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) 2009-2017 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 use OpenEMR\Core\Header;
  23
  24 // Check authorization.
  25 if (!acl_check('patients', 'demo', '', array('write','addonly'))) {
  26     die(xlt("Adding demographics is not authorized."));
  27 }
  28
  29 $CPR = 4; // cells per row
  30
  31 $searchcolor = empty($GLOBALS['layout_search_color']) ?
  32   '#ffff55' : $GLOBALS['layout_search_color'];
  33
  34 $WITH_SEARCH = ($GLOBALS['full_new_patient_form'] == '1' || $GLOBALS['full_new_patient_form'] == '2' );
  35 $SHORT_FORM  = ($GLOBALS['full_new_patient_form'] == '2' || $GLOBALS['full_new_patient_form'] == '3' || $GLOBALS['full_new_patient_form'] == '4');
  36
  37 $grparr = array();
  38 getLayoutProperties('DEM', $grparr);
  39
  40 function getLayoutRes()
  41 {
  42     global $SHORT_FORM;
  43     return sqlStatement("SELECT * FROM layout_options " .
  44     "WHERE form_id = 'DEM' AND uor > 0 AND field_id != '' " .
  45     ($SHORT_FORM ? "AND ( uor > 1 OR edit_options LIKE '%N%' ) " : "") .
  46     "ORDER BY group_id, seq");
  47 }
  48
  49 // Determine layout field search treatment from its data type:
  50 // 1 = text field
  51 // 2 = select list
  52 // 0 = not searchable
  53 //
  54 function getSearchClass($data_type)
  55 {
  56     switch ($data_type) {
  57         case 1: // single-selection list
  58         case 10: // local provider list
  59         case 11: // provider list
  60         case 12: // pharmacy list
  61         case 13: // squads
  62         case 14: // address book list
  63         case 26: // single-selection list with add
  64         case 35: // facilities
  65             return 2;
  66         case 2: // text field
  67         case 3: // textarea
  68         case 4: // date
  69             return 1;
  70     }
  71
  72     return 0;
  73 }
  74
  75 $fres = getLayoutRes();
  76 ?>
  77 <html>
  78 <head>
  79 <?php Header::setupHeader(['common','datetime-picker', 'jquery-ui']); ?>
  80 <title><?php echo xlt("Search or Add Patient"); ?></title>
  81
  82 <style>
  83 body {
  84  padding: 5pt 5pt 5pt 5pt;
  85 }
  86
  87 div.section {
  88  border: solid;
  89  border-width: 1px;
  90  border-color: #0000ff;
  91  margin: 0 0 0 10pt;
  92  padding: 5pt;
  93 }
  94
  95 .form-control {
  96     width: auto;
  97     display: inline;
  98     height: auto;
  99 }
 100 </style>
 101
 102 <?php include_once("{$GLOBALS['srcdir']}/options.js.php"); ?>
 103
 104 <SCRIPT LANGUAGE="JavaScript"><!--
 105 //Visolve - sync the radio buttons - Start
 106 if((top.window.parent) && (parent.window)){
 107         var wname = top.window.parent.left_nav;
 108         fname = (parent.window.name)?parent.window.name:window.name;
 109         wname.syncRadios();
 110 }//Visolve - sync the radio buttons - End
 111
 112 var mypcc = '<?php echo $GLOBALS['phone_country_code'] ?>';
 113
 114 // This may be changed to true by the AJAX search script.
 115 var force_submit = false;
 116
 117 //code used from http://tech.irt.org/articles/js037/
 118 function replace(string,text,by) {
 119  // Replaces text with by in string
 120  var strLength = string.length, txtLength = text.length;
 121  if ((strLength == 0) || (txtLength == 0)) return string;
 122
 123  var i = string.indexOf(text);
 124  if ((!i) && (text != string.substring(0,txtLength))) return string;
 125  if (i == -1) return string;
 126
 127  var newstr = string.substring(0,i) + by;
 128
 129  if (i+txtLength < strLength)
 130   newstr += replace(string.substring(i+txtLength,strLength),text,by);
 131
 132  return newstr;
 133 }
 134
 135 <?php for ($i=1; $i<=3; $i++) { ?>
 136 function auto_populate_employer_address<?php echo $i ?>(){
 137  var f = document.demographics_form;
 138  if (f.form_i<?php echo $i?>subscriber_relationship.options[f.form_i<?php echo $i?>subscriber_relationship.selectedIndex].value == "self") {
 139   f.i<?php echo $i?>subscriber_fname.value=f.form_fname.value;
 140   f.i<?php echo $i?>subscriber_mname.value=f.form_mname.value;
 141   f.i<?php echo $i?>subscriber_lname.value=f.form_lname.value;
 142   f.i<?php echo $i?>subscriber_street.value=f.form_street.value;
 143   f.i<?php echo $i?>subscriber_city.value=f.form_city.value;
 144   f.form_i<?php echo $i?>subscriber_state.value=f.form_state.value;
 145   f.i<?php echo $i?>subscriber_postal_code.value=f.form_postal_code.value;
 146   if (f.form_country_code)
 147     f.form_i<?php echo $i?>subscriber_country.value=f.form_country_code.value;
 148   f.i<?php echo $i?>subscriber_phone.value=f.form_phone_home.value;
 149   f.i<?php echo $i?>subscriber_DOB.value=f.form_DOB.value;
 150   f.i<?php echo $i?>subscriber_ss.value=f.form_ss.value;
 151   f.form_i<?php echo $i?>subscriber_sex.value = f.form_sex.value;
 152   f.i<?php echo $i?>subscriber_employer.value=f.form_em_name.value;
 153   f.i<?php echo $i?>subscriber_employer_street.value=f.form_em_street.value;
 154   f.i<?php echo $i?>subscriber_employer_city.value=f.form_em_city.value;
 155   f.form_i<?php echo $i?>subscriber_employer_state.value=f.form_em_state.value;
 156   f.i<?php echo $i?>subscriber_employer_postal_code.value=f.form_em_postal_code.value;
 157   if (f.form_em_country)
 158     f.form_i<?php echo $i?>subscriber_employer_country.value=f.form_em_country.value;
 159  }
 160 }
 161
 162 <?php } ?>
 163
 164 function upperFirst(string,text) {
 165  return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
 166 }
 167
 168 // The ins_search.php window calls this to set the selected insurance.
