interface/patient_file/summary/demographics_full.php

   1 <?php
   2  include_once("../../globals.php");
   3  include_once("$srcdir/acl.inc");
   4
   5  // Session pid must be right or bad things can happen when demographics are saved!
   6  //
   7  include_once("$srcdir/pid.inc");
   8  $set_pid = $_GET["set_pid"] ? $_GET["set_pid"] : $_GET["pid"];
   9  if ($set_pid && $set_pid != $_SESSION["pid"]) {
  10   setpid($set_pid);
  11  }
  12
  13  include_once("$srcdir/patient.inc");
  14
  15  $result = getPatientData($pid);
  16  $result2 = getEmployerData($pid);
  17
  18  // Check authorization.
  19  $thisauth = acl_check('patients', 'demo');
  20  if ($pid) {
  21   if ($thisauth != 'write')
  22    die("Updating demographics is not authorized.");
  23   if ($result['squad'] && ! acl_check('squads', $result['squad']))
  24    die("You are not authorized to access this squad.");
  25  } else {
  26   if ($thisauth != 'write' && $thisauth != 'addonly')
  27    die("Adding demographics is not authorized.");
  28  }
  29
  30 $relats = array('','self','spouse','child','other');
  31 $statii = array('married','single','divorced','widowed','separated','domestic partner');
  32
  33 $langi = getLanguages();
  34 $ethnoraciali = getEthnoRacials();
  35 $provideri = getProviderInfo();
  36 $insurancei = getInsuranceProviders();
  37 ?>
  38 <html>
  39 <head>
  40
  41 <link rel=stylesheet href="<?php echo $css_header; ?>" type="text/css">
  42
  43 <script type="text/javascript" src="../../../library/dialog.js"></script>
  44 <script type="text/javascript" src="../../../library/textformat.js"></script>
  45
  46 <SCRIPT LANGUAGE="JavaScript"><!--
  47
  48 var mypcc = '<?php echo $GLOBALS['phone_country_code'] ?>';
  49
  50 //code used from http://tech.irt.org/articles/js037/
  51 function replace(string,text,by) {
  52  // Replaces text with by in string
  53  var strLength = string.length, txtLength = text.length;
  54  if ((strLength == 0) || (txtLength == 0)) return string;
  55
  56  var i = string.indexOf(text);
  57  if ((!i) && (text != string.substring(0,txtLength))) return string;
  58  if (i == -1) return string;
  59
  60  var newstr = string.substring(0,i) + by;
  61
  62  if (i+txtLength < strLength)
  63   newstr += replace(string.substring(i+txtLength,strLength),text,by);
  64
  65  return newstr;
  66 }
  67
  68 function upperFirst(string,text) {
  69  return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
  70 }
  71
  72 <?php for ($i=1;$i<=3;$i++) { ?>
  73 function auto_populate_employer_address<?php echo $i ?>(){
  74  if (document.demographics_form.i<?php echo $i?>subscriber_relationship.options[document.demographics_form.i<?php echo $i?>subscriber_relationship.selectedIndex].value == "self") {
  75   document.demographics_form.i<?php echo $i?>subscriber_fname.value=document.demographics_form.fname.value;
  76   document.demographics_form.i<?php echo $i?>subscriber_mname.value=document.demographics_form.mname.value;
  77   document.demographics_form.i<?php echo $i?>subscriber_lname.value=document.demographics_form.lname.value;
  78   document.demographics_form.i<?php echo $i?>subscriber_street.value=document.demographics_form.street.value;
  79   document.demographics_form.i<?php echo $i?>subscriber_city.value=document.demographics_form.city.value;
  80   document.demographics_form.i<?php echo $i?>subscriber_state.value=document.demographics_form.state.value;
  81   document.demographics_form.i<?php echo $i?>subscriber_postal_code.value=document.demographics_form.postal_code.value;
  82   document.demographics_form.i<?php echo $i?>subscriber_country.value=document.demographics_form.country_code.value;
  83   document.demographics_form.i<?php echo $i?>subscriber_phone.value=document.demographics_form.phone_home.value;
  84   document.demographics_form.i<?php echo $i?>subscriber_DOB.value=document.demographics_form.dob.value;
  85   document.demographics_form.i<?php echo $i?>subscriber_ss.value=document.demographics_form.ss.value;
  86   document.demographics_form.i<?php echo $i?>subscriber_sex.selectedIndex = document.demographics_form.sex.selectedIndex;
  87   document.demographics_form.i<?php echo $i?>subscriber_employer.value=document.demographics_form.ename.value;
  88   document.demographics_form.i<?php echo $i?>subscriber_employer_street.value=document.demographics_form.estreet.value;
  89   document.demographics_form.i<?php echo $i?>subscriber_employer_city.value=document.demographics_form.ecity.value;
  90   document.demographics_form.i<?php echo $i?>subscriber_employer_state.value=document.demographics_form.estate.value;
  91   document.demographics_form.i<?php echo $i?>subscriber_employer_postal_code.value=document.demographics_form.epostal_code.value;
  92   document.demographics_form.i<?php echo $i?>subscriber_employer_country.value=document.demographics_form.ecountry.value;
  93  }
  94 }
  95
  96 <?php } ?>
  97
  98 function popUp(URL) {
  99  day = new Date();
 100  id = day.getTime();
 101  eval("page" + id + " = window.open(URL, '" + id + "', 'toolbar=0,scrollbars=1,location=0,statusbar=0,menubar=0,resizable=1,width=400,height=300,left = 440,top = 362');");
 102 }
 103
 104 function checkNum () {
 105  var re= new RegExp();
 106  re = /^\d*\.?\d*$/;
 107  str=document.demographics_form.monthly_income.value;
 108  if(re.exec(str))
 109  {
 110  }else{
 111   alert("Please enter a dollar amount using only numbers and a decimal point.");
 112  }
 113 }
 114
 115 // Indicates which insurance slot is being updated.
