interface/patient_file/summary/demographics_full.php

   1 <?php
   2
   3 /**
   4  * Edit demographics.
   5  *
   6  * @package   OpenEMR
   7  * @link      http://www.open-emr.org
   8  * @author    Brady Miller <brady.g.miller@gmail.com>
   9  * @copyright Copyright (c) 2017 Brady Miller <brady.g.miller@gmail.com>
  10  * @copyright Copyright (c) 2021 Rod Roark <rod@sunsetsystems.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("$srcdir/options.inc.php");
  16 require_once("$srcdir/validation/LBF_Validation.php");
  17 require_once("$srcdir/patientvalidation.inc.php");
  18 require_once("$srcdir/pid.inc.php");
  19 require_once("$srcdir/patient.inc.php");
  20
  21 use OpenEMR\Common\Acl\AclMain;
  22 use OpenEMR\Common\Csrf\CsrfUtils;
  23 use OpenEMR\Core\Header;
  24 use OpenEMR\Events\PatientDemographics\UpdateEvent;
  25
  26 // Session pid must be right or bad things can happen when demographics are saved!
  27 //
  28 $set_pid = $_GET["set_pid"] ?? ($_GET["pid"] ?? null);
  29 if ($set_pid && $set_pid != $_SESSION["pid"]) {
  30     setpid($set_pid);
  31 }
  32
  33 $result = getPatientData($pid, "*, DATE_FORMAT(DOB,'%Y-%m-%d') as DOB_YMD");
  34 $result2 = getEmployerData($pid);
  35
  36  // Check authorization.
  37 if ($pid) {
  38     // Create and fire the patient demographics update event
  39     $updateEvent = new UpdateEvent($pid);
  40     $updateEvent = $GLOBALS["kernel"]->getEventDispatcher()->dispatch($updateEvent, UpdateEvent::EVENT_HANDLE, 10);
  41
  42     if (
  43         !$updateEvent->authorized() ||
  44         !AclMain::aclCheckCore('patients', 'demo', '', 'write')
  45     ) {
  46         die(xlt('Updating demographics is not authorized.'));
  47     }
  48
  49     if ($result['squad'] && ! AclMain::aclCheckCore('squads', $result['squad'])) {
  50         die(xlt('You are not authorized to access this squad.'));
  51     }
  52 } else {
  53     if (!AclMain::aclCheckCore('patients', 'demo', '', array('write','addonly'))) {
  54         die(xlt('Adding demographics is not authorized.'));
  55     }
  56 }
  57
  58 $CPR = 4; // cells per row
  59
  60 // $statii = array('married','single','divorced','widowed','separated','domestic partner');
  61 // $provideri = getProviderInfo();
  62 if ($GLOBALS['insurance_information'] != '0') {
  63     $insurancei = getInsuranceProvidersExtra();
  64 } else {
  65     $insurancei = getInsuranceProviders();
  66 }
  67 //Check to see if only one insurance is allowed
  68 if ($GLOBALS['insurance_only_one']) {
  69     $insurance_array = array('primary');
  70 } else {
  71     $insurance_array = array('primary', 'secondary', 'tertiary');
  72 }
  73 ?>
  74 <!DOCTYPE html>
  75 <html>
  76 <head>
  77 <?php Header::setupHeader(['datetime-picker','common','select2', 'erx']);
  78 ?>
  79 <title><?php echo xlt('Edit Current Patient'); ?></title>
  80
  81 <?php include_once($GLOBALS['srcdir'] . "/options.js.php"); ?>
  82
  83 <script>
  84
  85 // Support for beforeunload handler.
  86 var somethingChanged = false;
  87
  88 $(function () {
  89     tabbify();
  90
  91     $('.swapIns').hide();
  92
  93     $(".select-previous-names").select2({
  94         theme: "bootstrap4",
  95         dropdownAutoWidth: true,
  96         width: 'resolve',
  97         <?php require($GLOBALS['srcdir'] . '/js/xl/select2.js.php'); ?>
  98     }).on("select2:unselecting", function (e) {
  99         $(this).data('state', 'unselected');
 100         var data = e.params.args.data;
 101         const message = "<span>" + xl("Are You Sure you want to delete this name?") + "</span>";
 102         const ele = opener.document.getElementById('form_name_history');
 103         dialog.confirm(message).then(returned => {
 104             if (returned !== true) {
 105                 if (data !== false) {
 106                     $(".select-previous-names > option").prop("selected", "selected").trigger("change");
 107                 }
 108                 return false;
 109             }
 110             // delete from table.
 111             const url = top.webroot_url + '/library/ajax/specialty_form_ajax.php?delete=true';
 112             let doData = new FormData();
 113             doData.append('csrf_token_form', <?php echo js_escape(CsrfUtils::collectCsrfToken()); ?>);
 114             doData.append('id', data.id);
 115             doData.append('task_name_history', 'delete');
 116             fetch(url, {
 117                 method: 'POST',
 118                 body: doData
 119             }).then(rtn => rtn.json()).then((rtn) => {
 120                 dialog.alert(xl("Returned: " + rtn));
 121                 if (rtn === 'Success') {
 122                     $(".select-previous-names option[value=" + data.id + "]").remove();
 123                 }
 124             });
 125         });
 126     }).on("select2:open", function (e) {
 127         if ($(this).data('state') === 'unselected') {
 128             $(this).removeData('state');
 129             let self = $(this);
 130             setTimeout(function () {
 131                 self.select2('close');
 132             }, 1);
 133         }
 134     }).on('select2:opening select2:closing', function (event) {
 135         let $search = $(this).parent().find('.select2-search__field');
 136         $search.prop('disabled', true);
 137     });
 138
 139     // careteam select2
 140     $(".select-dropdown").select2({
 141         theme: "bootstrap4",
 142         dropdownAutoWidth: true,
 143         width: 'resolve',
 144         <?php require($GLOBALS['srcdir'] . '/js/xl/select2.js.php'); ?>
 145     });
 146     if (typeof error !== 'undefined') {
 147         if (error) {
 148             alertMsg(error);
 149         }
 150     }
 151
 152     $(".medium_modal").on('click', function(e) {
 153         e.preventDefault();e.stopPropagation();
 154         let title = <?php echo xlj('Insurance Search/Select/Add'); ?>;
 155         let ins_url = $(this).attr('href') + encodeURIComponent(sendInsToSearch(insurance_index));
 156         dlgopen('', '', 700, 600, '', title, {
 157             buttons: [
 158                 {text: <?php echo xlj('Close'); ?>, close: true, style: 'default btn-sm'}
 159             ],
 160             allowResize: true,
 161             allowDrag: true,
 162             dialogId: '',
 163             type: 'iframe',
 164             url: ins_url
 165         });
 166     });
 167
 168     $('.datepicker').datetimepicker({
 169     <?php $datetimepicker_timepicker = false; ?>
 170     <?php $datetimepicker_showseconds = false; ?>
 171     <?php $datetimepicker_formatInput = true; ?>
 172     <?php $datetimepicker_minDate = false; ?>
 173     <?php $datetimepicker_maxDate = false; ?>
 174     <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 175     <?php // can add any additional javascript settings to datetimepicker here; need to prepend first setting with a comma ?>
 176   });
 177   $('.datetimepicker').datetimepicker({
 178     <?php $datetimepicker_timepicker = true; ?>
 179     <?php $datetimepicker_showseconds = false; ?>
 180     <?php $datetimepicker_formatInput = true; ?>
 181     <?php $datetimepicker_minDate = false; ?>
 182     <?php $datetimepicker_maxDate = false; ?>
