4 * Copyright (C) 2016-2017 Jerry Padgett <sjpadgett@gmail.com>
6 * LICENSE: This program is free software: you can redistribute it and/or modify
7 * it under the terms of the GNU Affero General Public License as
8 * published by the Free Software Foundation, either version 3 of the
9 * License, or (at your option) any later version.
11 * This program is distributed in the hope that it will be useful,
12 * but WITHOUT ANY WARRANTY; without even the implied warranty of
13 * MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE. See the
14 * GNU Affero General Public License for more details.
16 * You should have received a copy of the GNU Affero General Public License
17 * along with this program. If not, see <http://www.gnu.org/licenses/>.
20 * @author Jerry Padgett <sjpadgett@gmail.com>
21 * @author Terry Hill <teryhill@yahoo.com>
22 * @link http://www.open-emr.org
25 //require_once ("./../verify_session.php");
26 require_once("../../library/options.inc.php");
27 $this->assign('title', xlt("Patient Portal") . " | " . xlt("Patient Data"));
28 $this->assign('nav', 'patientdata');
30 * row keys are js underscore camelcase and follow the underscores varables used in this template
31 * $row['city'] or $row['postalCode'] e.t.c.. The keys do not match table columns ie postalCode here is postal_code in table.
38 echo "<script>var register='" . attr($this->register
) . "';var recid='" . attr($this->recid
) . "';var webRoot='" . $GLOBALS['web_root'] . "';var cpid='" . attr($this->cpid
) . "';var cuser='" . attr($this->cuser
) . "';</script>";
39 $_SESSION['whereto'] = 'profilepanel';
41 $this->display('_modalFormHeader.tpl.php');
44 <script type
="text/javascript">
46 // bring in the datepicker and datetimepicker localization and setting elements
47 <?php
require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4-alternate.js.php'); ?
>
49 $LAB.script("scripts/app/patientdata.js?v=<?php echo $GLOBALS['v_js_includes']; ?>").wait(function(){
50 $
(document
).ready(function(){
53 // hack for browsers or slow sessions which may respond inconsistently with document.ready-second chance at init
54 setTimeout(function(){
55 if (!page
.isInitialized
) page
.init();
59 <?php
if (attr($this->register
)) {?
>
61 .form
-group
.inline
.dynhide
{
65 padding
-top
: 0px
;padding
-bottom
: 5px
;
66 background
: #fff !important;
71 <div
class="container-fluid">
72 <script type
="text/template" id
="patientCollectionTemplate"></script
>
73 <!-- Could add
/manage table
list here
-->
74 <script type
="text/template" id
="patientModelTemplate"> <!-- -->
76 <div id
='profileHelp' class='well' style
='display:none;width: 650px; margin: 0 auto;'>
78 <?php
echo xlt('Any changes here will be reviewed by provider staff before commiting to chart. The following apply'); ?
>:<br
>
79 <?php
echo xlt('Change any item available and when ready click Send for review. The changes will be flagged and staff notified to review changes before commiting them to chart. During the time period before changes are reviewed the Revised button will show Pending and profile data is still available for changes. When accessing profile in pending state all previous edits will appear in Blue and current chart values in Red. You may revert any edit to chart value by clicking that red item (or vica versa) but remember that when you click Send for Review then items that populate the field items are the ones that are sent. Revert Edits button changes everything back to chart values and you may make changes from there. So to recap: Items in BLUE are patient edits with items in RED being original values before any edits.'); ?
>
81 <button
class="btn btn-primary btn-xs" type
="button" id
='dismissHelp'><?php
echo xlt('Dismiss'); ?
></button
>
83 <form
class="form-inline" onsubmit
="return false;">
85 <!-- <div
class="form-group inline" id
="idInputContainer">
86 <label
class="control-label" for="id">Id
</label
>
87 <div
class="controls inline-inputs">
88 <span
class="form-control uneditable-input" id
="id"><%
= _
.escape(item
.get('id') ||
'') %
></span
>
89 <span
class="help-inline"></span
>
92 <div
class="form-group inline" id
="provideridInputContainer">
93 <label
class="control-label" for="providerid"><?php
echo xlt('Select Primary Physician')?