 116 var insurance_index = 0;
 117
 118 // The OnClick handler for searching/adding the insurance company.
 119 function ins_search(ins) {
 120  insurance_index = ins;
 121  dlgopen('../../practice/ins_search.php', '_blank', 550, 400);
 122  return false;
 123 }
 124
 125 // The ins_search.php window calls this to set the selected insurance.
 126 function set_insurance(ins_id, ins_name) {
 127  var thesel = document.forms[0]['i' + insurance_index + 'provider'];
 128  var theopts = thesel.options; // the array of Option objects
 129  var i = 0;
 130  for (; i < theopts.length; ++i) {
 131   if (theopts[i].value == ins_id) {
 132    theopts[i].selected = true;
 133    return;
 134   }
 135  }
 136  // no matching option was found so create one, append it to the
 137  // end of the list, and select it.
 138  theopts[i] = new Option(ins_name, ins_id, false, true);
 139 }
 140
 141 // This capitalizes the first letter of each word in the passed input
 142 // element.  It also strips out extraneous spaces.
 143 function capitalizeMe(elem) {
 144  var a = elem.value.split(' ');
 145  var s = '';
 146  for(var i = 0; i < a.length; ++i) {
 147   if (a[i].length > 0) {
 148    if (s.length > 0) s += ' ';
 149    s += a[i].charAt(0).toUpperCase() + a[i].substring(1);
 150   }
 151  }
 152  elem.value = s;
 153 }
 154
 155 //-->
 156
 157 </script>
 158 </head>
 159
 160 <body <?php echo $top_bg_line; ?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
 161
 162 <form action='demographics_save.php' name='demographics_form' method='post'>
 163 <input type=hidden name=mode value=save>
 164
 165 <?php if ($GLOBALS['concurrent_layout']) { ?>
 166 <a href="demographics.php">
 167 <?php } else { ?>
 168 <a href="patient_summary.php" target=Main>
 169 <?php } ?>
 170 <font class=title><?php xl('Demographics','e'); ?></font>
 171 <font class=back><?php echo $tback;?></font></a>
 172
 173 <table border="0" cellpadding="0" width='100%'>
 174
 175  <tr>
 176   <td valign="top"><span class=required><?php xl('Name','e'); ?>: </span></td>
 177   <td colspan="4" nowrap>
 178    <select name=title tabindex="1"<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 179     <option value="<?php echo $result{"title"} ?>"><?php echo $result{"title"} ?></option>
 180     <option value="Mrs."><?php xl('Mrs','e'); ?>.</option>
 181     <option value="Ms."><?php xl('Ms','e'); ?>.</option>
 182     <option value="Mr."><?php xl('Mr','e'); ?>.</option>
 183     <option value="Dr."><?php xl('Dr','e'); ?>.</option>
 184    </select>
 185    <input tabindex="2" type=entry size=15 name=fname
 186     value="<?php echo $result{"fname"} ?>"
 187     onchange="capitalizeMe(this);" />
 188    <input tabindex="3" type=entry size=3 name=mname
 189     value="<?php echo $result{"mname"} ?>"
 190     onchange="capitalizeMe(this);" />
 191    <input tabindex="4" type=entry size=15 name=lname
 192     value="<?php echo $result{"lname"} ?>"
 193     onchange="capitalizeMe(this);" />
 194    &nbsp;
 195    <span class='bold'><?php echo ($GLOBALS['athletic_team']) ? 'OID ' : '' ?><?php xl('Number','e'); ?>: </span>
 196   </td>
 197   <td><input type='entry' size='10' name='pubpid' value="<?php echo $result{"pubpid"} ?>"></td>
 198  </tr>
 199
 200  <tr>
 201   <td valign='top'><span class='required'><?php xl('DOB','e'); ?>: </span></td>
 202   <td>
 203    <input tabindex='5' type='entry' size='11' name='dob'
 204     value='<?php if (substr($result['DOB'], 0, 4) != '0000') echo $result['DOB']; ?>'
 205     onkeyup='datekeyup(this,mypcc)'
 206     onblur='dateblur(this,mypcc)' title='yyyy-mm-dd' />
 207   </td>
 208   <td rowspan="12">&nbsp;</td>