 183     <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 184     <?php // can add any additional javascript settings to datetimepicker here; need to prepend first setting with a comma ?>
 185   });
 186   $('.datepicker-past').datetimepicker({
 187     <?php $datetimepicker_timepicker = false; ?>
 188     <?php $datetimepicker_showseconds = false; ?>
 189     <?php $datetimepicker_formatInput = true; ?>
 190     <?php $datetimepicker_minDate = false; ?>
 191     <?php $datetimepicker_maxDate = '+1970/01/01'; ?>
 192     <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 193     <?php // can add any additional javascript settings to datetimepicker here; need to prepend first setting with a comma ?>
 194   });
 195   $('.datetimepicker-past').datetimepicker({
 196     <?php $datetimepicker_timepicker = true; ?>
 197     <?php $datetimepicker_showseconds = false; ?>
 198     <?php $datetimepicker_formatInput = true; ?>
 199     <?php $datetimepicker_minDate = false; ?>
 200     <?php $datetimepicker_maxDate = '+1970/01/01'; ?>
 201     <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 202     <?php // can add any additional javascript settings to datetimepicker here; need to prepend first setting with a comma ?>
 203   });
 204   $('.datepicker-future').datetimepicker({
 205     <?php $datetimepicker_timepicker = false; ?>
 206     <?php $datetimepicker_showseconds = false; ?>
 207     <?php $datetimepicker_formatInput = true; ?>
 208     <?php $datetimepicker_minDate = '-1970/01/01'; ?>
 209     <?php $datetimepicker_maxDate = false; ?>
 210     <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 211     <?php // can add any additional javascript settings to datetimepicker here; need to prepend first setting with a comma ?>
 212   });
 213   $('.datetimepicker-future').datetimepicker({
 214     <?php $datetimepicker_timepicker = true; ?>
 215     <?php $datetimepicker_showseconds = false; ?>
 216     <?php $datetimepicker_formatInput = true; ?>
 217     <?php $datetimepicker_minDate = '-1970/01/01'; ?>
 218     <?php $datetimepicker_maxDate = false; ?>
 219     <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 220     <?php // can add any additional javascript settings to datetimepicker here; need to prepend first setting with a comma ?>
 221   });
 222
 223   // Support for beforeunload handler.
 224   $('.tab input, .tab select, .tab textarea').change(function() {
 225     somethingChanged = true;
 226   });
 227   window.addEventListener("beforeunload", function (e) {
 228     if (somethingChanged && !top.timed_out) {
 229       var msg = <?php echo xlj('You have unsaved changes.'); ?>;
 230       e.returnValue = msg;     // Gecko, Trident, Chrome 34+
 231       return msg;              // Gecko, WebKit, Chrome <34
 232     }
 233   });
 234
 235   if (window.checkSkipConditions) {
 236     checkSkipConditions();
 237   }
 238   // Hide swap ins button if insurance is primary
 239   $('#INSURANCE .tabNav a').click(function(){
 240     let text = $(this).text();
 241     if ( text != 'Primary') {
 242         $('.swapIns').show();
 243     } else {
 244         $('.swapIns').hide();
 245     }
 246   })
 247 });
 248
 249 var mypcc = <?php echo js_escape($GLOBALS['phone_country_code']); ?>;
 250
 251 //code used from http://tech.irt.org/articles/js037/
 252 function replace(string,text,by) {
 253  // Replaces text with by in string
 254  var strLength = string.length, txtLength = text.length;
 255  if ((strLength == 0) || (txtLength == 0)) return string;
 256
 257  var i = string.indexOf(text);
 258  if ((!i) && (text != string.substring(0,txtLength))) return string;
 259  if (i == -1) return string;
 260
 261  var newstr = string.substring(0,i) + by;
 262
 263  if (i+txtLength < strLength)
 264   newstr += replace(string.substring(i+txtLength,strLength),text,by);
 265
 266  return newstr;
 267 }
 268
 269 function upperFirst(string,text) {
 270  return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
 271 }
 272
 273 <?php for ($i = 1; $i <= 3; $i++) { ?>
 274 function auto_populate_employer_address<?php echo attr($i); ?>(){
 275  var f = document.demographics_form;
 276  if (f.form_i<?php echo attr($i); ?>subscriber_relationship.options[f.form_i<?php echo attr($i); ?>subscriber_relationship.selectedIndex].value == "self")
 277  {
 278   f.i<?php echo attr($i); ?>subscriber_fname.value=f.form_fname.value;
 279   f.i<?php echo attr($i); ?>subscriber_mname.value=f.form_mname.value;
 280   f.i<?php echo attr($i); ?>subscriber_lname.value=f.form_lname.value;
 281   f.i<?php echo attr($i); ?>subscriber_street.value=f.form_street.value;
 282   f.i<?php echo attr($i); ?>subscriber_street_line_2.value=f.form_street_line_2.value;
 283   f.i<?php echo attr($i); ?>subscriber_city.value=f.form_city.value;
 284   f.form_i<?php echo attr($i); ?>subscriber_state.value=f.form_state.value;
 285   f.i<?php echo attr($i); ?>subscriber_postal_code.value=f.form_postal_code.value;
 286   if (f.form_country_code)
 287     f.form_i<?php echo attr($i); ?>subscriber_country.value=f.form_country_code.value;
 288   f.i<?php echo attr($i); ?>subscriber_phone.value=f.form_phone_home.value;
 289   f.i<?php echo attr($i); ?>subscriber_DOB.value=f.form_DOB.value;
 290   if(typeof f.form_ss!="undefined")
 291     {
 292         f.i<?php echo attr($i); ?>subscriber_ss.value=f.form_ss.value;
 293     }
 294   f.form_i<?php echo attr($i); ?>subscriber_sex.value = f.form_sex.value;
 295   f.i<?php echo attr($i); ?>subscriber_employer.value=f.form_em_name.value;
 296   f.i<?php echo attr($i); ?>subscriber_employer_street.value=f.form_em_street.value;
 297   f.i<?php echo attr($i); ?>subscriber_employer_street_line_2.value=f.form_em_street_line_2.value;
 298   f.i<?php echo attr($i); ?>subscriber_employer_city.value=f.form_em_city.value;
 299   f.form_i<?php echo attr($i); ?>subscriber_employer_state.value=f.form_em_state.value;
 300   f.i<?php echo attr($i); ?>subscriber_employer_postal_code.value=f.form_em_postal_code.value;
 301   if (f.form_em_country)
 302     f.form_i<?php echo attr($i); ?>subscriber_employer_country.value=f.form_em_country.value;
 303  }
 304 }
 305
 306 <?php } ?>
 307
 308 function popUp(URL) {
 309  day = new Date();
 310  id = day.getTime();
 311  top.restoreSession();
 312  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');");
 313 }
 314
 315 function checkNum () {
 316  var re= new RegExp();
 317  re = /^\d*\.?\d*$/;
 318  str=document.demographics_form.monthly_income.value;
 319  if(re.exec(str))
 320  {
 321  }else{
 322   alert(<?php echo xlj('Please enter a monetary amount using only numbers and a decimal point.'); ?>);
 323  }
 324 }
 325
 326 function address_verify() {
 327     top.restoreSession();
 328     var f = document.demographics_form;
 329
 330     dlgopen('../../practice/address_verify.php?address1=' + encodeURIComponent(f.form_street.value) +
 331     '&address2=' + encodeURIComponent(f.form_street_line_2.value) +
 332     '&city=' + encodeURIComponent(f.form_city.value) +
 333     '&state=' + encodeURIComponent(f.form_state.value) +
 334     '&zip5=' + encodeURIComponent(f.form_postal_code.value.substring(0,5)) +
 335     '&zip4=' + encodeURIComponent(f.form_postal_code.value.substring(5,9))
 336     , '_blank', 400, 150, '', xl('Address Verify'));
 337
 338     return false;
 339 }
 340
 341 // Indicates which insurance slot is being updated.