 169 function set_insurance(ins_id, ins_name) {
 170  var thesel = document.forms[0]['i' + insurance_index + 'provider'];
 171  var theopts = thesel.options; // the array of Option objects
 172  var i = 0;
 173  for (; i < theopts.length; ++i) {
 174   if (theopts[i].value == ins_id) {
 175    theopts[i].selected = true;
 176    return;
 177   }
 178  }
 179  // no matching option was found so create one, append it to the
 180  // end of the list, and select it.
 181  theopts[i] = new Option(ins_name, ins_id, false, true);
 182 }
 183
 184 // Indicates which insurance slot is being updated.
 185 var insurance_index = 0;
 186
 187 // The OnClick handler for searching/adding the insurance company.
 188 function ins_search(ins) {
 189  insurance_index = ins;
 190  return false;
 191 }
 192
 193 function checkNum () {
 194  var re= new RegExp();
 195  re = /^\d*\.?\d*$/;
 196  str=document.forms[0].monthly_income.value;
 197  if(re.exec(str))
 198  {
 199  }else{
 200   alert("<?php echo xls("Please enter a dollar amount using only numbers and a decimal point."); ?>");
 201  }
 202 }
 203
 204 // This capitalizes the first letter of each word in the passed input
 205 // element.  It also strips out extraneous spaces.
 206 function capitalizeMe(elem) {
 207  var a = elem.value.split(' ');
 208  var s = '';
 209  for(var i = 0; i < a.length; ++i) {
 210   if (a[i].length > 0) {
 211    if (s.length > 0) s += ' ';
 212    s += a[i].charAt(0).toUpperCase() + a[i].substring(1);
 213   }
 214  }
 215  elem.value = s;
 216 }
 217
 218 // Onkeyup handler for policy number.  Allows only A-Z and 0-9.
 219 function policykeyup(e) {
 220  var v = e.value.toUpperCase();
 221  var filteredString="";
 222  for (var i = 0; i < v.length; ++i) {
 223   var c = v.charAt(i);
 224   if ((c >= '0' && c <= '9') ||
 225      (c >= 'A' && c <= 'Z') ||
 226      (c == '*') ||
 227      (c == '-') ||
 228      (c == '_') ||
 229      (c == '(') ||
 230      (c == ')') ||
 231      (c == '#'))
 232      {
 233          filteredString+=c;
 234      }
 235  }
 236  e.value = filteredString;
 237  return;
 238 }
 239
 240 function divclick(cb, divid) {
 241  var divstyle = document.getElementById(divid).style;
 242  if (cb.checked) {
 243   divstyle.display = 'block';
 244  } else {
 245   divstyle.display = 'none';
 246  }
 247  return true;
 248 }
 249
 250 // Compute the length of a string without leading and trailing spaces.