 209   <td><span class='bold'><?php xl('Emergency Contact','e'); ?>: </span></td>
 210   <td rowspan="12">&nbsp;</td>
 211   <td><input type='entry' size='10' name='contact_relationship'
 212    value="<?php echo $result{"contact_relationship"}?>"
 213    onchange="capitalizeMe(this);" /></td>
 214  </tr>
 215
 216  <tr>
 217   <td><span class=required><?php xl('Sex','e'); ?>: </span></td>
 218   <td>
 219    <select name=sex tabindex="6">
 220     <option value="Female" <?php if ($result{"sex"} == "Female") {echo "selected";};?>><?php xl('Female','e'); ?></option>
 221     <option value="Male" <?php if ($result{"sex"} == "Male") {echo "selected";};?>><?php xl('Male','e'); ?></option>
 222    </select>
 223   </td>
 224   <td><span class=bold><?php xl('Emergency Phone','e'); ?>:</span></td>
 225   <td><input type='text' size='20' name='phone_contact' value='<?php echo $result['phone_contact'] ?>' onkeyup='phonekeyup(this,mypcc)' /></td>
 226  </tr>
 227
 228  <tr>
 229   <td><span class=bold><?php xl('S.S.','e'); ?>: </span></td>
 230   <td><input tabindex="7" type=entry size=11 name=ss value="<?php echo $result{"ss"}?>"></td>
 231   <td><span class='bold'><?php xl('Home Phone','e'); ?>: </span></td>
 232   <td><input type='text' size='20' name='phone_home' value='<?php echo $result['phone_home'] ?>' onkeyup='phonekeyup(this,mypcc)' /></td>
 233  </tr>
 234
 235  <tr>
 236   <td><span class=required><?php xl('Address','e'); ?>: </span></td>
 237   <td><input tabindex="8" type=entry size=25 name=street value="<?php echo $result{"street"}?>"
 238    onchange="capitalizeMe(this);" /></td>
 239   <td><span class=bold><?php xl('Work Phone','e'); ?>:</span></td>
 240   <td><input type='text' size='20' name='phone_biz' value='<?php echo $result['phone_biz'] ?>' onkeyup='phonekeyup(this,mypcc)' /></td>
 241  </tr>
 242
 243  <tr>
 244   <td><span class=required><?php xl('City','e'); ?>: </span></td>
 245   <td><input tabindex="9" type=entry size=15 name=city value="<?php echo $result{"city"}?>"
 246    onchange="capitalizeMe(this);" /></td>
 247   <td><span class=bold><?php xl('Mobile Phone','e'); ?>: </span></td>
 248   <td><input type='text' size='20' name='phone_cell' value='<?php echo $result['phone_cell'] ?>' onkeyup='phonekeyup(this,mypcc)' /></td>
 249  </tr>
 250
 251  <tr>
 252   <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? 'State' : 'Locality' ?>: </span></td>
 253   <td><input tabindex="10" type=entry size=15 name=state value="<?php echo $result{"state"}?>"></td>
 254   <td><span class='bold'><?php xl('License/ID','e'); ?>: </span></td>
 255   <td><input tabindex="12" type='entry' size='15' name='drivers_license' value="<?php echo $result{"drivers_license"}?>"></td>
 256  </tr>
 257
 258  <tr>
 259   <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? 'Zip' : 'Postal' ?> <?php xl('Code','e'); ?>: </span></td>
 260   <td><input tabindex="11" type=entry size=6 name=postal_code value="<?php echo $result{"postal_code"}?>"></td>
 261   <td><span class='bold'><?php xl('Contact Email','e'); ?>: </span></td><td><input type=entry size=30 name=email value="<?php echo $result{"email"}?>"></td>
 262  </tr>
 263
 264  <tr>
 265   <td><span class='required'<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 266       <?php xl('Country','e'); ?>: </span></td>
 267   <td><input tabindex="13" type='entry' size='10' name='country_code'
 268        value="<?php echo $result{"country_code"}?>"
 269        <?php if ($GLOBALS['omit_employers']) echo "style='display:none'"; ?>></td>
 270 <?php if (!$GLOBALS['weight_loss_clinic']) { ?>
 271   <td><span class='bold' colspan='2'>