 342 var insurance_index = 0;
 343
 344 // The OnClick handler for searching/adding the insurance company.
 345 function ins_search(ins) {
 346     insurance_index = ins;
 347     return false;
 348 }
 349
 350 function sendInsToSearch(ins) {
 351     let thesel = $('#i' + ins + 'provider');
 352     let theseldata = $(thesel).select2('data');
 353     return theseldata[0]['id'];
 354 }
 355
 356 function InsSaveClose() {
 357     top.restoreSession();
 358     document.location.reload();
 359 }
 360 // The ins_search.php window calls this to set the selected insurance.
 361 function set_insurance(ins_id, ins_name) {
 362     thesel = $('#i' + insurance_index + 'provider');
 363     if ($(thesel).find("option[value='" + ins_id  + "']").length) {
 364         thesel.val(ins_id).trigger('change');
 365     } else {
 366         // no matching option was found so create one, append it to the
 367         // end of the list, and select it.
 368         let newOption = new Option(ins_name, ins_id, true, true);
 369         thesel.append(newOption).trigger('change');
 370     }
 371 }
 372
 373 // This capitalizes the first letter of each word in the passed input
 374 // element.  It also strips out extraneous spaces.
 375 function capitalizeMe(elem) {
 376  var a = elem.value.split(' ');
 377  var s = '';
 378  for(var i = 0; i < a.length; ++i) {
 379   if (a[i].length > 0) {
 380    if (s.length > 0) s += ' ';
 381    s += a[i].charAt(0).toUpperCase() + a[i].substring(1);
 382   }
 383  }
 384  elem.value = s;
 385 }
 386
 387 function divclick(cb, divid) {
 388  var divstyle = document.getElementById(divid).style;
 389  if (cb.checked) {
 390   divstyle.display = 'block';
 391  } else {
 392   divstyle.display = 'none';
 393  }
 394  return true;
 395 }
 396
 397 // Compute the length of a string without leading and trailing spaces.
 398 function trimlen(s) {
 399  var i = 0;
 400  var j = s.length - 1;
 401  for (; i <= j && s.charAt(i) == ' '; ++i);
 402  for (; i <= j && s.charAt(j) == ' '; --j);
 403  if (i > j) return 0;
 404  return j + 1 - i;
 405 }
 406
 407 function validate(f) {
 408  var errCount = 0;
 409  var errMsgs = new Array();
 410 <?php generate_layout_validation('DEM'); ?>
 411
 412  var msg = "";
 413  msg += <?php echo xlj('The following fields are required'); ?> + ":\n\n";
 414  for ( var i = 0; i < errMsgs.length; i++ ) {
 415     msg += errMsgs[i] + "\n";
 416  }
 417  msg += "\n" + <?php echo xlj('Please fill them in before continuing.'); ?>;
 418
 419  if ( errMsgs.length > 0 ) {
 420     alert(msg);
 421  }
 422
 423  //Misc  Deceased Date Validation for Future Date
 424 var dateVal = document.getElementById("form_deceased_date").value;
 425 var currentDate;
 426 var d = new Date();
 427 month = '' + (d.getMonth() + 1),
 428 day = '' + d.getDate(),
 429 year = d.getFullYear();
 430 if (month.length < 2) month = '0' + month;
 431 if (day.length < 2) day = '0' + day;
 432 currentDate = year+'-'+month+'-'+day;
 433 if(dateVal > currentDate)
 434 {
 435     alert (<?php echo xlj("Deceased Date should not be greater than Today"); ?>);
 436     return false;
 437 }
 438
 439 //Patient Data validations
 440     <?php if ($GLOBALS['erx_enable']) { ?>
 441  alertMsg='';
 442  for(i=0;i<f.length;i++){
 443   if(f[i].type=='text' && f[i].value)
 444   {
 445    if(f[i].name == 'form_fname' || f[i].name == 'form_mname' || f[i].name == 'form_lname')
 446    {
 447     alertMsg += checkLength(f[i].name,f[i].value,35);
 448     alertMsg += checkUsername(f[i].name,f[i].value);
 449    }
 450    else if(f[i].name == 'form_street' || f[i].name == 'form_city')
 451    {
 452     alertMsg += checkLength(f[i].name,f[i].value,35);
 453     alertMsg += checkAlphaNumericExtended(f[i].name,f[i].value);
 454    }
 455    else if(f[i].name == 'form_phone_home')
 456    {
 457     alertMsg += checkPhone(f[i].name,f[i].value);
 458    }
 459   }
 460  }
 461  if(alertMsg)
 462  {
 463    alert(alertMsg);
 464    return false;
 465  }
 466     <?php } ?>
 467  //return false;
 468
 469 // Some insurance validation.
