOBALS['omit_employers']) {
 610                 echo " style='display:none'";
 611 } ?>>
 612              <td class='required'><?php echo xlt('Subscriber Employer (SE)'); ?><br><label style='font-weight:normal'>
 613               (<?php echo xlt('if unemployed enter Student'); ?>,<br><?php echo xlt('PT Student, or leave blank'); ?>) </label></td>
 614               <td class='required'>:</td>
 615              <td><input type=entry class='form-control' size=25 name=i<?php echo $i?>subscriber_employer
 616               value="<?php echo attr($result3{"subscriber_employer"}); ?>"
 617                onchange="capitalizeMe(this);" /></td>
 618             </tr>
 619
 620             <tr<?php if ($GLOBALS['omit_employers']) {
 621                 echo " style='display:none'";
 622 } ?>>
 623              <td><label class=required><?php echo xlt('SE Address'); ?></label></td>
 624              <td class='required'>:</td>
 625              <td><input type=entry class='form-control' size=25 name=i<?php echo $i?>subscriber_employer_street
 626               value="<?php echo attr($result3{"subscriber_employer_street"}); ?>"
 627                onchange="capitalizeMe(this);" /></td>
 628             </tr>
 629
 630             <tr<?php if ($GLOBALS['omit_employers']) {
 631                 echo " style='display:none'";
 632 } ?>>
 633              <td colspan="3">
 634               <table>
 635                <tr>
 636                 <td><label class=required><?php echo xlt('SE City'); ?>: </label></td>
 637                 <td><input type=entry class='form-control' size=15 name=i<?php echo $i?>subscriber_employer_city
 638                value="<?php echo attr($result3{"subscriber_employer_city"}); ?>"
 639                 onchange="capitalizeMe(this);" /></td>
 640                 <td><label class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('SE State') : xlt('SE Locality') ?>: </label></td>
 641             <td>
 642                 <?php
 643                  // Modified 7/2009 by BM to incorporate data types
 644                 generate_form_field(array('data_type'=>$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'), $result3['subscriber_employer_state']);
 645                 ?>
 646                 </td>
 647                </tr>
 648                <tr>
 649                 <td><label class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('SE Zip Code') : xlt('SE Postal Code') ?>: </label></td>
 650                 <td><input type=entry class='form-control' size=15 name=i<?php echo $i?>subscriber_employer_postal_code value="<?php echo text($result3{"subscriber_employer_postal_code"}); ?>"></td>
 651                 <td><label class=required><?php echo xlt('SE Country'); ?>: </label></td>
 652             <td>
 653                     <?php
 654                   // Modified 7/2009 by BM to incorporate data types
 655                     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'), $result3['subscriber_employer_country']);
 656                     ?>
 657             </td>
 658                </tr>
 659               </table>
 660              </td>
 661             </tr>
 662
 663            </table>
 664           </div>
 665
 666           <div class="col-md-6">
 667         <table border="0">
 668             <tr>
 669                 <td><label class=required><?php echo xlt('Relationship'); ?></label></td>
 670                 <td class=required>:</td>
 671                 <td colspan=3><?php
 672                  // Modified 6/2009 by BM to use list_options and function
 673                  generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_relationship'),'list_id'=>'sub_relation','empty_title'=>' '), $result3['subscriber_relationship']);
 674                     ?>
 675
 676                 <a href="javascript:popUp('browse.php?browsenum=<?php echo $i?>')" class=text>(<?php echo xlt('Browse'); ?>)</a></td>
 677                 <td></td><td></td><td></td><td></td>
 678             </tr>
 679                       <tr>
 680                 <td width=120><label class=required><?php echo xlt('Subscriber'); ?> </label></td>
 681                 <td class=required>:</td>
 682                 <td colspan=3><input type=entry class='form-control'size=10 name=i<?php echo $i?>subscriber_fname   value="<?php echo attr($result3{"subscriber_fname"}); ?>" onchange="capitalizeMe(this);" />