 272    <?php echo $GLOBALS['omit_employers'] ? xl('List Immediate Family Members') : xl('User Defined Fields'); ?>:
 273   </span></td>
 274 <?php } ?>
 275  </tr>
 276
 277  <tr>
 278   <td><span class=required><?php xl('Marital Status','e'); ?>: </span></td>
 279   <td>
 280    <select name=status tabindex="14">
 281 <?php
 282  print "<!-- ".$result["status"]." -->\n";
 283  foreach ($statii as $s) {
 284   if ($s == "unassigned") {
 285    echo "<option value=''";
 286   } else {
 287    echo "<option value='".$s."'";
 288   }
 289
 290   if ($s == $result["status"])
 291    echo " selected";
 292
 293   echo ">".ucwords($s)."</option>\n";
 294  }
 295 ?>
 296    </select>
 297   </td>
 298
 299 <?php if ($GLOBALS['weight_loss_clinic']) { ?>
 300   <td class='bold'>Starting Weight</td>
 301   <td class='bold'>
 302    <input name="genericname1" size='4' value="<?php echo $result{"genericname1"} ?>" />
 303    &nbsp;Date:
 304    <input name="genericval1" size='10' value="<?php echo $result{"genericval1"} ?>" />
 305   </td>
 306 <?php } else { ?>
 307   <td><input name="genericname1" size='20' value="<?php echo $result{"genericname1"} ?>"
 308    onchange="capitalizeMe(this);" /></td>
 309   <td><input name="genericval1" size='20' value="<?php echo $result{"genericval1"} ?>"
 310    onchange="capitalizeMe(this);" /></td>
 311 <?php } ?>
 312
 313  </tr>
 314
 315  <tr>
 316   <td><span class=required><?php xl('Provider','e'); ?>: </span></td>
 317   <td>
 318    <select tabindex="15" name="providerID" onchange="javascript:document.demographics_form.referrer.value=upperFirst(this.options[this.selectedIndex].text,this.options[this.selectedIndex].text);">
 319     <option value=''><?php xl('Unassigned','e'); ?></option>
 320 <?php
 321  foreach ($provideri as $s) {
 322   //echo "defined provider is: " .trim($s['fname']." ".$s['lname']). " compared to : " .$result["referrer"] . "<br />";
 323
 324   echo "<option value='".$s['id']."'";
 325
 326   if ($s['id'] == $result["providerID"])
 327    echo " selected";
 328    echo ">".ucwords($s['fname']." ".$s['lname'])."</option>\n";
 329  }
 330 ?>
 331    </select>
 332   </td>
 333
 334 <?php if ($GLOBALS['weight_loss_clinic']) { ?>
 335   <td class='bold'>Ending Weight</td>
 336   <td class='bold'>
 337    <input name="genericname2" size='4' value="<?php echo $result{"genericname2"} ?>" />
 338    &nbsp;Date:
 339    <input name="genericval2" size='10' value="<?php echo $result{"genericval2"} ?>" />
 340   </td>
 341 <?php } else { ?>
 342   <td><input name="genericname2" size='20' value="<?php echo $result{"genericname2"};?>"
 343    onchange="capitalizeMe(this);" /></td>
 344   <td><input name="genericval2" size='20' value="<?php echo $result{"genericval2"};?>"
 345    onchange="capitalizeMe(this);" /></td>
 346 <?php } ?>
 347
 348  </tr>
 349
 350  <tr>
 351   <td><span class=bold><?php xl('Pharmacy','e'); ?>: </span></td>
 352   <td colspan='5'>
 353    <select name='pharmacy_id'>
 354     <option value='0'></option>
 355     <?php
 356      $pres = sqlStatement("SELECT d.id, d.name, a.line1, a.city, " .
 357      "p.area_code, p.prefix, p.number FROM pharmacies AS d " .
 358      "LEFT OUTER JOIN addresses AS a ON a.foreign_id = d.id " .
 359      "LEFT OUTER JOIN phone_numbers AS p ON p.foreign_id = d.id AND p.type = 2 " .
 360      "ORDER BY name, area_code, prefix, number");
 361      while ($prow = sqlFetchArray($pres)) {
 362       $key = $prow['id'];
 363       echo "    <option value='$key'";
 364       if ($result['pharmacy_id'] == $key) echo " selected";
 365       echo '>' . $prow['name'] . ' ' . $prow['area_code'] . '-' .
 366        $prow['prefix'] . '-' . $prow['number'] . ' / ' .
