interface/new/new_comprehensive.php

   1 <?php
   2 /**
   3  * New patient or search patient.
   4  *
   5  * @package   OpenEMR
   6  * @link      http://www.open-emr.org
   7  * @author    Rod Roark <rod@sunsetsystems.com>
   8  * @author    Brady Miller <brady.g.miller@gmail.com>
   9  * @copyright Copyright (c) 2009-2010 Rod Roark <rod@sunsetsystems.com>
  10  * @copyright Copyright (c) 2017 Brady Miller <brady.g.miller@gmail.com>
  11  * @license   https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  12  */
  13
  14 require_once("../globals.php");
  15 require_once("$srcdir/acl.inc");
  16 require_once("$srcdir/options.inc.php");
  17 require_once("$srcdir/patient.inc");
  18 require_once("$srcdir/erx_javascript.inc.php");
  19 require_once("$srcdir/validation/LBF_Validation.php");
  20 require_once("$srcdir/patientvalidation.inc.php");
  21
  22 // Check authorization.
  23 if (!acl_check('patients', 'demo', '', array('write','addonly'))) {
  24     die(xlt("Adding demographics is not authorized."));
  25 }
  26
  27 $CPR = 4; // cells per row
  28
  29 $searchcolor = empty($GLOBALS['layout_search_color']) ?
  30   '#ffff55' : $GLOBALS['layout_search_color'];
  31
  32 $WITH_SEARCH = ($GLOBALS['full_new_patient_form'] == '1' || $GLOBALS['full_new_patient_form'] == '2' );
  33 $SHORT_FORM  = ($GLOBALS['full_new_patient_form'] == '2' || $GLOBALS['full_new_patient_form'] == '3' || $GLOBALS['full_new_patient_form'] == '4');
  34
  35 function getLayoutRes()
  36 {
  37     global $SHORT_FORM;
  38     return sqlStatement("SELECT * FROM layout_options " .
  39     "WHERE form_id = 'DEM' AND uor > 0 AND field_id != '' " .
  40     ($SHORT_FORM ? "AND ( uor > 1 OR edit_options LIKE '%N%' ) " : "") .
  41     "ORDER BY group_name, seq");
  42 }
  43
  44 // Determine layout field search treatment from its data type:
  45 // 1 = text field
  46 // 2 = select list
  47 // 0 = not searchable
  48 //
  49 function getSearchClass($data_type)
  50 {
  51     switch ($data_type) {
  52         case 1: // single-selection list
  53         case 10: // local provider list
  54         case 11: // provider list
  55         case 12: // pharmacy list
  56         case 13: // squads
  57         case 14: // address book list
  58         case 26: // single-selection list with add
  59         case 35: // facilities
  60             return 2;
  61         case 2: // text field
  62         case 3: // textarea
  63         case 4: // date
  64             return 1;
  65     }
  66
  67     return 0;
  68 }
  69
  70 $fres = getLayoutRes();
  71 ?>
  72 <html>
  73 <head>
  74 <?php html_header_show(); ?>
  75
  76 <title><?php echo xlt("Search or Add Patient"); ?></title>
  77
  78 <link rel="stylesheet" href="<?php echo $css_header; ?>" type="text/css">
  79 <link rel="stylesheet" href="<?php echo $GLOBALS['assets_static_relative'] ?>/bootstrap-3-3-4/dist/css/bootstrap.min.css">
  80 <?php if ($_SESSION['language_direction'] == 'rtl') { ?>
  81     <link rel="stylesheet" href="<?php echo $GLOBALS['assets_static_relative'] ?>/bootstrap-rtl-3-3-4/dist/css/bootstrap-rtl.min.css">
  82 <?php } ?>
  83 <link rel="stylesheet" href="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-datetimepicker-2-5-4/build/jquery.datetimepicker.min.css">
  84 <link rel="stylesheet" type="text/css" href="../../library/js/fancybox/jquery.fancybox-1.2.6.css" media="screen" />
  85
  86 <style>
  87 body {
  88  padding: 5pt 5pt 5pt 5pt;
  89 }
  90
  91 div.section {
  92  border: solid;
  93  border-width: 1px;
  94  border-color: #0000ff;
  95  margin: 0 0 0 10pt;
  96  padding: 5pt;
  97 }
  98
  99 .form-control {
 100     width: auto;
 101     display: inline;
 102     height: auto;
 103 }
 104 </style>
 105
 106 <script type="text/javascript" src="../../library/dialog.js?v=<?php echo $v_js_includes; ?>"></script>
 107 <script type="text/javascript" src="../../library/textformat.js?v=<?php echo $v_js_includes; ?>"></script>
 108 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-min-1-7-2/index.js"></script>
 109 <script type="text/javascript" src="../../library/js/common.js?v=<?php echo $v_js_includes; ?>"></script>
 110 <script type="text/javascript" src="../../library/js/fancybox/jquery.fancybox-1.2.6.js"></script>
 111 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-datetimepicker-2-5-4/build/jquery.datetimepicker.full.min.js"></script>
 112
 113 <?php include_once("{$GLOBALS['srcdir']}/options.js.php"); ?>
 114
 115 <SCRIPT LANGUAGE="JavaScript"><!--
 116 //Visolve - sync the radio buttons - Start
 117 if((top.window.parent) && (parent.window)){
 118         var wname = top.window.parent.left_nav;
 119         fname = (parent.window.name)?parent.window.name:window.name;
 120         wname.syncRadios();
 121 }//Visolve - sync the radio buttons - End
 122
 123 var mypcc = '<?php echo $GLOBALS['phone_country_code'] ?>';
 124
 125 // This may be changed to true by the AJAX search script.