 251 function trimlen(s) {
 252  var i = 0;
 253  var j = s.length - 1;
 254  for (; i <= j && s.charAt(i) == ' '; ++i);
 255  for (; i <= j && s.charAt(j) == ' '; --j);
 256  if (i > j) return 0;
 257  return j + 1 - i;
 258 }
 259
 260 function validate(f) {
 261   var errMsgs = new Array();
 262     <?php generate_layout_validation('DEM'); ?>
 263     <?php if ($GLOBALS['erx_enable']) { ?>
 264   alertMsg='';
 265   for(i=0;i<f.length;i++){
 266     if(f[i].type=='text' && f[i].value)
 267     {
 268       if(f[i].name == 'form_fname' || f[i].name == 'form_mname' || f[i].name == 'form_lname')
 269       {
 270         alertMsg += checkLength(f[i].name,f[i].value,35);
 271         alertMsg += checkUsername(f[i].name,f[i].value);
 272       }
 273       else if(f[i].name == 'form_street' || f[i].name == 'form_city')
 274       {
 275         alertMsg += checkLength(f[i].name,f[i].value,35);
 276         alertMsg += checkAlphaNumericExtended(f[i].name,f[i].value);
 277       }
 278       else if(f[i].name == 'form_phone_home')
 279       {
 280        alertMsg += checkPhone(f[i].name,f[i].value);
 281       }
 282     }
 283   }
 284   if(alertMsg)
 285   {
 286     alert(alertMsg);
 287     return false;
 288   }
 289     <?php } ?>
 290   var msg = "";
 291   msg += "<?php echo xla('The following fields are required'); ?>:\n\n";
 292   for ( var i = 0; i < errMsgs.length; i++ ) {
 293          msg += errMsgs[i] + "\n";
 294   }
 295   msg += "\n<?php echo xla('Please fill them in before continuing.'); ?>";
 296
 297
 298 //Misc  Deceased Date Validation for Future Date
 299 var dateVal = document.getElementById("form_deceased_date").value;
 300 var currentDate;
 301 var d = new Date();
 302 month = '' + (d.getMonth() + 1),
 303 day = '' + d.getDate(),
 304 year = d.getFullYear();
 305 if (month.length < 2) month = '0' + month;
 306 if (day.length < 2) day = '0' + day;
 307 currentDate = year+'-'+month+'-'+day;
 308 if(errMsgs.length > 0 || dateVal > currentDate)
 309 {
 310 if(errMsgs.length > 0)
 311     alert(msg);
 312 if(dateVal > currentDate)
 313     alert ('<?php echo xls("Deceased Date should not be greater than Today"); ?>');
 314     return false;
 315 }
 316  return true;
 317 }
 318
 319 function toggleSearch(elem) {
 320  var f = document.forms[0];
 321 <?php if ($WITH_SEARCH) { ?>
 322  // Toggle background color.
 323  if (elem.style.backgroundColor == '')
 324   elem.style.backgroundColor = '<?php echo $searchcolor; ?>';
 325  else
 326   elem.style.backgroundColor = '';
 327 <?php } ?>
 328  if (force_submit) {
 329   force_submit = false;
 330   f.create.value = '<?php echo xla('Create New Patient'); ?>';
 331  }
 332  return true;
 333 }
 334
 335 // If a <select> list is dropped down, this is its name.
 336 var open_sel_name = '';
 337
 338 function selClick(elem) {
 339  if (open_sel_name == elem.name) {
 340   open_sel_name = '';
 341  }
 342  else {
 343   open_sel_name = elem.name;
 344   toggleSearch(elem);
 345  }
 346  return true;
 347 }
 348
 349 function selBlur(elem) {
 350  if (open_sel_name == elem.name) {
 351   open_sel_name = '';
 352  }
 353  return true;
 354 }
 355
 356 // This invokes the patient search dialog.
 357 function searchme() {
 358  var f = document.forms[0];
 359  var url = '../main/finder/patient_select.php?popup=1&csrf_token_form=<?php echo attr(urlencode(collectCsrfToken())); ?>';
 360
 361 <?php
 362 $lres = getLayoutRes();
 363
 364 while ($lrow = sqlFetchArray($lres)) {
 365     $field_id  = $lrow['field_id'];
 366     if (strpos($field_id, 'em_') === 0) {
 367         continue;
 368     }
 369
 370     $data_type = $lrow['data_type'];
 371     $fldname = "form_$field_id";
 372     switch (getSearchClass($data_type)) {
 373         case 1:
 374             echo
 375             " if (f.$fldname.style.backgroundColor != '' && trimlen(f.$fldname.value) > 0) {\n" .
 376             "  url += '&$field_id=' + encodeURIComponent(f.$fldname.value);\n" .
 377             " }\n";
 378             break;
 379         case 2:
 380             echo
 381             " if (f.$fldname.style.backgroundColor != '' && f.$fldname.selectedIndex > 0) {\n" .
 382             "  url += '&$field_id=' + encodeURIComponent(f.$fldname.options[f.$fldname.selectedIndex].value);\n" .