></label
>
94 <div
class="controls inline-inputs">
95 <select
class="form-control" id
="providerid" value
="<%= _.escape(item.get('providerid') || '') %>"></select
>
96 <span
class="help-inline"></span
>
99 <div
class="form-group inline" id
="titleInputContainer">
100 <label
class="control-label" for="title"><?php
echo xlt('Title')?
></label
><br
>
101 <div
class="controls inline-inputs">
103 # Generate drop down list for Title
104 echo generate_select_list('title', 'titles', $row['title'], xl('Title'), 'Unassigned', "form-control");
106 <span
class="help-inline"></span
>
110 <!-- <div
class="form-group inline" id
="financialInputContainer">
111 <label
class="control-label" for="financial"><?php
echo xlt('Financial')?
></label
>
112 <div
class="controls inline-inputs">
113 <input type
="text" class="form-control" id
="financial" placeholder
="Financial" value
="<%= _.escape(item.get('financial') || '') %>">
114 <span
class="help-inline"></span
>
117 <div
class="form-group inline" id
="fnameInputContainer">
118 <label
class="control-label" for="fname"><?php
echo xlt('First')?
></label
>
119 <div
class="controls inline-inputs">
120 <input type
="text" class="form-control" id
="fname" required placeholder
="<?php echo xla('First Name'); ?>" value
="<%= _.escape(item.get('fname') || '') %>">
121 <span
class="help-inline"></span
>
124 <div
class="form-group inline" id
="mnameInputContainer">
125 <label
class="control-label" for="mname"><?php
echo xlt('Middle')?
></label
>
126 <div
class="controls inline-inputs">
127 <input type
="text" class="form-control" id
="mname" placeholder
="<?php echo xla('Middle Name'); ?>" value
="<%= _.escape(item.get('mname') || '') %>">
128 <span
class="help-inline"></span
>
131 <div
class="form-group inline" id
="lnameInputContainer">
132 <label
class="control-label" for="lname"><?php
echo xlt('Last')?
></label
>
133 <div
class="controls inline-inputs">
134 <input type
="text" class="form-control" id
="lname" required placeholder
="<?php echo xla('Last Name'); ?>" value
="<%= _.escape(item.get('lname') || '') %>">
135 <span
class="help-inline"></span
>
138 <div
class="form-group inline dynhide hide" id
="pidInputContainer">
139 <label
class="control-label" for="pid"><?php
echo xlt('Pid')?
></label
>
140 <div
class="controls inline-inputs">
141 <input type
="text" class="form-control" id
="pid" placeholder
="<?php echo xla('Pid')?>" value
="<%= _.escape(item.get('pid') || '') %>">
142 <span
class="help-inline"></span
>
145 <div
class="form-group inline" id
="pubpidInputContainer">
146 <label
class="control-label" for="pubpid"><?php
echo xlt('Public Patient Id')?
></label
>
147 <div
class="controls inline-inputs">
148 <input type
="text" class="form-control" id
="pubpid" disabled value
="<%= _.escape(item.get('pubpid') || '') %>">
149 <span
class="help-inline"></span
>
152 <div
class="form-group inline" id
="dobInputContainer">
153 <label
class="control-label" for="dob"><?php
echo xlt('Birth Date')?
></label
>
154 <div
class="controls inline-inputs">
155 <div
class="input-group" >
156 <input id
="dob" type
="text" required
class="form-control jquery-date-picker" placeholder
="<?php echo xla('I know but we need it!'); ?>" value
="<%= item.get('dob') %>" />
158 <span
class="help-inline"></span
>
161 <div
class="form-group inline" id
="ssInputContainer">
162 <label
class="control-label" for="ss"><?php
echo xlt('SSN')?