 126 var force_submit = false;
 127
 128 //code used from http://tech.irt.org/articles/js037/
 129 function replace(string,text,by) {
 130  // Replaces text with by in string
 131  var strLength = string.length, txtLength = text.length;
 132  if ((strLength == 0) || (txtLength == 0)) return string;
 133
 134  var i = string.indexOf(text);
 135  if ((!i) && (text != string.substring(0,txtLength))) return string;
 136  if (i == -1) return string;
 137
 138  var newstr = string.substring(0,i) + by;
 139
 140  if (i+txtLength < strLength)
 141   newstr += replace(string.substring(i+txtLength,strLength),text,by);
 142
 143  return newstr;
 144 }
 145
 146 <?php for ($i=1; $i<=3; $i++) { ?>
 147 function auto_populate_employer_address<?php echo $i ?>(){
 148  var f = document.demographics_form;
 149  if (f.form_i<?php echo $i?>subscriber_relationship.options[f.form_i<?php echo $i?>subscriber_relationship.selectedIndex].value == "self") {
 150   f.i<?php echo $i?>subscriber_fname.value=f.form_fname.value;
 151   f.i<?php echo $i?>subscriber_mname.value=f.form_mname.value;
 152   f.i<?php echo $i?>subscriber_lname.value=f.form_lname.value;
 153   f.i<?php echo $i?>subscriber_street.value=f.form_street.value;
 154   f.i<?php echo $i?>subscriber_city.value=f.form_city.value;
 155   f.form_i<?php echo $i?>subscriber_state.value=f.form_state.value;
 156   f.i<?php echo $i?>subscriber_postal_code.value=f.form_postal_code.value;
 157   if (f.form_country_code)
 158     f.form_i<?php echo $i?>subscriber_country.value=f.form_country_code.value;
 159   f.i<?php echo $i?>subscriber_phone.value=f.form_phone_home.value;
 160   f.i<?php echo $i?>subscriber_DOB.value=f.form_DOB.value;
 161   f.i<?php echo $i?>subscriber_ss.value=f.form_ss.value;
 162   f.form_i<?php echo $i?>subscriber_sex.value = f.form_sex.value;
 163   f.i<?php echo $i?>subscriber_employer.value=f.form_em_name.value;
 164   f.i<?php echo $i?>subscriber_employer_street.value=f.form_em_street.value;
 165   f.i<?php echo $i?>subscriber_employer_city.value=f.form_em_city.value;
 166   f.form_i<?php echo $i?>subscriber_employer_state.value=f.form_em_state.value;
 167   f.i<?php echo $i?>subscriber_employer_postal_code.value=f.form_em_postal_code.value;
 168   if (f.form_em_country)
 169     f.form_i<?php echo $i?>subscriber_employer_country.value=f.form_em_country.value;
 170  }
 171 }
 172
 173 <?php } ?>
 174
 175 function upperFirst(string,text) {
 176  return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
 177 }
 178
 179 // The ins_search.php window calls this to set the selected insurance.
 180 function set_insurance(ins_id, ins_name) {
 181  var thesel = document.forms[0]['i' + insurance_index + 'provider'];
 182  var theopts = thesel.options; // the array of Option objects
 183  var i = 0;
 184  for (; i < theopts.length; ++i) {
 185   if (theopts[i].value == ins_id) {
 186    theopts[i].selected = true;
 187    return;
 188   }
 189  }
 190  // no matching option was found so create one, append it to the
 191  // end of the list, and select it.
 192  theopts[i] = new Option(ins_name, ins_id, false, true);
 193 }
 194
 195 // Indicates which insurance slot is being updated.
 196 var insurance_index = 0;
 197
 198 // The OnClick handler for searching/adding the insurance company.
 199 function ins_search(ins) {
 200  insurance_index = ins;
 201  return false;
 202 }
 203
 204 function checkNum () {
 205  var re= new RegExp();
 206  re = /^\d*\.?\d*$/;
 207  str=document.forms[0].monthly_income.value;
 208  if(re.exec(str))
 209  {
 210  }else{
 211   alert("<?php echo xls("Please enter a dollar amount using only numbers and a decimal point."); ?>");
 212  }
 213 }
 214
 215 // This capitalizes the first letter of each word in the passed input
 216 // element.  It also strips out extraneous spaces.
 217 function capitalizeMe(elem) {
 218  var a = elem.value.split(' ');
 219  var s = '';
 220  for(var i = 0; i < a.length; ++i) {
 221   if (a[i].length > 0) {
 222    if (s.length > 0) s += ' ';
 223    s += a[i].charAt(0).toUpperCase() + a[i].substring(1);
 224   }
 225  }
 226  elem.value = s;
 227 }
 228
 229 // Onkeyup handler for policy number.  Allows only A-Z and 0-9.