 383             " }\n";
 384             break;
 385     }
 386 }
 387 ?>
 388
 389  dlgopen(url, '_blank', 700, 500);
 390 }
 391 function srchDone(pid){
 392     top.restoreSession();
 393     document.location.href = "./../../patient_file/summary/demographics.php?set_pid=" + pid;
 394 }
 395 //-->
 396
 397 </script>
 398 </head>
 399
 400 <body class="body_top">
 401
 402 <?php
 403 /*Get the constraint from the DB-> LBF forms accordinf the form_id*/
 404 $constraints = LBF_Validation::generate_validate_constraints("DEM");
 405 ?>
 406 <script> var constraints = <?php echo $constraints;?>; </script>
 407
 408 <form action='new_comprehensive_save.php' name='demographics_form' id="DEM"  method='post' onsubmit='return submitme(<?php echo $GLOBALS['new_validate'] ? 1 : 0;?>,event,"DEM",constraints)'>
 409
 410     <div class="container-fluid">
 411         <div class="row">
 412             <div class="col-xs-12">
 413                 <div class="page-header">
 414                     <h2><?php echo xlt('Search or Add Patient');?></h2>
 415                 </div>
 416             </div>
 417             <div class="col-xs-12">
 418                 <div class="btn-group">
 419                     <?php if ($WITH_SEARCH) { ?>
 420                         <button type="button" class="btn btn-default btn-search" id="search" value="<?php echo xla('Search'); ?>">
 421                             <?php echo xlt('Search'); ?>
 422                         </button>
 423                     <?php } ?>
 424                     <button type="button" class="btn btn-default btn-save" name='create' id="create" value="<?php echo xla('Create New Patient'); ?>">
 425                         <?php echo xlt('Create New Patient'); ?>
 426                     </button>
 427                 </div>
 428                 <hr>
 429             </div>
 430         </div>
 431     </div>
 432
 433 <table width='100%' cellpadding='0' cellspacing='8'>
 434  <tr>
 435   <td align='left' valign='top'>
 436 <?php if ($SHORT_FORM) {
 437     echo "  <center>\n";
 438 } ?>
 439 <?php
 440
 441 function end_cell()
 442 {
 443     global $item_count, $cell_count;
 444     if ($item_count > 0) {
 445         echo "</td>";
 446         $item_count = 0;
 447     }
 448 }
 449
 450 function end_row()
 451 {
 452     global $cell_count, $CPR;
 453     end_cell();
 454     if ($cell_count > 0) {
 455         for (; $cell_count < $CPR;
 456         ++$cell_count) {
 457             echo "<td></td>";
 458         }
 459
 460         echo "</tr>\n";
 461         $cell_count = 0;
 462     }
 463 }
 464
 465 function end_group()
 466 {
 467     global $last_group, $SHORT_FORM;
 468     if (strlen($last_group) > 0) {
 469         end_row();
 470         echo " </table>\n";
 471         if (!$SHORT_FORM) {
 472             echo "</div>\n";
 473         }
 474     }
 475 }
 476
 477 $last_group    = '';
 478 $cell_count    = 0;
 479 $item_count    = 0;
 480 $display_style = 'block';
 481 $group_seq     = 0; // this gives the DIV blocks unique IDs
 482
 483 $condition_str = '';
 484
 485 while ($frow = sqlFetchArray($fres)) {
 486     $this_group = $frow['group_id'];
 487     $titlecols  = $frow['titlecols'];
 488     $datacols   = $frow['datacols'];
 489     $data_type  = $frow['data_type'];
 490     $field_id   = $frow['field_id'];
 491     $list_id    = $frow['list_id'];
 492     $currvalue  = '';
 493
 494     // Accumulate action conditions into a JSON expression for the browser side.
 495     accumActionConditions($field_id, $condition_str, $frow['conditions']);
 496
 497     if (strpos($field_id, 'em_') === 0) {
 498         $tmp = substr($field_id, 3);
 499         if (isset($result2[$tmp])) {
 500             $currvalue = $result2[$tmp];
 501         }
 502     } else {
 503         if (isset($result[$field_id])) {
 504             $currvalue = $result[$field_id];
 505         }
 506     }
 507
 508   // Handle a data category (group) change.
 509     if (strcmp($this_group, $last_group) != 0) {
 510         if (!$SHORT_FORM) {
 511             end_group();
 512             $group_seq++;    // ID for DIV tags
 513             $group_name = $grparr[$this_group]['grp_title'];
 514
 515             if (strlen($last_group) > 0) {
 516                 echo "<br />";
 517             }
 518
 519             echo "<span class='bold'><input type='checkbox' name='form_cb_$group_seq' id='form_cb_$group_seq' value='1' " .
 520             "onclick='return divclick(this,\"div_$group_seq\");'";
 521             if ($display_style == 'block') {
 522                 echo " checked";
 523             }
 524
 525             // Modified 6-09 by BM - Translate if applicable
 526             echo " /><b>" . xl_layout_label($group_name) . "</b></span>\n";
 527
 528             echo "<div id='div_$group_seq' class='section' style='display:$display_style;'>\n";
 529             echo " <table border='0' cellpadding='0'>\n";
 530             $display_style = 'none';
 531         } else if (strlen($last_group) == 0) {
 532             echo " <table border='0' cellpadding='0'>\n";
 533         }
 534
 535         $last_group = $this_group;
 536     }
 537
 538   // Handle starting of a new row.
 539     if (($titlecols > 0 && $cell_count >= $CPR) || $cell_count == 0) {
 540         end_row();
 541         echo "  <tr>";
 542     }
 543
 544     if ($item_count == 0 && $titlecols == 0) {
 545         $titlecols = 1;
 546     }
 547
 548     $field_id_label='label_'.$frow['field_id'];
 549   // Handle starting of a new label cell.