 470  for (var i = 1; i <= 3; ++i) {
 471   subprov = 'i' + i + 'provider';
 472   if (!f[subprov] || f[subprov].selectedIndex <= 0) continue;
 473   var subpfx = 'i' + i + 'subscriber_';
 474   var subrelat = f['form_' + subpfx + 'relationship'];
 475   var samename =
 476    f[subpfx + 'fname'].value == f.form_fname.value &&
 477    f[subpfx + 'mname'].value == f.form_mname.value &&
 478    f[subpfx + 'lname'].value == f.form_lname.value;
 479   var ss_regexp=/[0-9][0-9][0-9]-?[0-9][0-9]-?[0-9][0-9][0-9][0-9]/;
 480   var samess=true;
 481   var ss_valid=false;
 482   if(typeof f.form_ss!="undefined")
 483       {
 484         samess = f[subpfx + 'ss'].value == f.form_ss.value;
 485         ss_valid=ss_regexp.test(f[subpfx + 'ss'].value) && ss_regexp.test(f.form_ss.value);
 486       }
 487   if (subrelat.options[subrelat.selectedIndex].value == "self") {
 488    if (!samename) {
 489     if (!confirm(<?php echo xlj('Subscriber relationship is self but name is different! Is this really OK?'); ?>))
 490      return false;
 491    }
 492    if (!samess && ss_valid) {
 493     if(!confirm(<?php echo js_escape(xl('Subscriber relationship is self but SS number is different!') . " " . xl("Is this really OK?")); ?>))
 494     return false;
 495    }
 496   } // end self
 497   else {
 498    if (samename) {
 499     if (!confirm(<?php echo xlj('Subscriber relationship is not self but name is the same! Is this really OK?'); ?>))
 500      return false;
 501    }
 502    if (samess && ss_valid)  {
 503     if(!confirm(<?php echo js_escape(xl('Subscriber relationship is not self but SS number is the same!') . " " . xl("Is this really OK?")); ?>))
 504     return false;
 505    }
 506   } // end not self
 507  } // end for
 508
 509  return errMsgs.length < 1;
 510 }
 511
 512 // Added 06/2009 by BM to make compatible with list_options table and functions - using jquery
 513 $(function () {
 514
 515     <?php for ($i = 1; $i <= 3; $i++) { ?>
 516   $("#form_i<?php echo attr($i); ?>subscriber_relationship").change(function() { auto_populate_employer_address<?php echo attr($i); ?>(); });
 517     <?php } ?>
 518
 519 });
 520
 521 </script>
 522
 523 <style>
 524         div.demographicsEditContainer div.label_custom {
 525             font-size: 0.8rem;
 526             display: grid;
 527             align-items: center;
 528             line-height: 1.2;
 529             padding-top: 0 !important;
 530             margin-bottom: 0.2rem;
 531         }
 532
 533         div.insuranceEditContainer div.label_custom span {
 534             font-size: 0.8rem;
 535             display: inline-flex;
 536             height: 100%;
 537             align-items: center;
 538             line-height: 1.2;
 539         }
 540
 541         <?php
 542         if (!empty($GLOBALS['right_justify_labels_demographics']) && ($_SESSION['language_direction'] == 'ltr')) { ?>
 543         div.label_custom {
 544             text-align: right !important;
 545         }
 546
 547         div.tab td.data, div.data {
 548             padding-left: 0.5em;
 549             padding-right: 2em;
 550         }
 551             <?php
 552         }  ?>
 553 </style>
 554
 555 </head>
 556
 557 <?php
 558 /*Get the constraint from the DB-> LBF forms accordinf the form_id*/
 559 $constraints = LBF_Validation::generate_validate_constraints("DEM");
 560 ?>
 561 <script> var constraints = <?php echo $constraints;?>; </script>
 562
 563 <body class="body_top">
 564
 565 <form action='demographics_save.php' name='demographics_form' id="DEM" method='post' class='form-inline'
 566  onsubmit="submitme(<?php echo $GLOBALS['new_validate'] ? 1 : 0;?>,event,'DEM',constraints)">
 567 <input type="hidden" name="csrf_token_form" value="<?php echo attr(CsrfUtils::collectCsrfToken()); ?>" />
 568 <input type='hidden' name='mode' value='save' />
 569 <input type='hidden' name='db_id' value="<?php echo attr($result['id']); ?>" />
 570 <input type="hidden" name="isSwapClicked" value="" />
 571
 572     <div class="container-xl">
 573         <div class="row">
 574             <div class="col-12">
 575                 <h2><?php echo xlt('Edit Current Patient');?></h2>
 576             </div>
 577             <div class="col-12">
 578                 <div class="btn-group">
 579                     <button type="submit" class="btn btn-primary btn-save" id="submit_btn" disabled="disabled" value="<?php echo xla('Save'); ?>">
 580                         <?php echo xlt('Save'); ?>
 581                     </button>
 582                     <a class="btn btn-secondary btn-cancel" href="demographics.php" onclick="top.restoreSession()">
 583                         <?php echo xlt('Cancel'); ?>
 584                     </a>
 585                 </div>
 586                 <hr>
 587             </div>
 588         </div>
 589     </div>
 590 <?php
 591 $condition_str = '';
 592 ?>
 593 <br />
 594 <div class='container-xl demographicsEditContainer'>
 595     <div class="section-header">
 596         <span class="text font-weight-bold"><?php echo xlt("Demographics")?></span>
 597     </div>
 598     <ul class="tabNav">
 599         <?php display_layout_tabs('DEM', $result, $result2); ?>
 600     </ul>
 601
 602     <div class="tabContainer">
 603         <?php display_layout_tabs_data_editable('DEM', $result, $result2); ?>
 604     </div>
 605 </div>
 606 <br />
 607
 608 <div class='container-xl'>
 609
 610 <?php
 611 if (! $GLOBALS['simplified_demographics']) {
 612     //Check to see if only one insurance is allowed
 613     if ($GLOBALS['insurance_only_one']) {
 614         $insurance_headings = array(xl("Primary Insurance Provider"));
 615         $insurance_info = array();
 616         $insurance_info[1] = getInsuranceData($pid, "primary");
 617     } else {
 618         $insurance_headings = array(xl("Primary Insurance Provider"), xl("Secondary Insurance Provider"), xl("Tertiary Insurance provider"));
 619         $insurance_info = array();
 620         $insurance_info[1] = getInsuranceData($pid, "primary");
 621         $insurance_info[2] = getInsuranceData($pid, "secondary");
 622         $insurance_info[3] = getInsuranceData($pid, "tertiary");
 623     }
 624
 625
 626     ?>
 627     <div class="section-header">
 628        <span class="text font-weight-bold"><?php echo xlt("Insurance")?></span>
 629     </div>
 630     <div id="INSURANCE" class="insuranceEditContainer">
 631        <ul class="tabNav">
 632         <?php
 633         foreach ($insurance_array as $instype) {
 634             ?>
 635             <li <?php echo $instype == 'primary' ? 'class="current"' : '' ?>><a href="#"><?php $CapInstype = ucfirst($instype);
 636             echo xlt($CapInstype); ?></a></li><?php } ?>
 637         </ul>
 638
 639     <div class="tabContainer">
 640
 641     <?php
 642     for ($i = 1; $i <= 3; $i++) {
 643         $result3 = $insurance_info[$i];
 644         ?>
 645
 646      <div class="tab <?php echo $i == 1 ? 'current' : '' ?> h-auto w-auto">
 647       <div class="form-row">
 648         <div class="col-md-6"><!-- start left column -->
 649
 650           <div class="form-row"><!-- start nested row -->
 651             <div class="col-md-3 label_custom pb-3">
 652               <span class='required'><?php echo text($insurance_headings[$i - 1]); ?>:</span>
 653             </div>
 654             <div class="col-md-9">
 655               <a class="medium_modal btn btn-primary" href="../../practice/ins_search.php?ins=" role="button"
 656                 onclick="ins_search(<?php echo attr_js($i); ?>)"><?php echo xlt('Search/Add/Edit') ?></a>
 657               <select id="i<?php echo attr($i); ?>provider" name="i<?php echo attr($i); ?>provider" class="form-control form-control-sm sel2 mb-1" style="width: 250px;">