 230 function policykeyup(e) {
 231  var v = e.value.toUpperCase();
 232  var filteredString="";
 233  for (var i = 0; i < v.length; ++i) {
 234   var c = v.charAt(i);
 235   if ((c >= '0' && c <= '9') ||
 236      (c >= 'A' && c <= 'Z') ||
 237      (c == '*') ||
 238      (c == '-') ||
 239      (c == '_') ||
 240      (c == '(') ||
 241      (c == ')') ||
 242      (c == '#'))
 243      {
 244          filteredString+=c;
 245      }
 246  }
 247  e.value = filteredString;
 248  return;
 249 }
 250
 251 function divclick(cb, divid) {
 252  var divstyle = document.getElementById(divid).style;
 253  if (cb.checked) {
 254   divstyle.display = 'block';
 255  } else {
 256   divstyle.display = 'none';
 257  }
 258  return true;
 259 }
 260
 261 // Compute the length of a string without leading and trailing spaces.
 262 function trimlen(s) {
 263  var i = 0;
 264  var j = s.length - 1;
 265  for (; i <= j && s.charAt(i) == ' '; ++i);
 266  for (; i <= j && s.charAt(j) == ' '; --j);
 267  if (i > j) return 0;
 268  return j + 1 - i;
 269 }
 270
 271 function validate(f) {
 272   var errMsgs = new Array();
 273     <?php generate_layout_validation('DEM'); ?>
 274     <?php if ($GLOBALS['erx_enable']) { ?>
 275   alertMsg='';
 276   for(i=0;i<f.length;i++){
 277     if(f[i].type=='text' && f[i].value)
 278     {
 279       if(f[i].name == 'form_fname' || f[i].name == 'form_mname' || f[i].name == 'form_lname')
 280       {
 281         alertMsg += checkLength(f[i].name,f[i].value,35);
 282         alertMsg += checkUsername(f[i].name,f[i].value);
 283       }
 284       else if(f[i].name == 'form_street' || f[i].name == 'form_city')
 285       {
 286         alertMsg += checkLength(f[i].name,f[i].value,35);
 287         alertMsg += checkAlphaNumericExtended(f[i].name,f[i].value);
 288       }
 289       else if(f[i].name == 'form_phone_home')
 290       {
 291        alertMsg += checkPhone(f[i].name,f[i].value);
 292       }
 293     }
 294   }
 295   if(alertMsg)
 296   {
 297     alert(alertMsg);
 298     return false;
 299   }
 300     <?php } ?>
 301   var msg = "";
 302   msg += "<?php echo xla('The following fields are required'); ?>:\n\n";
 303   for ( var i = 0; i < errMsgs.length; i++ ) {
 304          msg += errMsgs[i] + "\n";
 305   }
 306   msg += "\n<?php echo xla('Please fill them in before continuing.'); ?>";
 307
 308
 309 //Misc  Deceased Date Validation for Future Date
 310 var dateVal = document.getElementById("form_deceased_date").value;
 311 var currentDate;
 312 var d = new Date();
 313 month = '' + (d.getMonth() + 1),
 314 day = '' + d.getDate(),
 315 year = d.getFullYear();
 316 if (month.length < 2) month = '0' + month;
 317 if (day.length < 2) day = '0' + day;
 318 currentDate = year+'-'+month+'-'+day;
 319 if(errMsgs.length > 0 || dateVal > currentDate)
 320 {
 321 if(errMsgs.length > 0)
 322     alert(msg);
 323 if(dateVal > currentDate)
 324     alert ('<?php echo xls("Deceased Date should not be greater than Today"); ?>');
 325     return false;
 326 }
 327  return true;
 328 }
 329
 330 function toggleSearch(elem) {
 331  var f = document.forms[0];
 332 <?php if ($WITH_SEARCH) { ?>
 333  // Toggle background color.
 334  if (elem.style.backgroundColor == '')
 335   elem.style.backgroundColor = '<?php echo $searchcolor; ?>';
 336  else
 337   elem.style.backgroundColor = '';
 338 <?php } ?>
 339  if (force_submit) {
 340   force_submit = false;
 341   f.create.value = '<?php echo xla('Create New Patient'); ?>';
 342  }
 343  return true;
 344 }
 345
 346 // If a <select> list is dropped down, this is its name.
 347 var open_sel_name = '';
 348
 349 function selClick(elem) {
 350  if (open_sel_name == elem.name) {
 351   open_sel_name = '';
 352  }
 353  else {
 354   open_sel_name = elem.name;
 355   toggleSearch(elem);
 356  }
 357  return true;
 358 }
 359
 360 function selBlur(elem) {
 361  if (open_sel_name == elem.name) {
 362   open_sel_name = '';
 363  }
 364  return true;
 365 }
 366
 367 // This invokes the patient search dialog.