 683                 <input type=entry class='form-control' size=3 name=i<?php echo $i?>subscriber_mname value="<?php echo attr($result3{"subscriber_mname"}); ?>" onchange="capitalizeMe(this);" />
 684                 <input type=entry class='form-control' size=10 name=i<?php echo $i?>subscriber_lname value="<?php echo attr($result3{"subscriber_lname"}); ?>" onchange="capitalizeMe(this);" /></td>
 685                 <td></td><td></td><td></td><td></td>
 686             </tr>
 687             <tr>
 688                 <td><label class=bold><?php echo xlt('D.O.B.'); ?> </label></td>
 689                 <td class=required>:</td>
 690                 <td><input type='entry' size='11' class='datepicker form-control' id='i<?php echo $i?>subscriber_DOB' name='i<?php echo $i?>subscriber_DOB' value='<?php echo attr(oeFormatShortDate($result3['subscriber_DOB'])); ?>' />
 691         </td>
 692                 <td><label class=bold><?php echo xlt('Sex'); ?>: </label></td>
 693                 <td><?php
 694                  // Modified 6/2009 by BM to use list_options and function
 695                  generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_sex'),'list_id'=>'sex'), $result3['subscriber_sex']);
 696                     ?>
 697                 </td>
 698                 <td></td><td></td> <td></td><td></td>
 699             </tr>
 700             <tr>
 701                 <td class=leftborder><label class=bold><?php echo xlt('S.S.'); ?> </label></td>
 702                 <td class=required>:</td>
 703                 <td><input type=entry class='form-control' size=11 name=i<?php echo $i?>subscriber_ss value="<?php echo attr(trim($result3{"subscriber_ss"})); ?>"></td>
 704             </tr>
 705
 706             <tr>
 707                 <td><label class=required><?php echo xlt('Subscriber Address'); ?> </label></td>
 708                 <td class=required>:</td>
 709                 <td><input type=entry class='form-control' size=20 name=i<?php echo $i?>subscriber_street value="<?php echo attr($result3{"subscriber_street"}); ?>" onchange="capitalizeMe(this);" /></td>
 710
 711                 <td><label class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('State') : xlt('Locality') ?>: </label></td>
 712                 <td>
 713                     <?php
 714                     // Modified 7/2009 by BM to incorporate data types
 715                     generate_form_field(array('data_type'=>$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']);
 716                 ?>
 717                 </td>
 718             </tr>
 719             <tr>
 720                 <td class=leftborder><label class=required><?php echo xlt('City'); ?></label></td>
 721                 <td class=required>:</td>
 722                 <td><input type=entry class='form-control' size=11 name=i<?php echo $i?>subscriber_city value="<?php echo attr($result3{"subscriber_city"}); ?>" onchange="capitalizeMe(this);" /></td><td class=leftborder><label class='required'<?php if ($GLOBALS['omit_employers']) {
 723                     echo " style='display:none'";
 724 } ?>><?php echo xlt('Country'); ?>: </label></td><td>
 725                     <?php
 726                     // Modified 7/2009 by BM to incorporate data types
 727                     generate_form_field(array('data_type'=>$GLOBALS['country_data_type'],'field_id'=>('i'.$i.'subscriber_country'),'list_id'=>$GLOBALS['country_list'],'fld_length'=>'10','max_length'=>'63','edit_options'=>'C'), $result3['subscriber_country']);
 728                     ?>
 729                 </td>
 730 </tr>
 731             <tr>
 732                 <td><label class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('Zip Code') : xlt('Postal Code') ?> </label></td>
 733                 <td class=required>:</td><td><input type=entry class='form-control' size=10 name=i<?php echo $i?>subscriber_postal_code value="<?php echo attr($result3{"subscriber_postal_code"}); ?>"></td>
 734
 735                 <td colspan=2>
 736                 </td><td></td>
 737             </tr>
 738             <tr>
 739                 <td><label class=bold><?php echo xlt('Subscriber Phone'); ?></label></td>
 740                 <td class=required>:</td>
 741                 <td><input type='text' class='form-control' size='20' name='i<?php echo $i?>subscriber_phone' value='<?php echo attr($result3["subscriber_phone"]); ?>' onkeyup='phonekeyup(this,mypcc)' /></td>