></label
>
163 <div
class="controls inline-inputs">
164 <input type
="text" class="form-control" id
="ss" title
="###-##-####" placeholder
="<?php echo xla('Social Security(Optional)'); ?>" value
="<%= _.escape(item.get('ss') || '') %>">
165 <span
class="help-inline"></span
>
168 <div
class="form-group inline" id
="sexInputContainer">
169 <label
class="control-label" for="sex"><?php
echo xlt('Gender')?
></label
><br
>
170 <div
class="controls inline-inputs">
172 # Generate drop down list for Sex
173 echo generate_select_list('sex', 'sex', $row['sex'], xl('Sex'), 'Unassigned');
175 <span
class="help-inline"></span
>
178 <!--<div
class="form-group inline" id
="pharmacyIdInputContainer">
179 <label
class="control-label" for="pharmacyId"><?php
echo xlt('Pharmacy Id')?
></label
>
180 <div
class="controls inline-inputs">
181 <input type
="text" class="form-control" id
="pharmacyId" placeholder
="<?php echo xla('Pharmacy Id'); ?>" value
="<%= _.escape(item.get('pharmacyId') || '') %>">
182 <span
class="help-inline"></span
>
185 <div
class="form-group inline" id
="statusInputContainer">
186 <label
class="control-label" for="status"><?php
echo xlt('Marital Status')?
></label
><br
>
187 <div
class="controls inline-inputs">
189 # Generate drop down list for Marital Status
190 echo generate_select_list('status', 'marital', $row['marital'], xl('Marital Status'), 'Unassigned', "form-control");
192 <span
class="help-inline"></span
>
195 <div
class="form-group inline" id
="streetInputContainer">
196 <label
class="control-label" for="street"><?php
echo xlt('Street')?
></label
>
197 <div
class="controls inline-inputs">
198 <input type
="text" class="form-control" id
="street" required placeholder
="<?php echo xla('Street'); ?>" value
="<%= _.escape(item.get('street') || '') %>"/>
199 <span
class="help-inline"></span
>
202 <div
class="form-group inline" id
="cityInputContainer">
203 <label
class="control-label" for="city"><?php
echo xlt('City')?
></label
>
204 <div
class="controls inline-inputs">
205 <input type
="text" class="form-control" id
="city" required placeholder
="<?php echo xla('City'); ?>" value
="<%= _.escape(item.get('city') || '') %>">
206 <span
class="help-inline"></span
>
209 <div
class="form-group inline" id
="stateInputContainer">
210 <label
class="control-label" for="state"><?php
echo xlt('State')?
></label
><br
>
211 <div
class="controls inline-inputs">
213 # Generate drop down list for State
214 echo generate_select_list('state', 'state', $row['state'], xl('State'), 'Unassigned', "form-control");
216 <span
class="help-inline"></span
>
219 <div
class="form-group inline" id
="postalCodeInputContainer">
220 <label
class="control-label" for="postalCode"><?php
echo xlt('Postal Code')?
></label
>
221 <div
class="controls inline-inputs">
222 <input type
="text" class="form-control" id
="postalCode" placeholder
="<?php echo xla('Postal Code'); ?>" value
="<%= _.escape(item.get('postalCode') || '') %>">
223 <span
class="help-inline"></span
>
226 <div
class="form-group inline" id
="countyInputContainer">
227 <label
class="control-label" for="county"><?php
echo xlt('County')?
></label
>
228 <div
class="controls inline-inputs">
229 <input type
="text" class="form-control" id
="county" placeholder
="<?php echo xla('County'); ?>" value
="<%= _.escape(item.get('county') || '') %>">
230 <span
class="help-inline"></span
>
233 <div
class="form-group inline" id
="countryCodeInputContainer">
234 <label
class="control-label" for="countryCode"><?php
echo xlt('Country Code')?
></label
>
235 <div
class="controls inline-inputs">
236 <input type
="text" class="form-control" id
="countryCode" placeholder
="<?php echo xla('Country Code'); ?>" value
="<%= _.escape(item.get('countryCode') || '') %>">
237 <span
class="help-inline"></span
>
240 <div
class="form-group inline" id
="phoneHomeInputContainer">
241 <label
class="control-label" for="phoneHome"><?php
echo xlt('Home Phone')?