 368 function searchme() {
 369  var f = document.forms[0];
 370  var url = '../main/finder/patient_select.php?popup=1';
 371
 372 <?php
 373 $lres = getLayoutRes();
 374
 375 while ($lrow = sqlFetchArray($lres)) {
 376     $field_id  = $lrow['field_id'];
 377     if (strpos($field_id, 'em_') === 0) {
 378         continue;
 379     }
 380
 381     $data_type = $lrow['data_type'];
 382     $fldname = "form_$field_id";
 383     switch (getSearchClass($data_type)) {
 384         case 1:
 385             echo
 386             " if (f.$fldname.style.backgroundColor != '' && trimlen(f.$fldname.value) > 0) {\n" .
 387             "  url += '&$field_id=' + encodeURIComponent(f.$fldname.value);\n" .
 388             " }\n";
 389             break;
 390         case 2:
 391             echo
 392             " if (f.$fldname.style.backgroundColor != '' && f.$fldname.selectedIndex > 0) {\n" .
 393             "  url += '&$field_id=' + encodeURIComponent(f.$fldname.options[f.$fldname.selectedIndex].value);\n" .
 394             " }\n";
 395             break;
 396     }
 397 }
 398 ?>
 399
 400  dlgopen(url, '_blank', 700, 500);
 401 }
 402
 403 //-->
 404
 405 </script>
 406 </head>
 407
 408 <body class="body_top">
 409
 410 <?php
 411 /*Get the constraint from the DB-> LBF forms accordinf the form_id*/
 412 $constraints = LBF_Validation::generate_validate_constraints("DEM");
 413 ?>
 414 <script> var constraints = <?php echo $constraints;?>; </script>
 415
 416 <form action='new_comprehensive_save.php' name='demographics_form' id="DEM"  method='post' onsubmit='return submitme(<?php echo $GLOBALS['new_validate'] ? 1 : 0;?>,event,"DEM",constraints)'>
 417
 418     <div class="container-fluid">
 419         <div class="row">
 420             <div class="col-xs-12">
 421                 <div class="page-header">
 422                     <h2><?php echo xlt('Search or Add Patient');?></h2>
 423                 </div>
 424             </div>
 425             <div class="col-xs-12">
 426                 <div class="btn-group">
 427                     <?php if ($WITH_SEARCH) { ?>
 428                         <button type="button" class="btn btn-default btn-search" id="search" value="<?php echo xla('Search'); ?>">
 429                             <?php echo xlt('Search'); ?>
 430                         </button>
 431                     <?php } ?>
 432                     <button type="button" class="btn btn-default btn-save" name='create' id="create" value="<?php echo xla('Create New Patient'); ?>">
 433                         <?php echo xlt('Create New Patient'); ?>
 434                     </button>
 435                 </div>
 436                 <hr>
 437             </div>
 438         </div>
 439     </div>
 440
 441 <table width='100%' cellpadding='0' cellspacing='8'>
 442  <tr>
 443   <td align='left' valign='top'>
 444 <?php if ($SHORT_FORM) {
 445     echo "  <center>\n";
 446 } ?>
 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, $SHORT_FORM;
 476     if (strlen($last_group) > 0) {
 477         end_row();
 478         echo " </table>\n";
 479         if (!$SHORT_FORM) {
 480             echo "</div>\n";
 481         }
 482     }
 483 }
 484
 485 $last_group    = '';
 486 $cell_count    = 0;
 487 $item_count    = 0;
 488 $display_style = 'block';
 489 $group_seq     = 0; // this gives the DIV blocks unique IDs
 490
 491 while ($frow = sqlFetchArray($fres)) {
 492     $this_group = $frow['group_name'];
 493     $titlecols  = $frow['titlecols'];
 494     $datacols   = $frow['datacols'];
 495     $data_type  = $frow['data_type'];
 496     $field_id   = $frow['field_id'];
 497     $list_id    = $frow['list_id'];
 498     $currvalue  = '';
 499     $condition_str = get_conditions_str($condition_str, $group_fields);
 500
 501     if (strpos($field_id, 'em_') === 0) {
 502         $tmp = substr($field_id, 3);
 503         if (isset($result2[$tmp])) {
 504             $currvalue = $result2[$tmp];
 505         }
 506     } else {
 507         if (isset($result[$field_id])) {
 508             $currvalue = $result[$field_id];
 509         }
 510     }
 511
 512   // Handle a data category (group) change.
 513     if (strcmp($this_group, $last_group) != 0) {
 514         if (!$SHORT_FORM) {
 515             end_group();
 516             $group_seq++;    // ID for DIV tags
 517             $group_name = substr($this_group, 1);
 518             if (strlen($last_group) > 0) {
 519                 echo "<br />";
 520             }
 521
 522             echo "<span class='bold'><input type='checkbox' name='form_cb_$group_seq' id='form_cb_$group_seq' value='1' " .