 550     if ($titlecols > 0) {
 551         end_cell();
 552         echo "<td colspan='$titlecols' id='$field_id_label'";
 553         echo ($frow['uor'] == 2) ? " class='required'" : " class='bold'";
 554         if ($cell_count == 2) {
 555             echo " style='padding-left:10pt'";
 556         }
 557
 558         echo ">";
 559         $cell_count += $titlecols;
 560     }
 561
 562     ++$item_count;
 563
 564     echo "<b>";
 565
 566   // Modified 6-09 by BM - Translate if applicable
 567     if ($frow['title']) {
 568         echo (xl_layout_label($frow['title']).":");
 569     } else {
 570         echo "&nbsp;";
 571     }
 572
 573     echo "</b>";
 574
 575   // Handle starting of a new data cell.
 576     if ($datacols > 0) {
 577         $id_field_text = "text_".$frow['field_id'];
 578         end_cell();
 579         echo "<td colspan='$datacols' class='text data'";
 580         if ($cell_count > 0) {
 581             echo " style='padding-left:5pt'". " id='".$id_field_text."'";
 582         }
 583
 584         echo ">";
 585         $cell_count += $datacols;
 586     }
 587
 588     ++$item_count;
 589     generate_form_field($frow, $currvalue);
 590 }
 591
 592 end_group();
 593 ?>
 594
 595 <?php
 596 if (! $GLOBALS['simplified_demographics']) {
 597     $insurancei = getInsuranceProviders();
 598     $pid = 0;
 599     $insurance_headings = array(xl("Primary Insurance Provider"), xl("Secondary Insurance Provider"), xl("Tertiary Insurance provider"));
 600     $insurance_info = array();
 601     $insurance_info[1] = getInsuranceData($pid, "primary");
 602     $insurance_info[2] = getInsuranceData($pid, "secondary");
 603     $insurance_info[3] = getInsuranceData($pid, "tertiary");
 604
 605     echo "<br /><span class='bold'><input type='checkbox' name='form_cb_ins' value='1' " .
 606     "onclick='return divclick(this,\"div_ins\");'";
 607     if ($display_style == 'block') {
 608         echo " checked";
 609     }
 610
 611     echo " /><b>" . xlt('Insurance') . "</b></span>\n";
 612     echo "<div id='div_ins' class='section' style='display:$display_style;'>\n";
 613
 614     for ($i=1; $i<=3; $i++) {
 615         $result3 = $insurance_info[$i];
 616     ?>
 617   <table border="0">
 618    <tr>
 619     <td valign='top' colspan='2'>
 620      <span class='required'><?php echo text($insurance_headings[$i -1]).":"?></span>
 621      <select name="i<?php echo $i?>provider" class="form-control">
 622     <option value=""><?php echo xlt('Unassigned'); ?></option>
 623 <?php
 624 foreach ($insurancei as $iid => $iname) {
 625     echo "<option value='" . attr($iid) . "'";
 626     if (strtolower($iid) == strtolower($result3{"provider"})) {
 627         echo " selected";
 628     }
 629
 630     echo ">" . text($iname) . "</option>\n";
 631 }
 632 ?>
 633      </select>&nbsp;<a class='medium_modal' href='../practice/ins_search.php' onclick='ins_search(<?php echo $i?>)'>
 634   <span> <?php echo xlt('Search/Add Insurer'); ?></span></a>
 635   </td>
 636  </tr>
 637  <tr>
 638   <td valign=top>
 639    <table border="0">
 640
 641     <tr>
 642      <td>
 643       <span class='required'><?php echo xlt('Plan Name'); ?>: </span>
 644      </td>
 645      <td>
 646       <input type='entry' class='form-control' size='20' name='i<?php echo $i?>plan_name' value="<?php echo attr($result3{"plan_name"}); ?>"
 647        onchange="capitalizeMe(this);" />&nbsp;&nbsp;
 648      </td>
 649     </tr>
 650
 651     <tr>
 652      <td>
 653       <span class='required'><?php echo xlt('Effective Date'); ?>: </span>
 654      </td>
 655      <td>
 656       <input type='entry' size='11' class='datepicker form-control' name='i<?php echo $i ?>effective_date'
 657        id='i<?php echo $i ?>effective_date'
 658        value='<?php echo attr($result3['date']); ?>'
 659        title='yyyy-mm-dd' />
 660      </td>
 661     </tr>
 662
 663     <tr>
 664      <td><span class=required><?php echo xlt('Policy Number'); ?>: </span></td>
 665      <td><input type='entry' class='form-control' size='16' name='i<?php echo $i?>policy_number' value="<?php echo attr($result3{"policy_number"}); ?>"
 666       onkeyup='policykeyup(this)'></td>
 667     </tr>
 668
 669     <tr>
 670      <td><span class=required><?php echo xlt('Group Number'); ?>: </span></td>
 671     <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>
 672     </tr>
 673
 674     <tr<?php echo ($GLOBALS['omit_employers']) ? " style='display:none'" : ""; ?>>
 675      <td class='required'><?php echo xlt('Subscriber Employer (SE)'); ?><br><span style='font-weight:normal'>
 676       (<?php echo xlt('if unemployed enter Student'); ?>,<br><?php echo xlt('PT Student, or leave blank'); ?>): </span></td>
 677      <td><input type=entry class='form-control' size=25 name=i<?php echo $i?>subscriber_employer