></label
>
242 <div
class="controls inline-inputs">
243 <input type
="text" class="form-control" id
="phoneHome" placeholder
="<?php echo xla('Phone Home'); ?>" value
="<%= _.escape(item.get('phoneHome') || '') %>">
244 <span
class="help-inline"></span
>
247 <div
class="form-group inline" id
="phoneBizInputContainer">
248 <label
class="control-label" for="phoneBiz"><?php
echo xlt('Business Phone')?
></label
>
249 <div
class="controls inline-inputs">
250 <input type
="text" class="form-control" id
="phoneBiz" placeholder
="<?php echo xla('Phone Biz'); ?>" value
="<%= _.escape(item.get('phoneBiz') || '') %>">
251 <span
class="help-inline"></span
>
254 <div
class="form-group inline" id
="phoneCellInputContainer">
255 <label
class="control-label" for="phoneCell"><?php
echo xlt('Cell Phone')?
></label
>
256 <div
class="controls inline-inputs">
257 <input type
="text" class="form-control" id
="phoneCell" placeholder
="<?php echo xla('Phone Cell'); ?>" value
="<%= _.escape(item.get('phoneCell') || '') %>">
258 <span
class="help-inline"></span
>
261 <div
class="form-group inline" id
="phoneContactInputContainer">
262 <label
class="control-label" for="phoneContact"><?php
echo xlt('Contact or Notify Phone')?
></label
>
263 <div
class="controls inline-inputs">
264 <input type
="text" class="form-control" id
="phoneContact" placeholder
="<?php echo xla('Phone Contact'); ?>" value
="<%= _.escape(item.get('phoneContact') || '') %>">
265 <span
class="help-inline"></span
>
268 <div
class="form-group inline" id
="contactRelationshipInputContainer">
269 <label
class="control-label" for="contactRelationship"><?php
echo xlt('Contact Relationship')?
></label
>
270 <div
class="controls inline-inputs">
271 <input type
="text" class="form-control" id
="contactRelationship" placeholder
="<?php echo xla('Contact Relationship'); ?>" value
="<%= _.escape(item.get('contactRelationship') || '') %>">
272 <span
class="help-inline"></span
>
275 <div
class="form-group inline" id
="dateInputContainer">
276 <label
class="control-label" for="date"><?php
echo xlt('Date')?
></label
>
277 <div
class="controls inline-inputs">
278 <div
class="input-group">
279 <input disabled id
="date" type
="text" class="form-control jquery-date-time-picker" value
="<%= item.get('date') %>" />
281 <span
class="help-inline"></span
>
284 <div
class="form-group inline dynhide" id
="refProvideridInputContainer">
285 <label
class="control-label" for="refProviderid"><?php
echo xlt('Referral Provider')?
></label
>
286 <div
class="controls inline-inputs">
287 <select disabled
class="form-control" id
="refProviderid" value
="<%= _.escape(item.get('refProviderid') || '') %>"></select
>
288 <span
class="help-inline"></span
>
291 <div
class="form-group inline" id
="emailInputContainer">
292 <label
class="control-label" for="email"><?php
echo xlt('Email')?
></label
>
293 <div
class="controls inline-inputs">
294 <input type
="email" class="form-control" id
="email" required placeholder
="<?php echo xla('Email'); ?>" value
="<%= _.escape(item.get('email') || '') %>">
295 <span
class="help-inline"></span
>
298 <div
class="form-group inline dynhide" id
="emailDirectInputContainer">
299 <label
class="control-label" for="emailDirect"><?php
echo xlt('Email Direct')?
></label
>
300 <div
class="controls inline-inputs">
301 <input type
="text" class="form-control" id
="emailDirect" placeholder
="<?php echo xla('Direct Email'); ?>" value
="<%= _.escape(item.get('emailDirect') || '') %>">
302 <span
class="help-inline"></span
>
305 <div
class="form-group inline" id
="languageInputContainer">
306 <label
class="control-label" for="language"><?php
echo xlt('Prefered Language')?