 523             "onclick='return divclick(this,\"div_$group_seq\");'";
 524             if ($display_style == 'block') {
 525                 echo " checked";
 526             }
 527
 528             // Modified 6-09 by BM - Translate if applicable
 529             echo " /><b>" . xl_layout_label($group_name) . "</b></span>\n";
 530
 531             echo "<div id='div_$group_seq' class='section' style='display:$display_style;'>\n";
 532             echo " <table border='0' cellpadding='0'>\n";
 533             $display_style = 'none';
 534         } else if (strlen($last_group) == 0) {
 535             echo " <table border='0' cellpadding='0'>\n";
 536         }
 537
 538         $last_group = $this_group;
 539     }
 540
 541   // Handle starting of a new row.
 542     if (($titlecols > 0 && $cell_count >= $CPR) || $cell_count == 0) {
 543         end_row();
 544         echo "  <tr>";
 545     }
 546
 547     if ($item_count == 0 && $titlecols == 0) {
 548         $titlecols = 1;
 549     }
 550
 551     $field_id_label='label_'.$frow['field_id'];
 552   // Handle starting of a new label cell.
 553     if ($titlecols > 0) {
 554         end_cell();
 555         echo "<td colspan='$titlecols' id='$field_id_label'";
 556         echo ($frow['uor'] == 2) ? " class='required'" : " class='bold'";
 557         if ($cell_count == 2) {
 558             echo " style='padding-left:10pt'";
 559         }
 560
 561         echo ">";
 562         $cell_count += $titlecols;
 563     }
 564
 565     ++$item_count;
 566
 567     echo "<b>";
 568
 569   // Modified 6-09 by BM - Translate if applicable
 570     if ($frow['title']) {
 571         echo (xl_layout_label($frow['title']).":");
 572     } else {
 573         echo "&nbsp;";
 574     }
 575
 576     echo "</b>";
 577
 578   // Handle starting of a new data cell.
 579     if ($datacols > 0) {
 580         $id_field_text = "text_".$frow['field_id'];
 581         end_cell();
 582         echo "<td colspan='$datacols' class='text data'";
 583         if ($cell_count > 0) {
 584             echo " style='padding-left:5pt'". " id='".$id_field_text."'";
 585         }
 586
 587         echo ">";
 588         $cell_count += $datacols;
 589     }
 590
 591     ++$item_count;
 592     generate_form_field($frow, $currvalue);
 593 }
 594
 595 end_group();
 596 ?>
 597
 598 <?php
 599 if (! $GLOBALS['simplified_demographics']) {
 600     $insurancei = getInsuranceProviders();
 601     $pid = 0;
 602     $insurance_headings = array(xl("Primary Insurance Provider"), xl("Secondary Insurance Provider"), xl("Tertiary Insurance provider"));
 603     $insurance_info = array();
 604     $insurance_info[1] = getInsuranceData($pid, "primary");
 605     $insurance_info[2] = getInsuranceData($pid, "secondary");
 606     $insurance_info[3] = getInsuranceData($pid, "tertiary");
 607
 608     echo "<br /><span class='bold'><input type='checkbox' name='form_cb_ins' value='1' " .
 609     "onclick='return divclick(this,\"div_ins\");'";
 610     if ($display_style == 'block') {
 611         echo " checked";
 612     }
 613
 614     echo " /><b>" . xlt('Insurance') . "</b></span>\n";
 615     echo "<div id='div_ins' class='section' style='display:$display_style;'>\n";
 616
 617     for ($i=1; $i<=3; $i++) {
 618         $result3 = $insurance_info[$i];
 619     ?>
 620   <table border="0">
 621    <tr>
 622     <td valign='top' colspan='2'>
 623      <span class='required'><?php echo text($insurance_headings[$i -1]).":"?></span>
 624      <select name="i<?php echo $i?>provider" class="form-control">
 625     <option value=""><?php echo xlt('Unassigned'); ?></option>
 626 <?php
 627 foreach ($insurancei as $iid => $iname) {
 628     echo "<option value='" . attr($iid) . "'";
 629     if (strtolower($iid) == strtolower($result3{"provider"})) {
 630         echo " selected";
 631     }
 632
 633     echo ">" . text($iname) . "</option>\n";
 634 }
 635 ?>
 636      </select>&nbsp;<a class='iframe medium_modal' href='../practice/ins_search.php' onclick='ins_search(<?php echo $i?>)'>
 637   <span> <?php echo xlt('Search/Add Insurer'); ?></span></a>
 638   </td>
 639  </tr>
 640  <tr>
 641   <td valign=top>
 642    <table border="0">
 643
 644     <tr>
 645      <td>
 646       <span class='required'><?php echo xlt('Plan Name'); ?>: </span>
 647      </td>
 648      <td>
 649       <input type='entry' class='form-control' size='20' name='i<?php echo $i?>plan_name' value="<?php echo attr($result3{"plan_name"}); ?>"
 650        onchange="capitalizeMe(this);" />&nbsp;&nbsp;
 651      </td>
 652     </tr>
 653
 654     <tr>
 655      <td>
 656       <span class='required'><?php echo xlt('Effective Date'); ?>: </span>
 657      </td>
 658      <td>
 659       <input type='entry' size='11' class='datepicker form-control' name='i<?php echo $i ?>effective_date'
 660        id='i<?php echo $i ?>effective_date'
 661        value='<?php echo attr($result3['date']); ?>'
 662        title='yyyy-mm-dd' />
 663      </td>
 664     </tr>
 665
 666     <tr>
 667      <td><span class=required><?php echo xlt('Policy Number'); ?>: </span></td>