 367        $prow['line1'] . ' / ' . $prow['city'] . "</option>\n";
 368      }
 369     ?>
 370    </select>
 371   </td>
 372  </tr>
 373
 374  <tr>
 375   <td colspan='6'>
 376    <a href="javascript:document.demographics_form.submit();" class='link_submit'>[<?php xl('Save Patient Demographics','e'); ?>]</a>
 377    <hr>
 378   </td>
 379  </tr>
 380 </table>
 381
 382 <?php if (! $GLOBALS['athletic_team']) { ?>
 383
 384 <table width='100%'>
 385  <tr>
 386   <th colspan='4' align='left' class='bold'><?php xl('HIPAA Choices','e'); ?>:</th>
 387  </tr>
 388  <tr>
 389   <td class='bold' width='10%' nowrap><?php xl('Did you receive a copy of the HIPAA Notice?','e'); ?> </td>
 390   <td class='bold'>
 391    <select name = "hipaa_notice">
 392 <?php
 393  echo "    <option>" .xl('NO'). "</option>\n";
 394  $opt_sel = ($result['hipaa_notice'] == 'YES' || ($GLOBALS['weight_loss_clinic'] && !$result['hipaa_notice']))
 395   ? ' selected' : '';
 396  echo "    <option$opt_sel>" .xl('YES'). "</option>\n";
 397 ?>
 398    </select>
 399   </td>
 400   <td class='bold' width='10%' nowrap><?php xl('Allow Voice Msg','e'); ?>:</td>
 401   <td class='bold'>
 402    <select name="hipaa_voice">
 403 <?php
 404  echo "    <option>" .xl('NO'). "</option>\n";
 405  $opt_sel = ($result['hipaa_voice'] == 'YES' || ($GLOBALS['weight_loss_clinic'] && !$result['hipaa_voice']))
 406   ? ' selected' : '';
 407  echo "    <option$opt_sel>" .xl('YES'). "</option>\n";
 408 ?>
 409    </select>
 410   </td>
 411  </tr>
 412  <tr>
 413   <td class='bold' width='10%' nowrap><?php xl('Allow Mail','e'); ?>:</td>
 414   <td class='bold'>
 415    <select name="hipaa_mail">
 416 <?php
 417  echo "    <option>" .xl('NO'). "</option>\n";
 418  $opt_sel = ($result['hipaa_mail'] == 'YES' || ($GLOBALS['weight_loss_clinic'] && !$result['hipaa_mail']))
 419   ? ' selected' : '';
 420  echo "    <option$opt_sel>" .xl('YES'). "</option>\n";
 421 ?>
 422    </select>
 423   </td>
 424   <td class='bold' width='10%' nowrap><?php xl('Who may we leave a message with?','e'); ?> </td>
 425   <td><input name="hipaa_message" size='20' value="<?php echo $result['hipaa_message']; ?>"
 426    onchange="capitalizeMe(this);" /></td>
 427  </tr>
 428  <tr>
 429   <td colspan='4'>
 430    <a href="javascript:document.demographics_form.submit();" class=link_submit>[<?php xl('Save Patient Demographics','e'); ?>]</a>
 431    <br><hr>
 432   </td>
 433  </tr>
 434 </table>
 435
 436 <?php } ?>
 437
 438 <table width='100%'<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 439  <tr>
 440   <td valign=top>
 441    <input type=hidden size=30 name=referrer value="<?php echo ucfirst($result{"referrer"});?>">
 442    <input type=hidden size=20 name=referrerID value="<?php echo $result{"referrerID"}?>">
 443    <input type=hidden size=20 name=db_id value="<?php echo $result{"id"}?>">
 444    <table>
 445     <tr>
 446      <td><span class=bold><?php xl('Occupation','e'); ?>: </span></td>
 447      <td><input type=entry size=20 name=occupation value="<?php echo $result{"occupation"}?>"></td>
 448     </tr>
 449     <tr>
 450      <td class='bold'><?php xl('Employer','e'); ?>:</td>
 451      <td><input type=entry size=20 name=ename value="<?php echo $result2{"name"}?>"
 452       onchange="capitalizeMe(this);" /></td>
 453     </tr>
 454     <tr>
 455      <td colspan='2' class='bold' style='font-weight:normal'>(<?php xl('if unemployed enter Student, PT Student, or leave blank','e'); ?>)</td>
 456     </tr>
 457 <?php if ($GLOBALS['athletic_team']) { ?>
 458     <tr>
 459      <td colspan='2' class='bold' style='font-weight:normal'>&nbsp;</td>
 460     </tr>
 461     <tr>
 462      <td><span class='bold'><?php xl('Squad','e'); ?>: </span></td>
 463      <td>
 464       <select name='squad'>
 465        <option value=''>&nbsp;</option>
 466 <?php
 467  $squads = acl_get_squads();
 468  if ($squads) {
 469   foreach ($squads as $key => $value) {
 470    echo "       <option value='$key'";
 471    if ($result['squad'] == $key) echo " selected";
 472    echo ">" . $value[3] . "</option>\n";
 473   }
 474  }
 475 ?>
 476       </select>
 477      </td>
 478     </tr>
 479 <?php } ?>
 480    </table>
 481   </td>
 482   <td valign=top>
 483
 484 <?php if (! $GLOBALS['simplified_demographics']) { ?>
 485
 486    <table>
 487     <tr>
 488      <td><span class=bold><?php xl('Employer Address','e'); ?></span></td>
 489      <td><span class=bold></span>
 490       <input type=entry size=25 name=estreet value="<?php echo $result2{"street"} ?>"
 491        onchange="capitalizeMe(this);" /></td>