></label
>
307 <div
class="controls inline-inputs">
308 <input type
="text" class="form-control" id
="language" placeholder
="<?php echo xla('Language'); ?>" value
="<%= _.escape(item.get('language') || '') %>">
309 <span
class="help-inline"></span
>
312 <div
class="form-group inline" id
="raceInputContainer">
313 <label
class="control-label" for="race"><?php
echo xlt('Race')?
></label
><br
>
314 <div
class="controls inline-inputs">
316 # Generate drop down list for Race
317 echo generate_select_list('race', 'race', $row[ 'race'], xl('Race'), 'Unassigned', "form-control");
319 <span
class="help-inline"></span
>
322 <div
class="form-group inline" id
="ethnicityInputContainer">
323 <label
class="control-label" for="ethnicity"><?php
echo xlt('Ethnicity')?
></label
><br
>
324 <div
class="controls inline-inputs">
326 # Generate drop down list for Ethnicity
327 echo generate_select_list('ethnicity', 'ethnicity', $row['ethnicity'], xl('Ethnicity'), 'Unassigned', "form-control");
329 <span
class="help-inline"></span
>
332 <div
class="form-group inline" id
="religionInputContainer">
333 <label
class="control-label" for="religion"><?php
echo xlt('Religion')?
></label
><br
>
334 <div
class="controls inline-inputs">
336 # Generate drop down list for Religion
337 echo generate_select_list('religion', 'religious_affiliation', $row['religion'], xl('Religion'), 'Unassigned', "form-control");
339 <span
class="help-inline"></span
>
342 <div
class="form-group inline dynhide" id
="familySizeInputContainer">
343 <label
class="control-label" for="familySize"><?php
echo xlt('Family Size')?
></label
>
344 <div
class="controls inline-inputs">
345 <input type
="text" class="form-control" id
="familySize" placeholder
="<?php echo xla('Family Size'); ?>" value
="<%= _.escape(item.get('familySize') || '') %>">
346 <span
class="help-inline"></span
>
349 <div
class="form-group inline" id
="referralSourceInputContainer">
350 <label
class="control-label" for="referralSource"><?php
echo xlt('How Refered')?
></label
><br
>
351 <div
class="controls inline-inputs">
353 # Generate drop down list for Referral Source
354 echo generate_select_list('referralSource', 'refsource', $row['referralSource'], xl('Referral Source'), 'Unassigned', "form-control");
356 <span
class="help-inline"></span
>
359 <div
class="form-group inline dynhide" id
="regdateInputContainer">
360 <label
class="control-label" for="regdate"><?php
echo xlt('Registration Date')?
></label
>
361 <div
class="controls inline-inputs">
362 <div
class="input-group">
363 <input disabled id
="regdate" type
="text" class="form-control jquery-date-picker" value
="<%= item.get('regdate') %>" />
365 <span
class="help-inline"></span
>
368 <div
class="form-group inline" id
="mothersnameInputContainer">
369 <label
class="control-label" for="mothersname"><?php
echo xlt('Mothers Name')?
></label
>
370 <div
class="controls inline-inputs">
371 <input type
="text" class="form-control" id
="mothersname" placeholder
="<?php echo xla('Mothers Name'); ?>" value
="<%= _.escape(item.get('mothersname') || '') %>">
372 <span
class="help-inline"></span
>
375 <div
class="form-group inline dynhide" id
="guardiansnameInputContainer">
376 <label
class="control-label" for="guardiansname"><?php
echo xlt('Guardians Name')?
></label
>
377 <div
class="controls inline-inputs">
378 <input type
="text" class="form-control" id
="guardiansname" placeholder
="<?php echo xla('Guardiansname'); ?>" value
="<%= _.escape(item.get('guardiansname') || '') %>">
379 <span
class="help-inline"></span
>
382 <div
class="form-group inline" id
="hipaaMailInputContainer">
383 <label
class="control-label" for="hipaaMail"><?php
echo xlt('Allow Postal Mail')?