 668      <td><input type='entry' class='form-control' size='16' name='i<?php echo $i?>policy_number' value="<?php echo attr($result3{"policy_number"}); ?>"
 669       onkeyup='policykeyup(this)'></td>
 670     </tr>
 671
 672     <tr>
 673      <td><span class=required><?php echo xlt('Group Number'); ?>: </span></td>
 674     <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>
 675     </tr>
 676
 677     <tr<?php echo ($GLOBALS['omit_employers']) ? " style='display:none'" : ""; ?>>
 678      <td class='required'><?php echo xlt('Subscriber Employer (SE)'); ?><br><span style='font-weight:normal'>
 679       (<?php echo xlt('if unemployed enter Student'); ?>,<br><?php echo xlt('PT Student, or leave blank'); ?>): </span></td>
 680      <td><input type=entry class='form-control' size=25 name=i<?php echo $i?>subscriber_employer
 681       value="<?php echo attr($result3{"subscriber_employer"}); ?>"
 682        onchange="capitalizeMe(this);" /></td>
 683     </tr>
 684
 685     <tr<?php echo ($GLOBALS['omit_employers']) ? " style='display:none'" : ""; ?>>
 686      <td><span class=required><?php echo xlt('SE Address'); ?>: </span></td>
 687      <td><input type=entry class='form-control' size=25 name=i<?php echo $i?>subscriber_employer_street
 688       value="<?php echo attr($result3{"subscriber_employer_street"}); ?>"
 689        onchange="capitalizeMe(this);" /></td>
 690     </tr>
 691
 692     <tr<?php echo ($GLOBALS['omit_employers']) ? " style='display:none'" : ""; ?>>
 693      <td colspan="2">
 694       <table>
 695        <tr>
 696         <td><span class=required><?php echo xlt('SE City'); ?>: </span></td>
 697         <td><input type=entry class='form-control' size=15 name=i<?php echo $i?>subscriber_employer_city
 698          value="<?php echo attr($result3{"subscriber_employer_city"}); ?>"
 699           onchange="capitalizeMe(this);" /></td>
 700         <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('SE State') : xlt('SE Locality') ?>: </span></td>
 701     <td>
 702             <?php
 703             // Modified 7/2009 by BM to incorporate data types
 704             generate_form_field(array('data_type'=>$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'), $result3['subscriber_employer_state']);
 705                 ?>
 706           </td>
 707          </tr>
 708          <tr>
 709             <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('SE Zip Code') : xlt('SE Postal Code') ?>: </span></td>
 710             <td><input type=entry class='form-control' size=10 name=i<?php echo $i?>subscriber_employer_postal_code value="<?php echo attr($result3{"subscriber_employer_postal_code"}); ?>"></td>
 711             <td><span class=required><?php xl('SE Country', 'e'); ?>: </span></td>
 712       <td>
 713                 <?php
 714               // Modified 7/2009 by BM to incorporate data types
 715                 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']);
 716                 ?>
 717       </td>
 718          </tr>
 719         </table>
 720        </td>
 721       </tr>
 722
 723      </table>
 724     </td>
 725
 726     <td valign=top>
 727        <span class=required><?php echo xlt('Subscriber'); ?>: </span>
 728        <input type=entry class='form-control' size=10 name=i<?php echo $i?>subscriber_fname
 729         value="<?php echo attr($result3{"subscriber_fname"}); ?>"
 730       onchange="capitalizeMe(this);" />
 731        <input type=entry class='form-control' size=3 name=i<?php echo $i?>subscriber_mname
 732         value="<?php echo attr($result3{"subscriber_mname"}); ?>"
 733       onchange="capitalizeMe(this);" />
 734        <input type=entry class='form-control' size=10 name=i<?php echo $i?>subscriber_lname
 735         value="<?php echo attr($result3{"subscriber_lname"}); ?>"
 736       onchange="capitalizeMe(this);" />
 737      <br>
 738        <span class=required><?php echo xlt('Relationship'); ?>: </span>
 739         <?php
 740       // Modified 6/2009 by BM to use list_options and function
 741         generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_relationship'),'list_id'=>'sub_relation','empty_title'=>' '), $result3['subscriber_relationship']);
 742         ?>
 743        <a href="javascript:popUp('../../interface/patient_file/summary/browse.php?browsenum=<?php echo $i?>')" class=text>(<?php echo xla('Browse'); ?>)</a><br />
 744
 745        <span class=bold><?php echo xlt('D.O.B.'); ?>: </span>
 746        <input type='entry' size='11' class='datepicker form-control' name='i<?php echo $i?>subscriber_DOB'
 747       id='i<?php echo $i?>subscriber_DOB'
 748       value='<?php echo attr($result3['subscriber_DOB']); ?>'
 749     title='yyyy-mm-dd' />
 750
 751        <span class=bold><?php echo xlt('S.S.'); ?>: </span>
 752        <input type=entry class='form-control' size=11 name=i<?php echo $i?>subscriber_ss value="<?php echo attr($result3{"subscriber_ss"}); ?>">&nbsp;
 753        <span class=bold><?php echo xlt('Sex'); ?>: </span>
 754         <?php
 755       // Modified 6/2009 by BM to use list_options and function
 756         generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_sex'),'list_id'=>'sex'), $result3['subscriber_sex']);