 678       value="<?php echo attr($result3{"subscriber_employer"}); ?>"
 679        onchange="capitalizeMe(this);" /></td>
 680     </tr>
 681
 682     <tr<?php echo ($GLOBALS['omit_employers']) ? " style='display:none'" : ""; ?>>
 683      <td><span class=required><?php echo xlt('SE Address'); ?>: </span></td>
 684      <td><input type=entry class='form-control' size=25 name=i<?php echo $i?>subscriber_employer_street
 685       value="<?php echo attr($result3{"subscriber_employer_street"}); ?>"
 686        onchange="capitalizeMe(this);" /></td>
 687     </tr>
 688
 689     <tr<?php echo ($GLOBALS['omit_employers']) ? " style='display:none'" : ""; ?>>
 690      <td colspan="2">
 691       <table>
 692        <tr>
 693         <td><span class=required><?php echo xlt('SE City'); ?>: </span></td>
 694         <td><input type=entry class='form-control' size=15 name=i<?php echo $i?>subscriber_employer_city
 695          value="<?php echo attr($result3{"subscriber_employer_city"}); ?>"
 696           onchange="capitalizeMe(this);" /></td>
 697         <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('SE State') : xlt('SE Locality') ?>: </span></td>
 698     <td>
 699             <?php
 700             // Modified 7/2009 by BM to incorporate data types
 701             generate_form_field(array('data_type'=>$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'), $result3['subscriber_employer_state']);
 702                 ?>
 703           </td>
 704          </tr>
 705          <tr>
 706             <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('SE Zip Code') : xlt('SE Postal Code') ?>: </span></td>
 707             <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>
 708             <td><span class=required><?php xl('SE Country', 'e'); ?>: </span></td>
 709       <td>
 710                 <?php
 711               // Modified 7/2009 by BM to incorporate data types
 712                 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']);
 713                 ?>
 714       </td>
 715          </tr>
 716         </table>
 717        </td>
 718       </tr>
 719
 720      </table>
 721     </td>
 722
 723     <td valign=top>
 724        <span class=required><?php echo xlt('Subscriber'); ?>: </span>
 725        <input type=entry class='form-control' size=10 name=i<?php echo $i?>subscriber_fname
 726         value="<?php echo attr($result3{"subscriber_fname"}); ?>"
 727       onchange="capitalizeMe(this);" />
 728        <input type=entry class='form-control' size=3 name=i<?php echo $i?>subscriber_mname
 729         value="<?php echo attr($result3{"subscriber_mname"}); ?>"
 730       onchange="capitalizeMe(this);" />
 731        <input type=entry class='form-control' size=10 name=i<?php echo $i?>subscriber_lname
 732         value="<?php echo attr($result3{"subscriber_lname"}); ?>"
 733       onchange="capitalizeMe(this);" />
 734      <br>
 735        <span class=required><?php echo xlt('Relationship'); ?>: </span>
 736         <?php
 737       // Modified 6/2009 by BM to use list_options and function
 738         generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_relationship'),'list_id'=>'sub_relation','empty_title'=>' '), $result3['subscriber_relationship']);
 739         ?>
 740        <a href="javascript:popUp('../../interface/patient_file/summary/browse.php?browsenum=<?php echo $i?>')" class=text>(<?php echo xla('Browse'); ?>)</a><br />
 741
 742        <span class=bold><?php echo xlt('D.O.B.'); ?>: </span>
 743        <input type='entry' size='11' class='datepicker form-control' name='i<?php echo $i?>subscriber_DOB'
 744       id='i<?php echo $i?>subscriber_DOB'
 745       value='<?php echo attr($result3['subscriber_DOB']); ?>'
 746     title='yyyy-mm-dd' />
 747
 748        <span class=bold><?php echo xlt('S.S.'); ?>: </span>
 749        <input type=entry class='form-control' size=11 name=i<?php echo $i?>subscriber_ss value="<?php echo attr($result3{"subscriber_ss"}); ?>">&nbsp;
 750        <span class=bold><?php echo xlt('Sex'); ?>: </span>
 751         <?php
 752       // Modified 6/2009 by BM to use list_options and function
 753         generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_sex'),'list_id'=>'sex'), $result3['subscriber_sex']);
 754         ?>
 755      <br>
 756        <span class=required><?php echo xlt('Subscriber Address'); ?>: </span>
 757        <input type=entry class='form-control' size=25 name=i<?php echo $i?>subscriber_street
 758       value="<?php echo attr($result3{"subscriber_street"}); ?>"
 759     onchange="capitalizeMe(this);" /><br>
 760        <span class=required><?php echo xlt('City'); ?>: </span>
 761        <input type=entry class='form-control' size=15 name=i<?php echo $i?>subscriber_city
 762       value="<?php echo attr($result3{"subscriber_city"}); ?>"
 763     onchange="capitalizeMe(this);" />