 742                 <td colspan=2><label class=bold><?php echo xlt('CoPay'); ?>: <input type=text class='form-control' size="6" name=i<?php echo $i?>copay value="<?php echo attr($result3{"copay"}); ?>"></label></td>
 743                 <td colspan=2>
 744                 </td><td></td><td></td>
 745             </tr>
 746             <tr>
 747                 <td colspan=0><label class='required'><?php echo xlt('Accept Assignment'); ?></label></td>
 748                 <td class=required>:</td>
 749                 <td colspan=2>
 750                     <select class='form-control' name=i<?php echo $i?>accept_assignment>
 751                      <option value="TRUE" <?php if (strtoupper($result3{"accept_assignment"}) == "TRUE") {
 752                             echo "selected";
 753 }?>><?php echo xlt('YES'); ?></option>
 754                      <option value="FALSE" <?php if (strtoupper($result3{"accept_assignment"}) == "FALSE") {
 755                             echo "selected";
 756 }?>><?php echo xlt('NO'); ?></option>
 757                     </select>
 758                 </td>
 759                 <td></td><td></td>
 760                 <td colspan=2>
 761                 </td><td></td>
 762             </tr>
 763       <tr>
 764         <td><label class='bold'><?php echo xlt('Secondary Medicare Type'); ?></label></td>
 765         <td class='bold'>:</td>
 766         <td colspan='6'>
 767           <select class='form-control sel2' name=i<?php echo $i?>policy_type>
 768 <?php
 769 foreach ($policy_types as $key => $value) {
 770     echo "            <option value ='" . attr($key) . "'";
 771     if ($key == $result3['policy_type']) {
 772         echo " selected";
 773     }
 774
 775     echo ">" . text($value) . "</option>\n";
 776 }
 777 ?>
 778         </select>
 779       </td>
 780     </tr>
 781       </table>
 782
 783         </div>
 784       </div>
 785
 786       </div>
 787
 788     <?php
 789     } //end insurer for loop ?>
 790
 791    </div>
 792 </div>
 793
 794 <?php } // end of "if not simplified_demographics" ?>
 795 </div></div>
 796
 797 </form>
 798
 799 <br>
 800
 801 <script language="JavaScript">
 802
 803 // Array of skip conditions for the checkSkipConditions() function.
 804 var skipArray = [
 805 <?php echo $condition_str; ?>
 806 ];
 807
 808 // hard code validation for old validation, in the new validation possible to add match rules
 809 <?php if ($GLOBALS['new_validate'] == 0) { ?>
 810  // fix inconsistently formatted phone numbers from the database
 811  var f = document.forms[0];
 812  if (f.form_phone_contact) phonekeyup(f.form_phone_contact,mypcc);
 813  if (f.form_phone_home   ) phonekeyup(f.form_phone_home   ,mypcc);
 814  if (f.form_phone_biz    ) phonekeyup(f.form_phone_biz    ,mypcc);
 815  if (f.form_phone_cell   ) phonekeyup(f.form_phone_cell   ,mypcc);
 816
 817 <?php if (! $GLOBALS['simplified_demographics']) { ?>
 818  phonekeyup(f.i1subscriber_phone,mypcc);
 819  phonekeyup(f.i2subscriber_phone,mypcc);
 820  phonekeyup(f.i3subscriber_phone,mypcc);
 821 <?php } ?>
 822
 823 <?php }?>
 824
 825 <?php if ($set_pid) { ?>
 826  parent.left_nav.setPatient(<?php echo "'" . addslashes($result['fname']) . " " . addslashes($result['lname']) . "'," . addslashes($pid) . ",'" . addslashes($result['pubpid']) . "','', ' " . xls('DOB') . ": " . addslashes(oeFormatShortDate($result['DOB_YMD'])) . " " . xls('Age') . ": " . addslashes(getPatientAgeDisplay($result['DOB_YMD'])) . "'"; ?>);
 827 <?php } ?>
 828
 829 <?php echo $date_init; ?>
 830 </script>
 831
 832 <!-- include support for the list-add selectbox feature -->
 833 <?php include $GLOBALS['fileroot']."/library/options_listadd.inc"; ?>
 834
 835 <?php /*Include the validation script and rules for this form*/
 836 $form_id="DEM";
 837 //LBF forms use the new validation depending on the global value
 838 $use_validate_js=$GLOBALS['new_validate'];
 839
 840 ?>
 841 <?php  include_once("$srcdir/validation/validation_script.js.php");?>
 842
 843
 844 </body>
 845 <script language='JavaScript'>
 846     var duplicateFieldsArray=[];
 847
 848 //This code deals with demographics before save action -
 849     <?php if (($GLOBALS['gbl_edit_patient_form'] == '1') && (checkIfPatientValidationHookIsActive())) :?>
 850
 851                 //Use the Zend patient validation hook.