 757         ?>
 758      <br>
 759        <span class=required><?php echo xlt('Subscriber Address'); ?>: </span>
 760        <input type=entry class='form-control' size=25 name=i<?php echo $i?>subscriber_street
 761       value="<?php echo attr($result3{"subscriber_street"}); ?>"
 762     onchange="capitalizeMe(this);" /><br>
 763        <span class=required><?php echo xlt('City'); ?>: </span>
 764        <input type=entry class='form-control' size=15 name=i<?php echo $i?>subscriber_city
 765       value="<?php echo attr($result3{"subscriber_city"}); ?>"
 766     onchange="capitalizeMe(this);" />
 767        <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('State') : xlt('Locality') ?>: </span>
 768         <?php
 769       // Modified 7/2009 by BM to incorporate data types
 770         generate_form_field(array('data_type'=>$GLOBALS['state_data_type'],'field_id'=>('i'.$i.'subscriber_state'),'list_id'=>$GLOBALS['state_list'],'fld_length'=>'15','max_length'=>'63','edit_options'=>'C'), $result3['subscriber_state']);
 771         ?>
 772      <br />
 773        <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('Zip Code') : xlt('Postal Code') ?>: </span>
 774        <input type=entry class='form-control' size=10 name=i<?php echo $i?>subscriber_postal_code value="<?php echo attr($result3{"subscriber_postal_code"}); ?>">
 775        <span class='required'<?php echo ($GLOBALS['omit_employers']) ? " style='display:none'" : ""; ?>>
 776         <?php echo xlt('Country'); ?>: </span>
 777         <?php
 778       // Modified 7/2009 by BM to incorporate data types
 779         generate_form_field(array('data_type'=>$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']);
 780         ?>
 781      <br />
 782        <span class=bold><?php echo xlt('Subscriber Phone'); ?>:
 783        <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)' />
 784      </span><br />
 785        <span 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"}); ?>">
 786      </span><br />
 787        <span class='required'><?php echo xlt('Accept Assignment'); ?>: </span>
 788        <select class='form-control' name=i<?php echo $i?>accept_assignment>
 789          <option value="TRUE" <?php echo (strtoupper($result3{"accept_assignment"}) == "TRUE") ? "selected" : ""; ?>><?php echo xlt('YES'); ?></option>
 790          <option value="FALSE" <?php echo (strtoupper($result3{"accept_assignment"}) == "FALSE") ? "selected" : ""; ?>><?php echo xlt('NO'); ?></option>
 791        </select>
 792     </td>
 793    </tr>
 794
 795   </table>
 796   <hr />
 797     <?php
 798     }
 799
 800     echo "</div>\n";
 801 } // end of "if not simplified_demographics"
 802 ?>
 803
 804 <?php if ($SHORT_FORM) {
 805     echo "  </center>\n";
 806 } ?>
 807
 808   </td>
 809   <td align='right' valign='top' width='1%' nowrap>
 810    <!-- Image upload stuff was here but got moved. -->
 811   </td>
 812  </tr>
 813 </table>
 814
 815 </form>
 816
 817 <!-- include support for the list-add selectbox feature -->
 818 <?php include($GLOBALS['fileroot']."/library/options_listadd.inc"); ?>
 819
 820 </body>
 821
 822 <script language="JavaScript">
 823
 824 // hard code validation for old validation, in the new validation possible to add match rules
 825 <?php if ($GLOBALS['new_validate'] == 0) { ?>
 826
 827 // fix inconsistently formatted phone numbers from the database
 828 var f = document.forms[0];
 829 if (f.form_phone_contact) phonekeyup(f.form_phone_contact,mypcc);
 830 if (f.form_phone_home   ) phonekeyup(f.form_phone_home   ,mypcc);
 831 if (f.form_phone_biz    ) phonekeyup(f.form_phone_biz    ,mypcc);
 832 if (f.form_phone_cell   ) phonekeyup(f.form_phone_cell   ,mypcc);
 833
 834 <?php }?>
 835
 836 <?php echo $date_init; ?>
 837
 838 // -=- jQuery makes life easier -=-
 839
 840 // var matches = 0; // number of patients that match the demographic information being entered
 841 // var override = false; // flag that overrides the duplication warning
 842
 843 $(document).ready(function() {
 844 enable_modals();
 845  $(".medium_modal").fancybox( {
 846                 'overlayOpacity' : 0.0,
 847                 'showCloseButton' : true,
 848                 'frameHeight' : 460,
 849                 'frameWidth' : 650
 850         });
 851     // added to integrate insurance stuff
 852     <?php for ($i=1; $i<=3; $i++) { ?>
 853     $("#form_i<?php echo $i?>subscriber_relationship").change(function() { auto_populate_employer_address<?php echo $i?>(); });
 854     <?php } ?>
 855
 856     $('#search').click(function() { searchme(); });
 857     $('#create').click(function() { check()});
 858
 859     var check = function(e) {
 860         <?php if ($GLOBALS['new_validate']) {?>
 861             var valid = submitme(<?php echo $GLOBALS['new_validate'] ? 1 : 0;?>,e,"DEM",constraints);
 862         <?php } else {?>
 863             top.restoreSession();
 864             var f = document.forms[0];
 865             var valid = validate(f);
 866         <?php }?>
 867         if (valid) {
 868             if (force_submit) {
 869                 // In this case dups were shown already and Save should just save.