 658                 <option value=""><?php echo xlt('Unassigned'); ?></option>
 659                 <?php
 660                 foreach ($insurancei as $iid => $iname) {
 661                     echo "<option value='" . attr($iid) . "'";
 662                     if (!empty($result3["provider"]) && (strtolower($iid) == strtolower($result3["provider"]))) {
 663                         echo " selected";
 664                     }
 665                     echo ">" . text($iname) . "</option>\n";
 666                 }
 667                 ?>
 668               </select>
 669             </div>
 670           </div><!-- end nested row -->
 671
 672           <div class="form-row"><!-- start nested row -->
 673             <div class="col-md-3 pb-1 label_custom">
 674               <span class='required'><?php echo xlt('Plan Name'); ?>:</span>
 675             </div>
 676             <div class="col-md-6">
 677               <input type='entry' class='form-control form-control-sm mb-1' size='20'
 678                name='i<?php echo attr($i); ?>plan_name'
 679                value="<?php echo attr($result3["plan_name"] ?? ''); ?>"
 680                onchange="capitalizeMe(this);" />
 681             </div>
 682             <div class="col-md-3 swapIns <?php echo (empty($GLOBALS['enable_swap_secondary_insurance'])) ? ' d-none"' : '"'; ?>>
 683                 <a class="btn btn-secondary pb-1" href="#" role="button"
 684                     onclick="document.forms[0].isSwapClicked.value=<?php echo attr($i); ?>; document.forms[0].submit()">
 685                         <?php echo ($i == '2') ? xlt('Swap with Primary') : xlt('Swap with Secondary'); ?>
 686                 </a>
 687             </div>
 688           </div><!-- end nested row -->
 689
 690           <div class="form-row"><!-- start nested row -->
 691             <div class="col-md-3 pb-1 label_custom ">
 692               <span class='required'><?php echo xlt('Effective Date'); ?>:</span>
 693             </div>
 694             <div class="col-md-9">
 695               <input type='entry' size='16' class='datepicker form-control form-control-sm mb-1'
 696                id='i<?php echo attr($i); ?>effective_date'
 697                name='i<?php echo attr($i); ?>effective_date'
 698                value='<?php echo attr(oeFormatShortDate($result3['date'] ?? '')); ?>' />
 699             </div>
 700           </div><!-- end nested row -->
 701
 702           <div class="form-row"><!-- start nested row -->
 703             <div class="col-md-3 pb-1 label_custom ">
 704               <span class='required'><?php echo xlt('Effective Date End'); ?>:</span>
 705             </div>
 706             <div class="col-md-9">
 707               <input type='entry' size='16' class='datepicker form-control form-control-sm mb-1'
 708                id='i<?php echo attr($i); ?>effective_date_end'
 709                name='i<?php echo attr($i); ?>effective_date_end'
 710                value='<?php echo attr(oeFormatShortDate($result3['date_end'] ?? '')); ?>' />
 711             </div>
 712           </div><!-- end nested row -->
 713
 714           <div class="form-row"><!-- start nested row -->
 715             <div class="col-md-3 pb-1 label_custom">
 716               <span class='required'><?php echo xlt('Policy Number'); ?>:</span>
 717             </div>
 718             <div class="col-md-9">
 719               <input type='entry' class='form-control form-control-sm mb-1' size='16'
 720                name='i<?php echo attr($i); ?>policy_number'
 721                value="<?php echo attr($result3["policy_number"] ?? ''); ?>"
 722                onkeyup='policykeyup(this)' />
 723             </div>
 724           </div><!-- end nested row -->
 725
 726           <div class="form-row"><!-- start nested row -->
 727             <div class="col-md-3 pb-1 label_custom ">
 728               <span class='required'><?php echo xlt('Group Number'); ?>:</span>
 729             </div>
 730             <div class="col-md-9">
 731               <input type="text" class='form-control form-control-sm mb-1' size='16'
 732                name='i<?php echo attr($i); ?>group_number'
 733                value="<?php echo attr($result3["group_number"] ?? ''); ?>"
 734                onkeyup='policykeyup(this)' />
 735             </div>
 736           </div><!-- end nested row -->
 737
 738           <div class="form-row"<?php echo $GLOBALS['omit_employers'] ? " style='display:none'" : ""; ?>><!-- start nested row -->
 739             <div class="col-md-3 pb-4 label_custom">
 740               <span class='required'><?php echo xlt('Subscriber Employer (SE)'); ?>:</span>
 741             </div>
 742             <div class="col-md-9">
 743               <input type='entry' class='form-control form-control-sm' size='25'
 744                name='i<?php echo attr($i); ?>subscriber_employer'
 745                value="<?php echo attr($result3["subscriber_employer"] ?? ''); ?>"
 746                onchange="capitalizeMe(this);" />
 747                <span class='small mb-1'><br /><?php echo xlt('if unemployed enter Student'); ?>,
 748                <?php echo xlt('PT Student, or leave blank'); ?></span>
 749             </div>
 750           </div><!-- end nested row -->
 751
 752           <div class="form-row"<?php echo $GLOBALS['omit_employers'] ? " style='display:none'" : ""; ?>><!-- start nested row -->
 753             <div class="col-md-3 pb-1 label_custom">
 754               <span class='required'><?php echo xlt('SE Address'); ?>:</span>
 755             </div>
 756             <div class="col-md-9">
 757               <input type='entry' class='form-control form-control-sm mb-1' size='25'
 758                name='i<?php echo attr($i); ?>subscriber_employer_street'
 759                value="<?php echo attr($result3["subscriber_employer_street"] ?? ''); ?>"
 760                onchange="capitalizeMe(this);" />
 761             </div>
 762             <div class="col-md-3 pb-1 label_custom">
 763               <span class='required'><?php echo xlt('SE Address Line 2'); ?>:</span>
 764             </div>
 765             <div class="col-md-9">
 766               <input type='entry' class='form-control form-control-sm mb-1' size='25'
 767                name='i<?php echo attr($i); ?>subscriber_employer_street_line_2'
 768                value="<?php echo attr($result3["subscriber_employer_street_line_2"] ?? ''); ?>"
 769                onchange="capitalizeMe(this);" />
 770             </div>
 771           </div><!-- end nested row -->
 772
 773           <div class="form-row"<?php echo $GLOBALS['omit_employers'] ? " style='display:none'" : ""; ?>><!-- start nested row -->
 774             <div class="col-md-3 pb-1 label_custom">
 775               <span class='required'><?php echo xlt('SE City'); ?>:</span>
 776             </div>
 777             <div class="col-md-9">
 778               <input type='entry' class='form-control form-control-sm mb-1' size='15'
 779                name='i<?php echo attr($i); ?>subscriber_employer_city'
 780                value="<?php echo attr($result3["subscriber_employer_city"] ?? ''); ?>"
 781                onchange="capitalizeMe(this);" />
 782             </div>
 783           </div><!-- end nested row -->
 784
 785           <div class="form-row"<?php echo $GLOBALS['omit_employers'] ? " style='display:none'" : ""; ?>><!-- start nested row -->
 786             <div class="col-md-3 pb-1 label_custom">
 787               <span class='required'><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('SE State') : xlt('SE Locality') ?>:</span>
 788             </div>
 789             <div class="col-md-9">
 790               <?php
 791                 generate_form_field(
 792                     array(