 492     </tr>
 493     <tr>
 494      <td><span class=bold><?php xl('City','e'); ?>: </span></td>
 495      <td><input type=entry size=15 name=ecity value="<?php echo $result2{"city"}?>"
 496       onchange="capitalizeMe(this);" /></td>
 497     </tr>
 498     <tr>
 499      <td><span class=bold><?php echo ($GLOBALS['phone_country_code'] == '1') ? 'State' : 'Locality' ?>: </span></td><td><input type=entry size=15 name=estate value="<?php echo $result2{"state"}?>"></td>
 500     </tr>
 501     <tr>
 502      <td><span class=bold><?php echo ($GLOBALS['phone_country_code'] == '1') ? 'Zip' : 'Postal' ?> <?php xl('Code','e'); ?>: </span></td><td><input type=entry size=10 name=epostal_code value="<?php echo $result2{"postal_code"}?>"></td>
 503     </tr>
 504     <tr>
 505      <td><span class=bold><?php xl('Country','e'); ?>: </span></td>
 506      <td><input type=entry size=10 name=ecountry value="<?php echo $result2{"country"}?>"
 507       onchange="capitalizeMe(this);" /></td>
 508     </tr>
 509    </table>
 510
 511 <?php } ?>
 512
 513   </td>
 514   <td valign=top></td>
 515  </tr>
 516
 517  <tr>
 518   <td colspan=4>
 519    <a href="javascript:document.demographics_form.submit();" class=link_submit>[<?php xl('Save Patient Demographics','e'); ?>]</a><hr></td>
 520  </tr>
 521
 522 <?php if (! $GLOBALS['athletic_team'] && ! $GLOBALS['simplified_demographics']) { ?>
 523
 524  <tr>
 525   <td valign='top'>
 526    <span class='bold'><?php xl('Language','e'); ?>: </span><br>
 527    <select onchange="javascript:document.demographics_form.language.value=upperFirst(this.options[this.selectedIndex].value,this.options[this.selectedIndex].value);">
 528 <?php
 529  foreach ($langi as $s) {
 530   if ($s == "unassigned") {
 531    echo "<option value=''";
 532   } else {
 533    echo "<option value='".$s."'";
 534   }
 535   if ($s == strtolower($result["language"]))
 536    echo " selected";
 537   echo ">".ucwords($s)."</option>\n";
 538  }
 539 ?>
 540    </select><br>
 541    <input type=entry size=30 name=language value="<?php echo ucfirst($result{"language"});?>"><br><br />
 542    <span class=bold><?php xl('Race/Ethnicity','e'); ?>: </span><br>
 543    <select onchange="javascript:document.demographics_form.ethnoracial.value=upperFirst(this.options[this.selectedIndex].value,this.options[this.selectedIndex].value);">
 544 <?php
 545  foreach ($ethnoraciali as $s) {
 546   if ($s == "unassigned") {
 547    echo "<option value=''";
 548   } else {
 549    echo "<option value='".$s."'";
 550   }
 551   if ($s == strtolower($result["ethnoracial"]))
 552    echo " selected";
 553   echo ">".ucwords($s)."</option>\n";
 554  }
 555 ?>
 556    </select>
 557    <br>
 558    <input type=entry size=30 name=ethnoracial value="<?php echo ucfirst($result{"ethnoracial"});?>"><br>
 559   </td>
 560   <td valign=top>
 561    <table>
 562     <tr>
 563      <td><span class=bold><?php xl('Financial Review Date','e'); ?>: </span></td><td><input type=entry size=11 name=financial_review value="<?php if ($result{"financial_review"} != "0000-00-00 00:00:00") {echo date("m/d/Y",strtotime($result{"financial_review"}));} else {echo "MM/DD/YYYY";}?>"></td>
 564     </tr>
 565     <tr>
 566      <td><span class=bold><?php xl('Family Size','e'); ?>: </span></td><td><input type=entry size=20 name=family_size value="<?php echo $result{"family_size"}?>"></td>
 567     </tr>
 568     <tr>
 569      <td><span class=bold><?php xl('Monthly Income','e'); ?>: </span></td><td><input type=entry size=20 name=monthly_income onblur="javascript:checkNum();" value="<?php echo $result{"monthly_income"}?>"><span class=small>(<?php xl('Numbers only','e'); ?>)</span></td>
 570     </tr>
 571     <tr>
 572      <td><span class=bold><?php xl('Homeless, etc.','e'); ?>: </span></td><td><input type=entry size=20 name=homeless value="<?php echo $result{"homeless"}?>"></td>
 573     </tr>
 574     <tr>
 575      <td><span class=bold><?php xl('Interpreter','e'); ?>: </span></td><td><input type=entry size=20 name=interpretter value="<?php echo $result{"interpretter"}?>"></td>
 576     </tr>
 577     <tr>
 578      <td><span class=bold><?php xl('Migrant/Seasonal','e'); ?>: </span></td><td><input type=entry size=20 name=migrantseasonal value="<?php echo $result{"migrantseasonal"}?>"></td>
 579     </tr>
 580    </table>
 581   </td>
 582   <td valign=top></td>
 583  </tr>
 584
 585  <tr>
 586   <td colspan=4>
 587    <a href="javascript:document.demographics_form.submit();" class=link_submit>[<?php xl('Save Patient Demographics','e'); ?>]</a>
 588    <hr>
 589   </td>