 870                 top.restoreSession();
 871                 f.submit();
 872                 return;
 873             }
 874
 875         <?php
 876         // D in edit_options indicates the field is used in duplication checking.
 877         // This constructs a list of the names of those fields.
 878         $mflist = "";
 879         $mfres = sqlStatement("SELECT * FROM layout_options " .
 880             "WHERE form_id = 'DEM' AND uor > 0 AND field_id != '' AND " .
 881             "(edit_options LIKE '%D%' OR  edit_options LIKE '%W%' )" .
 882             "ORDER BY group_name, seq");
 883         while ($mfrow = sqlFetchArray($mfres)) {
 884             $field_id  = $mfrow['field_id'];
 885             if (strpos($field_id, 'em_') === 0) {
 886                 continue;
 887             }
 888
 889             if (!empty($mflist)) {
 890                 $mflist .= ",";
 891             }
 892
 893             $mflist .= "'" . htmlentities($field_id) . "'";
 894         }
 895 ?>
 896         <?php if (($GLOBALS['full_new_patient_form'] == '4') && (checkIfPatientValidationHookIsActive())) :?>
 897             // Use zend module patient validation hook to open the controller and send the dup-checker fields.
 898             var url ='<?php echo  $GLOBALS['web_root']."/interface/modules/zend_modules/public/patientvalidation";?>';
 899         <?php else :?>
 900             // Build and invoke the URL to create the dup-checker dialog.
 901             var url = 'new_search_popup.php';
 902         <?php endif;?>
 903
 904         var flds = new Array(<?php echo $mflist; ?>);
 905         var separator = '?';
 906         for (var i = 0; i < flds.length; ++i) {
 907             var fval = $('#form_' + flds[i]).val();
 908             if (fval && fval != '') {
 909                 url += separator;
 910                 separator = '&';
 911                 url += 'mf_' + flds[i] + '=' + encodeURIComponent(fval);
 912             }
 913         }
 914         url+="&close"
 915         dlgopen(url, '_blank', 700, 500);
 916         } // end function
 917     } // end function
 918
 919
 920 // Set onclick/onfocus handlers for toggling background color.
 921 <?php
 922 $lres = getLayoutRes();
 923 while ($lrow = sqlFetchArray($lres)) {
 924     $field_id  = $lrow['field_id'];
 925     if (strpos($field_id, 'em_') === 0) {
 926         continue;
 927     }
 928
 929     switch (getSearchClass($lrow['data_type'])) {
 930         case 1:
 931             echo "    \$('#form_$field_id').click(function() { toggleSearch(this); });\n";
 932             break;
 933         case 2:
 934             echo "    \$('#form_$field_id').click(function() { selClick(this); });\n";
 935             echo "    \$('#form_$field_id').blur(function() { selBlur(this); });\n";
 936             break;
 937     }
 938 }
 939 ?>
 940
 941   $('.datepicker').datetimepicker({
 942     <?php $datetimepicker_timepicker = false; ?>
 943     <?php $datetimepicker_showseconds = false; ?>
 944     <?php $datetimepicker_formatInput = false; ?>
 945     <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 946     <?php // can add any additional javascript settings to datetimepicker here; need to prepend first setting with a comma ?>
 947   });
 948   $('.datetimepicker').datetimepicker({
 949     <?php $datetimepicker_timepicker = true; ?>
 950     <?php $datetimepicker_showseconds = false; ?>
 951     <?php $datetimepicker_formatInput = false; ?>
 952     <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 953     <?php // can add any additional javascript settings to datetimepicker here; need to prepend first setting with a comma ?>
 954   });
 955
 956 }); // end document.ready
 957
 958 </script>
 959 <?php /*Include the validation script and rules for this form*/
 960 $form_id="DEM";
 961 ?>
 962
 963 <?php
 964 //LBF forms use the new validation depending on the global value
 965 $use_validate_js=$GLOBALS['new_validate'];
 966 include_once("$srcdir/validation/validation_script.js.php");?>
 967 <script language='JavaScript'>
 968     // Array of skip conditions for the checkSkipConditions() function.
 969     var skipArray = [
 970         <?php echo $condition_str; ?>
 971     ];
 972     checkSkipConditions();
 973     $("input").change(function() {
 974         checkSkipConditions();
 975     });
 976     $("select").change(function() {
 977         checkSkipConditions();
 978     });
 979 </script>
 980
 981 </html>