 793                         'data_type' => $GLOBALS['state_data_type'],
 794                         'field_id' => ('i' . $i . 'subscriber_employer_state'),
 795                         'list_id' => $GLOBALS['state_list'],
 796                         'fld_length' => '15',
 797                         'max_length' => '63',
 798                         'edit_options' => 'C',
 799                         'smallform' => 'true'
 800                     ),
 801                     ($result3['subscriber_employer_state'] ?? '')
 802                 );
 803                 ?>
 804             </div>
 805           </div><!-- end nested row -->
 806
 807           <div class="form-row"<?php echo $GLOBALS['omit_employers'] ? " style='display:none'" : ""; ?>><!-- start nested row -->
 808             <div class="col-md-3 pb-1 label_custom">
 809               <span class='required'><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('SE Zip Code') : xlt('SE Postal Code') ?>:</span>
 810             </div>
 811             <div class="col-md-9">
 812               <input type='entry' class='form-control form-control-sm mb-1' size='15'
 813                name='i<?php echo attr($i); ?>subscriber_employer_postal_code'
 814                value="<?php echo attr($result3["subscriber_employer_postal_code"] ?? ''); ?>" />
 815             </div>
 816           </div><!-- end nested row -->
 817
 818           <div class="form-row"<?php echo $GLOBALS['omit_employers'] ? " style='display:none'" : ""; ?>><!-- start nested row -->
 819             <div class="col-md-3 pb-1 label_custom">
 820               <span class='required'><?php echo xlt('SE Country'); ?>:</span>
 821             </div>
 822             <div class="col-md-9">
 823               <?php
 824                 // Modified 7/2009 by BM to incorporate data types
 825                 generate_form_field(
 826                     array(
 827                         'data_type' => $GLOBALS['country_data_type'],
 828                         'field_id' => ('i' . $i . 'subscriber_employer_country'),
 829                         'list_id' => $GLOBALS['country_list'],
 830                         'fld_length' => '10',
 831                         'max_length' => '63',
 832                         'edit_options' => 'C',
 833                         'smallform' => 'true'
 834                     ),
 835                     ($result3['subscriber_employer_country'] ?? '')
 836                 );
 837                 ?>
 838             </div>
 839           </div><!-- end nested row -->
 840
 841         </div><!-- end left column -->
 842
 843         <div class="col-md-6"><!-- start right column -->
 844
 845           <div class="form-row"><!-- start nested row -->
 846             <div class="col-md-3 pb-1 label_custom">
 847               <span class='required'><?php echo xlt('Relationship'); ?>:</span>
 848             </div>
 849             <div class="col-md-9">
 850               <?php
 851                 // Modified 6/2009 by BM to use list_options and function
 852                 generate_form_field(
 853                     array(
 854                         'data_type' => 1,
 855                         'field_id' => ('i' . $i . 'subscriber_relationship'),
 856                         'list_id' => 'sub_relation',
 857                         'empty_title' => ' ',
 858                         'smallform' => ' form-control form-control-sm mb-1'
 859                     ),
 860                     ($result3['subscriber_relationship'] ?? '')
 861                 );
 862                 ?>
 863               <a href="javascript:popUp('browse.php?browsenum=<?php echo attr_url($i); ?>')"
 864                class='text'>(<?php echo xlt('Browse'); ?>)</a>
 865             </div>
 866           </div><!-- end nested row -->
 867
 868           <div class="form-row"><!-- start nested row -->
 869             <div class="col-md-3 pb-1 label_custom">
 870               <span class='required'><?php echo xlt('Subscriber'); ?>:</span>
 871             </div>
 872             <div class="col-md-9">
 873               <input type='entry' class='form-control form-control-sm mb-1' size='10'
 874                name='i<?php echo attr($i); ?>subscriber_fname'
 875                value="<?php echo attr($result3["subscriber_fname"] ?? ''); ?>"
 876                onchange="capitalizeMe(this);" />
 877               <input type='entry' class='form-control form-control-sm mb-1' size='3'
 878                name='i<?php echo attr($i); ?>subscriber_mname'
 879                value="<?php echo attr($result3["subscriber_mname"] ?? ''); ?>"
 880                onchange="capitalizeMe(this);" />
 881               <input type='entry' class='form-control form-control-sm mb-1' size='10'
 882                name='i<?php echo attr($i); ?>subscriber_lname'
 883                value="<?php echo attr($result3["subscriber_lname"] ?? ''); ?>"
 884                onchange="capitalizeMe(this);" />
 885             </div>
 886           </div><!-- end nested row -->
 887
 888           <div class="form-row"><!-- start nested row -->
 889             <div class="col-md-3 pb-1 label_custom">
 890               <span><?php echo xlt('D.O.B.'); ?>:</span>
 891             </div>
 892             <div class="col-md-9">
 893               <input type='entry' class='datepicker form-control form-control-sm mb-1 mw-100'
 894                id='i<?php echo attr($i); ?>subscriber_DOB' size='11'
 895                name='i<?php echo attr($i); ?>subscriber_DOB'
 896                value='<?php echo attr(oeFormatShortDate($result3['subscriber_DOB'] ?? '')); ?>' />
 897             </div>
 898           </div><!-- end nested row -->
 899
 900           <div class="form-row"><!-- start nested row -->
 901             <div class="col-md-3 pb-1 label_custom">
 902               <span><?php echo xlt('Sex'); ?>:</span>
 903             </div>
 904             <div class="col-md-9">
 905               <?php
 906                 // Modified 6/2009 by BM to use list_options and function
 907                 generate_form_field(
 908                     array(
 909                         'data_type' => 1,
 910                         'field_id' => ('i' . $i . 'subscriber_sex'),
 911                         'list_id' => 'sex',
 912                         'smallform' => ' form-control form-control-sm mb-1'
 913                     ),
 914                     ($result3['subscriber_sex'] ?? '')
 915                 );
 916                 ?>
 917             </div>
 918           </div><!-- end nested row -->
 919
 920           <div class="form-row"><!-- start nested row -->
 921             <div class="col-md-3 pb-1 label_custom">
 922               <span><?php echo xlt('S.S.'); ?>:</span>
 923             </div>
 924             <div class="col-md-9">
 925               <input type='entry' class='form-control form-control-sm mb-1 mw-100' size='11'
 926                name='i<?php echo attr($i); ?>subscriber_ss'
 927                value="<?php echo attr(trim($result3["subscriber_ss"] ?? '')); ?>" />
 928             </div>
 929           </div><!-- end nested row -->
 930
 931           <div class="form-row"><!-- start nested row -->
 932             <div class="col-md-3 pb-1 label_custom">
 933               <span class='required'><?php echo xlt('Subscriber Address'); ?>:</span>
 934             </div>
 935             <div class="col-md-9">
 936               <input type='entry' class='form-control form-control-sm mb-1 mw-100' size='20'
 937                name='i<?php echo attr($i); ?>subscriber_street'
 938                value="<?php echo attr($result3["subscriber_street"] ?? ''); ?>"
 939                onchange="capitalizeMe(this);" />
 940             </div>
 941           </div><!-- end nested row -->