 764        <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('State') : xlt('Locality') ?>: </span>
 765         <?php
 766       // Modified 7/2009 by BM to incorporate data types
 767         generate_form_field(array('data_type'=>$GLOBALS['state_data_type'],'field_id'=>('i'.$i.'subscriber_state'),'list_id'=>$GLOBALS['state_list'],'fld_length'=>'15','max_length'=>'63','edit_options'=>'C'), $result3['subscriber_state']);
 768         ?>
 769      <br />
 770        <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('Zip Code') : xlt('Postal Code') ?>: </span>
 771        <input type=entry class='form-control' size=10 name=i<?php echo $i?>subscriber_postal_code value="<?php echo attr($result3{"subscriber_postal_code"}); ?>">
 772        <span class='required'<?php echo ($GLOBALS['omit_employers']) ? " style='display:none'" : ""; ?>>
 773         <?php echo xlt('Country'); ?>: </span>
 774         <?php
 775       // Modified 7/2009 by BM to incorporate data types
 776         generate_form_field(array('data_type'=>$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']);
 777         ?>
 778      <br />
 779        <span class=bold><?php echo xlt('Subscriber Phone'); ?>:
 780        <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)' />
 781      </span><br />
 782        <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"}); ?>">
 783      </span><br />
 784        <span class='required'><?php echo xlt('Accept Assignment'); ?>: </span>
 785        <select class='form-control' name=i<?php echo $i?>accept_assignment>
 786          <option value="TRUE" <?php echo (strtoupper($result3{"accept_assignment"}) == "TRUE") ? "selected" : ""; ?>><?php echo xlt('YES'); ?></option>
 787          <option value="FALSE" <?php echo (strtoupper($result3{"accept_assignment"}) == "FALSE") ? "selected" : ""; ?>><?php echo xlt('NO'); ?></option>
 788        </select>
 789     </td>
 790    </tr>
 791
 792   </table>
 793   <hr />
 794     <?php
 795     }
 796
 797     echo "</div>\n";
 798 } // end of "if not simplified_demographics"
 799 ?>
 800
 801 <?php if ($SHORT_FORM) {
 802     echo "  </center>\n";
 803 } ?>
 804
 805   </td>
 806   <td align='right' valign='top' width='1%' nowrap>
 807    <!-- Image upload stuff was here but got moved. -->
 808   </td>
 809  </tr>
 810 </table>
 811
 812 </form>
 813
 814 <!-- include support for the list-add selectbox feature -->
 815 <?php include($GLOBALS['fileroot']."/library/options_listadd.inc"); ?>
 816
 817 </body>
 818
 819 <script language="JavaScript">
 820
 821 // hard code validation for old validation, in the new validation possible to add match rules
 822 <?php if ($GLOBALS['new_validate'] == 0) { ?>
 823
 824 // fix inconsistently formatted phone numbers from the database
 825 var f = document.forms[0];
 826 if (f.form_phone_contact) phonekeyup(f.form_phone_contact,mypcc);
 827 if (f.form_phone_home   ) phonekeyup(f.form_phone_home   ,mypcc);
 828 if (f.form_phone_biz    ) phonekeyup(f.form_phone_biz    ,mypcc);
 829 if (f.form_phone_cell   ) phonekeyup(f.form_phone_cell   ,mypcc);
 830
 831 <?php }?>
 832
 833 <?php echo $date_init; ?>
 834
 835 // -=- jQuery makes life easier -=-
 836
 837 // var matches = 0; // number of patients that match the demographic information being entered
 838 // var override = false; // flag that overrides the duplication warning
 839
 840 $(document).ready(function() {
 841     $(".medium_modal").on('click', function(e) {
 842         e.preventDefault();e.stopPropagation();
 843         dlgopen('', '', 650, 460, '', '', {
 844             buttons: [
 845                 {text: '<?php echo xla('Close'); ?>', close: true, style: 'default btn-sm'}
 846             ],
 847             //onClosed: 'refreshme',
 848             allowResize: false,
 849             allowDrag: true,
 850             dialogId: '',
 851             type: 'iframe',
 852             url: $(this).attr('href')
 853         });
 854     });
 855     // added to integrate insurance stuff
 856     <?php for ($i=1; $i<=3; $i++) { ?>
 857     $("#form_i<?php echo $i?>subscriber_relationship").change(function() { auto_populate_employer_address<?php echo $i?>(); });
 858     <?php } ?>
 859
 860     $('#search').click(function() { searchme(); });
 861     $('#create').click(function() { check()});
 862
 863     var check = function(e) {
 864         <?php if ($GLOBALS['new_validate']) {?>
 865             var valid = submitme(<?php echo $GLOBALS['new_validate'] ? 1 : 0;?>,e,"DEM",constraints);
 866         <?php } else {?>
 867             top.restoreSession();
 868             var f = document.forms[0];
 869             var valid = validate(f);
 870         <?php }?>
 871         if (valid) {
 872             if (force_submit) {
 873                 // In this case dups were shown already and Save should just save.