 852                 //TODO - get the edit part of patient validation hook to work smoothly and then
 853                 //       remove the closeBeforeOpening=1 in the url below.
 854
 855         var f = $("form");
 856
 857         // Use hook to open the controller and get the new patient validation .
 858         // when no params are sent this window will be closed from the zend controller.
 859         var url ='<?php echo  $GLOBALS['web_root']."/interface/modules/zend_modules/public/patientvalidation";?>';
 860         $("#submit_btn").attr("name","btnSubmit");
 861         $("#submit_btn").attr("id","btnSubmit");
 862         $("#btnSubmit").click(function( event ) {
 863
 864       top.restoreSession();
 865
 866             if(!submitme(<?php echo $GLOBALS['new_validate'] ? 1 : 0;?>,event,'DEM',constraints)){
 867                 event.preventDefault();
 868                 return;
 869             }
 870             somethingChanged = false;
 871             <?php
 872             // D in edit_options indicates the field is used in duplication checking.
 873             // This constructs a list of the names of those fields.
 874             $mflist = "";
 875             $mfres = sqlStatement("SELECT field_id FROM layout_options " .
 876                 "WHERE form_id = 'DEM' AND uor > 0 AND field_id != '' AND " .
 877                 "(edit_options LIKE '%D%' OR edit_options LIKE '%E%')  " .
 878                 "ORDER BY group_id, seq");
 879             while ($mfrow = sqlFetchArray($mfres)) {
 880                 $field_id  = $mfrow['field_id'];
 881                 if (strpos($field_id, 'em_') === 0) {
 882                     continue;
 883                 }
 884
 885                 if (!empty($mflist)) {
 886                     $mflist .= ",";
 887                 }
 888
 889                     $mflist .= "'" . text($field_id) . "'";
 890             } ?>
 891
 892             var flds = new Array(<?php echo $mflist; ?>);
 893             var separator = '?';
 894             var valueIsChanged=false;
 895             for (var i = 0; i < flds.length; ++i) {
 896                 var fval = $('#form_' + flds[i]).val();
 897                 if(duplicateFieldsArray['#form_' + flds[i]]!=fval) {
 898                     valueIsChanged = true;
 899
 900                 }
 901
 902                 if (fval && fval != '') {
 903                     url += separator;
 904                     separator = '&';
 905                     url += 'mf_' + flds[i] + '=' + encodeURIComponent(fval);
 906                 }
 907             }
 908
 909
 910             //Only if check for duplicates values are changed open the popup hook screen
 911             if(valueIsChanged) {
 912                 event.preventDefault();
 913                 //("value has changed for duplicate check inputs");
 914             url += '&page=edit&closeBeforeOpening=1&mf_id='+$("[name='db_id']").val();
 915             dlgopen(url, '_blank', 700, 500);
 916             }
 917             else {//other wise submit me is a success just submit the form
 918                 $('#DEM').submit();
 919             }
 920         });
 921
 922     <?php endif;?>
 923
 924     $(document).ready(function(){
 925         //When document is ready collect all the values Marked with D (check duplicate) stored in the db into array duplicateFieldsArray.
 926         var flds = new Array(<?php echo $mflist; ?>);
 927         for (var i = 0; i < flds.length; ++i) {
 928             var fval = $('#form_' + flds[i]).val();
 929             duplicateFieldsArray['#form_' + flds[i]] = fval;
 930         }
 931         $(".sel2").select2({
 932             <?php require($GLOBALS['srcdir'] . '/js/xl/select2.js.php'); ?>
 933         });
 934     })
 935 </script>
 936
 937
 938 </html>