 942
 943           <div class="form-row"><!-- start nested row -->
 944             <div class="col-md-3 pb-1 label_custom">
 945               <span class='required'><?php echo xlt('Address Line 2'); ?>:</span>
 946             </div>
 947             <div class="col-md-9">
 948               <input type='entry' class='form-control form-control-sm mb-1 mw-100' size='20'
 949                name='i<?php echo attr($i); ?>subscriber_street_line_2'
 950                value="<?php echo attr($result3["subscriber_street_line_2"] ?? ''); ?>"
 951                onchange="capitalizeMe(this);" />
 952             </div>
 953           </div><!-- end nested row -->
 954
 955           <div class="form-row"><!-- start nested row -->
 956             <div class="col-md-3 pb-1 label_custom">
 957               <span class='required'><?php echo xlt('City'); ?>:</span>
 958             </div>
 959             <div class="col-md-9">
 960               <input type='entry' class='form-control form-control-sm mb-1 mw-100' size='11'
 961                name='i<?php echo attr($i); ?>subscriber_city'
 962                value="<?php echo attr($result3["subscriber_city"] ?? ''); ?>"
 963                onchange="capitalizeMe(this);" />
 964             </div>
 965           </div><!-- end nested row -->
 966
 967           <div class="form-row"><!-- start nested row -->
 968             <div class="col-md-3 pb-1 label_custom">
 969               <span class='required'><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('State') : xlt('Locality') ?>:</span>
 970             </div>
 971             <div class="col-md-9">
 972               <?php
 973                 // Modified 7/2009 by BM to incorporate data types
 974                 generate_form_field(
 975                     array(
 976                         'data_type' => $GLOBALS['state_data_type'],
 977                         'field_id' => ('i' . $i . 'subscriber_state'),
 978                         'list_id' => $GLOBALS['state_list'],
 979                         'fld_length' => '15',
 980                         'max_length' => '63',
 981                         'edit_options' => 'C',
 982                         'smallform' => 'true'
 983                     ),
 984                     ($result3['subscriber_state'] ?? '')
 985                 );
 986                 ?>
 987             </div>
 988           </div><!-- end nested row -->
 989
 990           <div class="form-row"><!-- start nested row -->
 991             <div class="col-md-3 pb-1 label_custom">
 992               <span class='required'><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('Zip Code') : xlt('Postal Code') ?>:</span>
 993             </div>
 994             <div class="col-md-9">
 995               <input type='entry' class='form-control form-control-sm mb-1' size='15'
 996                name='i<?php echo attr($i); ?>subscriber_postal_code'
 997                value="<?php echo attr($result3["subscriber_postal_code"] ?? ''); ?>" />
 998             </div>
 999           </div><!-- end nested row -->
1000
1001           <div class="form-row"><!-- start nested row -->
1002             <div class="col-md-3 pb-1 label_custom">
1003               <span class='required'><?php echo xlt('Country'); ?>:</span>
1004             </div>
1005             <div class="col-md-9">
1006               <?php
1007                 // Modified 7/2009 by BM to incorporate data types
1008                 generate_form_field(
1009                     array(
1010                         'data_type' => $GLOBALS['country_data_type'],
1011                         'field_id' => ('i' . $i . 'subscriber_country'),
1012                         'list_id' => $GLOBALS['country_list'],
1013                         'fld_length' => '10',
1014                         'max_length' => '63',
1015                         'edit_options' => 'C',
1016                         'smallform' => 'true'
1017                     ),
1018                     ($result3['subscriber_country'] ?? '')
1019                 );
1020                 ?>
1021             </div>
1022           </div><!-- end nested row -->
1023
1024           <div class="form-row"><!-- start nested row -->
1025             <div class="col-md-3 pb-1 label_custom">
1026               <span><?php echo xlt('Subscriber Phone'); ?>:</span>
1027             </div>
1028             <div class="col-md-9">
1029               <input type='text' class='form-control form-control-sm mb-1' size='20'
1030                name='i<?php echo attr($i); ?>subscriber_phone'
1031                value='<?php echo attr($result3["subscriber_phone"] ?? ''); ?>'
1032                onkeyup='phonekeyup(this,mypcc)' />
1033             </div>
1034           </div><!-- end nested row -->
1035
1036           <div class="form-row"><!-- start nested row -->
1037             <div class="col-md-3 pb-1 label_custom">
1038               <span><?php echo xlt('CoPay'); ?>:</span>
1039             </div>
1040             <div class="col-md-9">
1041               <input type='text' class='form-control form-control-sm mb-1' size="6"
1042                name='i<?php echo attr($i); ?>copay'
1043                value="<?php echo attr($result3["copay"] ?? ''); ?>" />
1044             </div>
1045           </div><!-- end nested row -->
1046
1047           <div class="form-row"><!-- start nested row -->
1048             <div class="col-md-3 pb-1 label_custom">
1049               <span class='required'><?php echo xlt('Accept Assignment'); ?>:</span>
1050             </div>
1051             <div class="col-md-9">
1052               <select class='form-control form-control-sm mb-1'
1053                name='i<?php echo attr($i); ?>accept_assignment'>
1054                   <option value="TRUE"
1055                    <?php echo (!empty($result3["accept_assignment"]) && (strtoupper($result3["accept_assignment"]) == "TRUE")) ? "selected" : ""; ?>>
1056                    <?php echo xlt('YES'); ?></option>
1057                   <option value="FALSE"
1058                    <?php echo (!empty($result3["accept_assignment"]) && (strtoupper($result3["accept_assignment"]) == "FALSE")) ? "selected" : ""; ?>>
1059                    <?php echo xlt('NO'); ?></option>
1060               </select>
1061             </div>
1062           </div><!-- end nested row -->
1063
1064           <div class="form-row"><!-- start nested row -->
1065             <div class="col-md-3 pb-1 label_custom">
1066               <span><?php echo xlt('Secondary Medicare Type'); ?>:</span>
1067             </div>
1068             <div class="col-md-9">
1069               <select class='form-control form-control-sm mb-1 sel2' name='i<?php echo attr($i); ?>policy_type'>
1070                 <?php
1071                 if (!empty($policy_types)) {
1072                     foreach ($policy_types as $key => $value) {
1073                         echo "            <option value ='" . attr($key) . "'";
1074                         if (!empty($result3['policy_type']) && ($key == $result3['policy_type'])) {
1075                             echo " selected";
1076                         }
1077                         echo ">" . text($value) . "</option>\n";
1078                     }
1079                 }
1080                 ?>
1081               </select>
1082             </div>
1083           </div><!-- end nested row -->
1084
1085         </div><!-- end right column -->
1086       </div>
1087     </div>
1088
1089         <?php
1090     } //end insurer for loop ?>
1091
1092    </div>
1093 </div>
1094
1095 <?php } // end of "if not simplified_demographics" ?>
1096 </div>
1097 </div>
1098 </form>
1099
1100 <br />
1101
1102 <script>
1103
1104 // Array of skip conditions for the checkSkipConditions() function.