 590  </tr>
 591
 592 <?php } ?>
 593
 594 </table>
 595
 596 <?php
 597  if (! $GLOBALS['simplified_demographics']) {
 598   $insurance_headings = array("Primary Insurance Provider:", "Secondary Insurance Provider", "Tertiary Insurance provider");
 599   $insurance_info = array();
 600   $insurance_info[1] = getInsuranceData($pid,"primary");
 601   $insurance_info[2] = getInsuranceData($pid,"secondary");
 602   $insurance_info[3] = getInsuranceData($pid,"tertiary");
 603   for($i=1;$i<=3;$i++) {
 604    $result3 = $insurance_info[$i];
 605 ?>
 606 <table border="0">
 607  <tr>
 608   <td valign=top>
 609    <table border="0">
 610     <tr>
 611      <td colspan="5"><span class='required'><?php echo $insurance_headings[$i -1]?></span></td>
 612     </tr>
 613     <tr>
 614      <td colspan="5">
 615       <select name="i<?php echo $i?>provider">
 616        <option value=""><?php xl('Unassigned','e'); ?></option>
 617 <?php
 618  foreach ($insurancei as $iid => $iname) {
 619   echo "<option value='" . $iid . "'";
 620   if (strtolower($iid) == strtolower($result3{"provider"}))
 621    echo " selected";
 622   echo ">" . $iname . "</option>\n";
 623  }
 624 ?>
 625       </select>&nbsp;<a href='' onclick='return ins_search(<?php echo $i?>)'><?php xl('Search/Add Insurer','e'); ?></a>
 626      </td>
 627     </tr>
 628     <tr>
 629      <td><span class=required><?php xl('Plan Name','e'); ?>: </span></td>
 630      <td><input type=entry size=20 name=i<?php echo $i?>plan_name value="<?php echo $result3{"plan_name"} ?>"
 631       onchange="capitalizeMe(this);" /></td>
 632     </tr>
 633     <tr>
 634      <td><span class=required><?php xl('Policy Number','e'); ?>: </span></td><td><input type=entry size=16 name=i<?php echo $i?>policy_number value="<?php echo $result3{"policy_number"}?>"></td>
 635     </tr>
 636     <tr>
 637      <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 $result3{"group_number"}?>"></td>
 638     </tr>
 639
 640     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 641      <td class='required'><?php xl('Subscriber Employer (SE)','e'); ?><br><span style='font-weight:normal'>
 642       (<?php xl('if unemployed enter Student','e'); ?>,<br><?php xl('PT Student, or leave blank','e'); ?>): </span></td>
 643      <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer
 644       value="<?php echo $result3{"subscriber_employer"}?>"
 645        onchange="capitalizeMe(this);" /></td>
 646     </tr>
 647
 648     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 649      <td><span class=required><?php xl('SE Address','e'); ?>: </span></td>
 650      <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer_street
 651       value="<?php echo $result3{"subscriber_employer_street"}?>"
 652        onchange="capitalizeMe(this);" /></td>
 653     </tr>
 654
 655     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 656      <td colspan="2">
 657       <table>
 658        <tr>
 659         <td><span class=required><?php xl('SE City','e'); ?>: </span></td>
 660         <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_city
 661          value="<?php echo $result3{"subscriber_employer_city"}?>"
 662           onchange="capitalizeMe(this);" /></td>
 663         <td><span class=required><?php xl('SE','e'); ?> <?php echo ($GLOBALS['phone_country_code'] == '1') ? 'State' : 'Locality' ?>: </span></td>
 664         <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_state
 665          value="<?php echo $result3{"subscriber_employer_state"}?>"></td>
 666        </tr>
 667        <tr>
 668         <td><span class=required><?php xl('SE','e'); ?> <?php echo ($GLOBALS['phone_country_code'] == '1') ? 'Zip' : 'Postal' ?> <?php xl('Code','e'); ?>: </span></td>
 669         <td><input type=entry size=10 name=i<?php echo $i?>subscriber_employer_postal_code value="<?php echo $result3{"subscriber_employer_postal_code"}?>"></td>
 670         <td><span class=required><?php xl('SE Country','e'); ?>: </span></td>
 671         <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer_country
 672          value="<?php echo $result3{"subscriber_employer_country"}?>"
 673          onchange="capitalizeMe(this);" /></td>
 674        </tr>
 675       </table>
 676      </td>
 677     </tr>
 678
 679    </table>
 680   </td>
 681
 682   <td valign=top>
 683    <span class=required><?php xl('Subscriber','e'); ?>: </span>
 684    <input type=entry size=10 name=i<?php echo $i?>subscriber_fname
 685     value="<?php echo $result3{"subscriber_fname"}?>"
 686     onchange="capitalizeMe(this);" />