></label
>
384 <div
class="controls inline-inputs">
385 <label
class="btn btn-default btn-gradient btn-sm"><input id
="hipaaMail0" name
="hipaaMail" type
="radio" value
="NO"<%
if (item
.get('hipaaMail')=="NO") { %
> checked
="checked"<%
} %
>><?php
echo xlt('NO'); ?
></label
>
386 <label
class="btn btn-default btn-gradient btn-sm"><input id
="hipaaMail1" name
="hipaaMail" type
="radio" value
="YES"<%
if (item
.get('hipaaMail')=="YES") { %
> checked
="checked"<%
} %
>><?php
echo xlt('YES'); ?
></label
>
387 <label
class="btn btn-default btn-gradient btn-sm"><input id
="hipaaMail2" name
="hipaaMail" type
="radio" value
=""<%
if (item
.get('hipaaMail')=="") { %
> checked
="checked"<%
} %
>><?php
echo xlt('Unassigned'); ?
></label
>
388 <span
class="help-inline"></span
>
391 <div
class="form-group inline" id
="hipaaVoiceInputContainer">
392 <label
class="control-label" for="hipaaVoice"><?php
echo xlt('Allow Voice Call')?
></label
>
393 <div
class="controls inline-inputs">
394 <label
class="btn btn-default btn-gradient btn-sm"><input id
="hipaaVoice0" name
="hipaaVoice" type
="radio" value
="NO"<%
if (item
.get('hipaaVoice')=="NO") { %
> checked
="checked"<%
} %
>><?php
echo xlt('NO'); ?
></label
>
395 <label
class="btn btn-default btn-gradient btn-sm"><input id
="hipaaVoice1" name
="hipaaVoice" type
="radio" value
="YES"<%
if (item
.get('hipaaVoice')=="YES") { %
> checked
="checked"<%
} %
>><?php
echo xlt('YES'); ?
></label
>
396 <label
class="btn btn-default btn-gradient btn-sm"><input id
="hipaaVoice2" name
="hipaaVoice" type
="radio" value
=""<%
if (item
.get('hipaaVoice')=="") { %
> checked
="checked"<%
} %
>><?php
echo xlt('Unassigned'); ?
></label
>
397 <span
class="help-inline"></span
>
400 <div
class="form-group inline" id
="hipaaNoticeInputContainer">
401 <label
class="control-label" for="hipaaNotice"><?php
echo xlt('Allow Notice')?
></label
>
402 <div
class="controls inline-inputs">
403 <label
class="btn btn-default btn-gradient btn-sm"><input id
="hipaaNotice0" name
="hipaaNotice" type
="radio" value
="NO"<%
if (item
.get('hipaaNotice')=="NO") { %
> checked
="checked"<%
} %
>><?php
echo xlt('NO'); ?
></label
>
404 <label
class="btn btn-default btn-gradient btn-sm"><input id
="hipaaNotice1" name
="hipaaNotice" type
="radio" value
="YES"<%
if (item
.get('hipaaNotice')=="YES") { %
> checked
="checked"<%
} %
>><?php
echo xlt('YES'); ?
></label
>
405 <label
class="btn btn-default btn-gradient btn-sm"><input id
="hipaaNotice2" name
="hipaaNotice" type
="radio" value
=""<%
if (item
.get('hipaaNotice')=="") { %
> checked
="checked"<%
} %
>><?php
echo xlt('Unassigned'); ?
></label
>
406 <span
class="help-inline"></span
>
409 <div
class="form-group inline dynhide" id
="hipaaMessageInputContainer">
410 <label
class="control-label" for="hipaaMessage"><?php
echo xlt('Hipaa Message')?
></label
>
411 <div
class="controls inline-inputs">
412 <input type
="text" class="form-control" id
="hipaaMessage" placeholder
="<?php echo xla('Hipaa Message'); ?>" value
="<%= _.escape(item.get('hipaaMessage') || '') %>">
413 <span
class="help-inline"></span
>
416 <div
class="form-group inline" id
="hipaaAllowsmsInputContainer">
417 <label
class="control-label" for="hipaaAllowsms"><?php
echo xlt('Allow SMS')?