 874                 top.restoreSession();
 875                 f.submit();
 876                 return;
 877             }
 878
 879         <?php
 880         // D in edit_options indicates the field is used in duplication checking.
 881         // This constructs a list of the names of those fields.
 882         $mflist = "";
 883         $mfres = sqlStatement("SELECT * FROM layout_options " .
 884             "WHERE form_id = 'DEM' AND uor > 0 AND field_id != '' AND " .
 885             "(edit_options LIKE '%D%' OR  edit_options LIKE '%W%' )" .
 886             "ORDER BY group_id, seq");
 887         while ($mfrow = sqlFetchArray($mfres)) {
 888             $field_id  = $mfrow['field_id'];
 889             if (strpos($field_id, 'em_') === 0) {
 890                 continue;
 891             }
 892
 893             if (!empty($mflist)) {
 894                 $mflist .= ",";
 895             }
 896
 897             $mflist .= "'" . htmlentities($field_id) . "'";
 898         }
 899 ?>
 900         <?php if (($GLOBALS['full_new_patient_form'] == '4') && (checkIfPatientValidationHookIsActive())) :?>
 901             // Use zend module patient validation hook to open the controller and send the dup-checker fields.
 902             var url ='<?php echo  $GLOBALS['web_root']."/interface/modules/zend_modules/public/patientvalidation";?>';
 903         <?php else :?>
 904             // Build and invoke the URL to create the dup-checker dialog.
 905             var url = 'new_search_popup.php';
 906         <?php endif;?>
 907
 908         var flds = new Array(<?php echo $mflist; ?>);
 909         var separator = '?';
 910         for (var i = 0; i < flds.length; ++i) {
 911             var fval = $('#form_' + flds[i]).val();
 912             if (fval && fval != '') {
 913                 url += separator;
 914                 separator = '&';
 915                 url += 'mf_' + flds[i] + '=' + encodeURIComponent(fval);
 916             }
 917         }
 918         url+="&close"
 919         dlgopen(url, '_blank', 700, 500);
 920         } // end function
 921     } // end function
 922
 923 // Set onclick/onfocus handlers for toggling background color.
 924 <?php
 925 $lres = getLayoutRes();
 926 while ($lrow = sqlFetchArray($lres)) {
 927     $field_id  = $lrow['field_id'];
 928     if (strpos($field_id, 'em_') === 0) {
 929         continue;
 930     }
 931
 932     switch (getSearchClass($lrow['data_type'])) {
 933         case 1:
 934             echo "    \$('#form_$field_id').click(function() { toggleSearch(this); });\n";
 935             break;
 936         case 2:
 937             echo "    \$('#form_$field_id').click(function() { selClick(this); });\n";
 938             echo "    \$('#form_$field_id').blur(function() { selBlur(this); });\n";
 939             break;
 940     }
 941 }
 942 ?>
 943
 944   $('.datepicker').datetimepicker({
 945     <?php $datetimepicker_timepicker = false; ?>
 946     <?php $datetimepicker_showseconds = false; ?>
 947     <?php $datetimepicker_formatInput = true; ?>
 948     <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 949     <?php // can add any additional javascript settings to datetimepicker here; need to prepend first setting with a comma ?>
 950   });
 951   $('.datetimepicker').datetimepicker({
 952     <?php $datetimepicker_timepicker = true; ?>
 953     <?php $datetimepicker_showseconds = false; ?>
 954     <?php $datetimepicker_formatInput = true; ?>
 955     <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 956     <?php // can add any additional javascript settings to datetimepicker here; need to prepend first setting with a comma ?>
 957   });
 958
 959 }); // end document.ready
 960
 961 // callback for new patient save confirm from new_search_popup.php
 962 // note that dlgclose() callbacks mostly need to init outside dom.
 963 function srcConfirmSave() {
 964     document.forms[0].submit();
 965 }
 966
 967 </script>
 968 <?php /*Include the validation script and rules for this form*/
 969 $form_id="DEM";
 970 ?>
 971
 972 <?php
 973 //LBF forms use the new validation depending on the global value
 974 $use_validate_js=$GLOBALS['new_validate'];
 975 include_once("$srcdir/validation/validation_script.js.php");?>
 976 <script language='JavaScript'>
 977     // Array of skip conditions for the checkSkipConditions() function.
 978     var skipArray = [
 979         <?php echo $condition_str; ?>
 980     ];
 981     checkSkipConditions();
 982     $("input").change(function() {
 983         checkSkipConditions();
 984     });
 985     $("select").change(function() {
 986         checkSkipConditions();
 987     });
 988 </script>
 989
 990 </html>