 687    <input type=entry size=3 name=i<?php echo $i?>subscriber_mname
 688     value="<?php echo $result3{"subscriber_mname"}?>"
 689     onchange="capitalizeMe(this);" />
 690    <input type=entry size=10 name=i<?php echo $i?>subscriber_lname
 691     value="<?php echo $result3{"subscriber_lname"}?>"
 692     onchange="capitalizeMe(this);" />
 693    <br>
 694    <span class=required><?php xl('Relationship','e'); ?>: </span>
 695    <select name=i<?php echo $i?>subscriber_relationship onchange="javascript:auto_populate_employer_address<?php echo $i?>();">
 696 <?php
 697  foreach ($relats as $s) {
 698   if ($s == "unassigned") {
 699    echo "<option value=''";
 700   } else {
 701    echo "<option value='".$s."'";
 702   }
 703   if ($s == strtolower($result3['subscriber_relationship']))
 704    echo " selected";
 705   echo ">".ucfirst($s)."</option>\n";
 706 }
 707 ?>
 708    </select>
 709    <a href="javascript:popUp('browse.php?browsenum=<?php echo $i?>')" class=text>(<?php xl('Browse','e'); ?>)</a><br />
 710    <span class=bold><?php xl('D.O.B.','e'); ?>: </span>
 711    <input type='entry' size='11' name='i<?php echo $i?>subscriber_DOB'
 712     value='<?php echo $result3['subscriber_DOB'] ?>'
 713     onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)'
 714     title='yyyy-mm-dd' />
 715    <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;
 716    <span class=bold><?php xl('Sex','e'); ?>: </span>
 717    <select name=i<?php echo $i?>subscriber_sex>
 718     <option value="Female" <?php if (strtolower($result3{"subscriber_sex"}) == "female") echo "selected"?>><?php xl('Female','e'); ?></option>
 719     <option value="Male" <?php if (strtolower($result3{"subscriber_sex"}) == "male") echo "selected"?>><?php xl('Male','e'); ?></option>
 720    </select>
 721    <br>
 722    <span class=required><?php xl('Subscriber Address','e'); ?>: </span>
 723    <input type=entry size=25 name=i<?php echo $i?>subscriber_street
 724     value="<?php echo $result3{"subscriber_street"}?>"
 725     onchange="capitalizeMe(this);" /><br>
 726    <span class=required><?php xl('City','e'); ?>: </span>
 727    <input type=entry size=15 name=i<?php echo $i?>subscriber_city
 728     value="<?php echo $result3{"subscriber_city"}?>"
 729     onchange="capitalizeMe(this);" />
 730    <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? 'State' : 'Locality' ?>: </span><input type=entry size=15 name=i<?php echo $i?>subscriber_state value="<?php echo $result3{"subscriber_state"}?>"><br>
 731    <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? 'Zip' : 'Postal' ?> <?php xl('Code','e'); ?>: </span><input type=entry size=10 name=i<?php echo $i?>subscriber_postal_code value="<?php echo $result3{"subscriber_postal_code"}?>">
 732    <span class='required'<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 733    <?php xl('Country','e'); ?>:
 734    <input type=entry size=10 name=i<?php echo $i?>subscriber_country
 735     value="<?php echo $result3{"subscriber_country"}?>"
 736     onchange="capitalizeMe(this);" /><br></span>
 737    <span class=bold><?php xl('Subscriber Phone','e'); ?>:
 738    <input type='text' size='20' name='i<?php echo $i?>subscriber_phone' value='<?php echo $result3["subscriber_phone"] ?>' onkeyup='phonekeyup(this,mypcc)' />
 739    </span><br />
 740    <span class=bold><?php xl('CoPay','e'); ?>: <input type=text size="6" name=i<?php echo $i?>copay value="<?php echo $result3{"copay"}?>">
 741   </td>
 742  </tr>
 743 </table>
 744 <a href="javascript:document.demographics_form.submit();" class=link_submit>[<?php xl('Save Patient Demographics','e'); ?>]</a>
 745 <hr>
 746
 747 <?php
 748   } //end insurer for loop
 749  } // end of "if not simplified_demographics"
 750 ?>
 751
 752 </form>
 753
 754 <br>
 755
 756 <script language="JavaScript">
 757
 758  // fix inconsistently formatted phone numbers from the database
 759  var f = document.forms[0];
 760  phonekeyup(f.phone_contact,mypcc);
 761  phonekeyup(f.phone_home,mypcc);
 762  phonekeyup(f.phone_biz,mypcc);
 763  phonekeyup(f.phone_cell,mypcc);
 764
 765 <?php if (! $GLOBALS['simplified_demographics']) { ?>
 766  phonekeyup(f.i1subscriber_phone,mypcc);
 767  phonekeyup(f.i2subscriber_phone,mypcc);
 768  phonekeyup(f.i3subscriber_phone,mypcc);
 769 <?php } ?>
 770
 771 <?php if ($GLOBALS['concurrent_layout'] && $set_pid) { ?>
 772  parent.left_nav.setPatient(<?php echo "'" . $result['fname'] . " " . $result['lname'] . "',$pid,''"; ?>);
 773  parent.left_nav.setRadio(window.name, 'dem');
 774 <?php } ?>
 775
 776 </script>
 777
 778 </body>
 779 </html>