></label
>
418 <div
class="controls inline-inputs">
419 <label
class="btn btn-default btn-gradient btn-sm"><input id
="hipaaAllowsms0" name
="hipaaAllowsms" type
="radio" value
="NO"<%
if (item
.get('hipaaAllowsms')=="NO") { %
> checked
="checked"<%
} %
>><?php
echo xlt('NO'); ?
></label
>
420 <label
class="btn btn-default btn-gradient btn-sm"><input id
="hipaaAllowsms1" name
="hipaaAllowsms" type
="radio" value
="YES"<%
if (item
.get('hipaaAllowsms')=="YES") { %
> checked
="checked"<%
} %
>><?php
echo xlt('YES'); ?
></label
>
421 <label
class="btn btn-default btn-gradient btn-sm"><input id
="hipaaAllowsms2" name
="hipaaAllowsms" type
="radio" value
=""<%
if (item
.get('hipaaAllowsms')=="") { %
> checked
="checked"<%
} %
>><?php
echo xlt('Unassigned'); ?
></label
>
422 <span
class="help-inline"></span
>
425 <div
class="form-group inline" id
="hipaaAllowemailInputContainer">
426 <label
class="control-label" for="hipaaAllowemail"><?php
echo xlt('Allow Email')?
></label
>
427 <div
class="controls inline-inputs">
428 <label
class="btn btn-default btn-gradient btn-sm"><input id
="hipaaAllowemail0" name
="hipaaAllowemail" type
="radio" value
="NO"<%
if (item
.get('hipaaAllowemail')=="NO") { %
> checked
="checked"<%
} %
>><?php
echo xlt('NO'); ?
></label
>
429 <label
class="btn btn-default btn-gradient btn-sm"><input id
="hipaaAllowemail1" name
="hipaaAllowemail" type
="radio" value
="YES"<%
if (item
.get('hipaaAllowemail')=="YES") { %
> checked
="checked"<%
} %
>><?php
echo xlt('YES'); ?
></label
>
430 <label
class="btn btn-default btn-gradient btn-sm"><input id
="hipaaAllowemail2" name
="hipaaAllowemail" type
="radio" value
=""<%
if (item
.get('hipaaAllowemail')=="") { %
> checked
="checked"<%
} %
>><?php
echo xlt('Unassigned'); ?
></label
>
431 <span
class="help-inline"></span
>
434 <div
class="form-group inline" id
="allowImmRegUseInputContainer">
435 <label
class="control-label" for="allowImmRegUse"><?php
echo xlt('Allow Immunization Registry Use')?
></label
>
436 <div
class="controls inline-inputs">
437 <label
class="btn btn-default btn-gradient btn-sm"><input id
="allowImmRegUse0" name
="allowImmRegUse" type
="radio" value
="NO"<%
if (item
.get('allowImmRegUse')=="NO") { %
> checked
="checked"<%
} %
>><?php
echo xlt('NO'); ?
></label
>
438 <label
class="btn btn-default btn-gradient btn-sm"><input id
="allowImmRegUse1" name
="allowImmRegUse" type
="radio" value
="YES"<%
if (item
.get('allowImmRegUse')=="YES") { %
> checked
="checked"<%
} %
>><?php
echo xlt('YES'); ?
></label
>
439 <label
class="btn btn-default btn-gradient btn-sm"><input id
="allowImmRegUse2" name
="allowImmRegUse" type
="radio" value
=""<%
if (item
.get('allowImmRegUse')=="") { %
> checked
="checked"<%
} %
>><?php
echo xlt('Unassigned'); ?
></label
>
440 <span
class="help-inline"></span
>
443 <div
class="form-group inline" id
="allowImmInfoShareInputContainer">
444 <label
class="control-label" for="allowImmInfoShare"><?php
echo xlt('Allow Immunization Info Share')?