1105 var skipArray = [
1106 <?php echo $condition_str; ?>
1107 ];
1108
1109 // hard code validation for old validation, in the new validation possible to add match rules
1110 <?php if ($GLOBALS['new_validate'] == 0) { ?>
1111  // fix inconsistently formatted phone numbers from the database
1112  var f = document.forms[0];
1113  if (f.form_phone_contact) phonekeyup(f.form_phone_contact,mypcc);
1114  if (f.form_phone_home   ) phonekeyup(f.form_phone_home   ,mypcc);
1115  if (f.form_phone_biz    ) phonekeyup(f.form_phone_biz    ,mypcc);
1116  if (f.form_phone_cell   ) phonekeyup(f.form_phone_cell   ,mypcc);
1117
1118     <?php if (! $GLOBALS['simplified_demographics']) { ?>
1119  phonekeyup(f.i1subscriber_phone,mypcc);
1120  phonekeyup(f.i2subscriber_phone,mypcc);
1121  phonekeyup(f.i3subscriber_phone,mypcc);
1122     <?php } ?>
1123
1124 <?php }?>
1125
1126 <?php if ($set_pid) { ?>
1127  parent.left_nav.setPatient(<?php echo js_escape($result['fname'] . " " . $result['lname']) . "," . js_escape($pid) . "," . js_escape($result['pubpid']) . ",''," . js_escape(" " . xl('DOB') . ": " . oeFormatShortDate($result['DOB_YMD']) . " " . xl('Age') . ": " . getPatientAgeDisplay($result['DOB_YMD'])); ?>);
1128 <?php } ?>
1129
1130 <?php echo $date_init; ?>
1131 </script>
1132
1133 <!-- include support for the list-add selectbox feature -->
1134 <?php require $GLOBALS['fileroot'] . "/library/options_listadd.inc.php"; ?>
1135
1136 <?php /*Include the validation script and rules for this form*/
1137 $form_id = "DEM";
1138 //LBF forms use the new validation depending on the global value
1139 $use_validate_js = $GLOBALS['new_validate'];
1140
1141 ?>
1142 <?php  include_once("$srcdir/validation/validation_script.js.php");?>
1143
1144
1145 <script>
1146     var duplicateFieldsArray=[];
1147
1148 //This code deals with demographics before save action -
1149     <?php if (($GLOBALS['gbl_edit_patient_form'] == '1') && (checkIfPatientValidationHookIsActive())) :?>
1150                 //Use the Zend patient validation hook.
1151                 //TODO - get the edit part of patient validation hook to work smoothly and then
1152                 //       remove the closeBeforeOpening=1 in the url below.
1153
1154         var f = $("form");
1155
1156         // Use hook to open the controller and get the new patient validation .
1157         // when no params are sent this window will be closed from the zend controller.
1158         var url ='<?php echo  $GLOBALS['web_root'] . "/interface/modules/zend_modules/public/patientvalidation";?>';
1159         $("#submit_btn").attr("name","btnSubmit");
1160         $("#submit_btn").attr("id","btnSubmit");
1161         $("#btnSubmit").click(function( event ) {
1162
1163       top.restoreSession();
1164
1165             if(!submitme(<?php echo $GLOBALS['new_validate'] ? 1 : 0;?>,event,'DEM',constraints)){
1166                 event.preventDefault();
1167                 return;
1168             }
1169             somethingChanged = false;
1170             <?php
1171             // D in edit_options indicates the field is used in duplication checking.
1172             // This constructs a list of the names of those fields.
1173             $mflist = "";
1174             $mfres = sqlStatement("SELECT field_id FROM layout_options " .
1175                 "WHERE form_id = 'DEM' AND uor > 0 AND field_id != '' AND " .
1176                 "(edit_options LIKE '%D%' OR edit_options LIKE '%E%')  " .
1177                 "ORDER BY group_id, seq");
1178             while ($mfrow = sqlFetchArray($mfres)) {
1179                 $field_id  = $mfrow['field_id'];
1180                 if (strpos($field_id, 'em_') === 0) {
1181                     continue;
1182                 }
1183
1184                 if (!empty($mflist)) {
1185                     $mflist .= ",";
1186                 }
1187
1188                     $mflist .= js_escape($field_id);
1189             } ?>
1190
1191             var flds = new Array(<?php echo $mflist; ?>);
1192             var separator = '?';
1193             var valueIsChanged=false;
1194             for (var i = 0; i < flds.length; ++i) {
1195                 var fval = $('#form_' + flds[i]).val();
1196                 if(duplicateFieldsArray['#form_' + flds[i]]!=fval) {
1197                     valueIsChanged = true;
1198
1199                 }
1200
1201                 if (fval && fval != '') {
1202                     url += separator;
1203                     separator = '&';
1204                     url += 'mf_' + flds[i] + '=' + encodeURIComponent(fval);
1205                 }
1206             }
1207
1208
1209             //Only if check for duplicates values are changed open the popup hook screen
1210             if(valueIsChanged) {
1211                 event.preventDefault();
1212                 //("value has changed for duplicate check inputs");
1213             url += '&page=edit&closeBeforeOpening=1&mf_id=' + encodeURIComponent($("[name='db_id']").val());
1214             dlgopen(url, '_blank', 700, 500);
1215             }
1216             else {//other wise submit me is a success just submit the form
1217                 $('#DEM').submit();
1218             }
1219         });
1220
1221     <?php endif;?>
1222
1223     $(function () {
1224         //When document is ready collect all the values Marked with D (check duplicate) stored in the db into array duplicateFieldsArray.
1225         var flds = new Array(<?php echo ($mflist ?? ''); ?>);
1226         for (var i = 0; i < flds.length; ++i) {
1227             var fval = $('#form_' + flds[i]).val();
1228             duplicateFieldsArray['#form_' + flds[i]] = fval;
1229         }
1230         $(".sel2").select2({
1231             theme: "bootstrap4",
1232             dropdownAutoWidth: true,
1233             width: 'resolve',
1234         <?php require($GLOBALS['srcdir'] . '/js/xl/select2.js.php'); ?>
1235         });
1236         <?php if ($GLOBALS['usps_webtools_enable']) { ?>
1237             $("#value_id_text_postal_code").append(
1238                 "<input type='button' class='btn btn-sm btn-secondary mb-1' onclick='address_verify()' value='<?php echo xla('Verify Address') ?>' />");
1239         <?php } ?>
1240     })
1241 </script>
1242
1243 </body>
1244 </html>