></label
>
445 <div
class="controls inline-inputs">
446 <label
class="btn btn-default btn-gradient btn-sm"><input id
="allowImmInfoShare0" name
="allowImmInfoShare" type
="radio" value
="NO"<%
if (item
.get('allowImmInfoShare')=="NO") { %
> checked
="checked"<%
} %
>><?php
echo xlt('NO'); ?
></label
>
447 <label
class="btn btn-default btn-gradient btn-sm"><input id
="allowImmInfoShare1" name
="allowImmInfoShare" type
="radio" value
="YES"<%
if (item
.get('allowImmInfoShare')=="YES") { %
> checked
="checked"<%
} %
>><?php
echo xlt('YES'); ?
></label
>
448 <label
class="btn btn-default btn-gradient btn-sm"><input id
="allowImmInfoShare2" name
="allowImmInfoShare" type
="radio" value
=""<%
if (item
.get('allowImmInfoShare')=="") { %
> checked
="checked"<%
} %
>><?php
echo xlt('Unassigned'); ?
></label
>
449 <span
class="help-inline"></span
>
452 <div
class="form-group inline" id
="allowHealthInfoExInputContainer">
453 <label
class="control-label" for="allowHealthInfoEx"><?php
echo xlt('Allow Health Info Exchange')?
></label
>
454 <div
class="controls inline-inputs">
455 <label
class="btn btn-default btn-gradient btn-sm"><input id
="allowHealthInfoEx0" name
="allowHealthInfoEx" type
="radio" value
="NO"<%
if (item
.get('allowHealthInfoEx')=="NO") { %
> checked
="checked"<%
} %
>><?php
echo xlt('NO'); ?
></label
>
456 <label
class="btn btn-default btn-gradient btn-sm"><input id
="allowHealthInfoEx1" name
="allowHealthInfoEx" type
="radio" value
="YES"<%
if (item
.get('allowHealthInfoEx')=="YES") { %
> checked
="checked"<%
} %
>><?php
echo xlt('YES'); ?
></label
>
457 <label
class="btn btn-default btn-gradient btn-sm"><input id
="allowHealthInfoEx2" name
="allowHealthInfoEx" type
="radio" value
=""<%
if (item
.get('allowHealthInfoEx')=="") { %
> checked
="checked"<%
} %
>><?php
echo xlt('Unassigned'); ?
></label
>
458 <span
class="help-inline"></span
>
461 <div
class="form-group inline" id
="allowPatientPortalInputContainer">
462 <label
class="control-label" for="allowPatientPortal"><?php
echo xlt('Allow Patient Portal')?
></label
>
463 <div
class="controls inline-inputs">
464 <label
class="btn btn-default btn-gradient btn-sm"><input disabled id
="allowPatientPortal0" name
="allowPatientPortal" type
="radio" value
="NO"<%
if (item
.get('allowPatientPortal')=="NO") { %
> checked
="checked"<%
} %
>><?php
echo xlt('NO'); ?
></label
>
465 <label
class="btn btn-default btn-gradient btn-sm"><input disabled id
="allowPatientPortal1" name
="allowPatientPortal" type
="radio" value
="YES"<%
if (item
.get('allowPatientPortal')=="YES") { %
> checked
="checked"<%
} %
>><?php
echo xlt('YES'); ?
></label
>
466 <label
class="btn btn-default btn-gradient btn-sm"><input disabled id
="allowPatientPortal2" name
="allowPatientPortal" type
="radio" value
=""<%
if (item
.get('allowPatientPortal')=="") { %
> checked
="checked"<%
} %
>><?php
echo xlt('Unassigned'); ?
></label
>
467 <span
class="help-inline"></span
>
470 <div
class="form-group inline dynhide" id
="careTeamInputContainer">
471 <label
class="control-label" for="careTeam"><?php
echo xlt('Care Team')?
></label
>
472 <div
class="controls inline-inputs">
473 <select
class="form-control" id
="careTeam" placeholder
="<?php echo xla('Care Team'); ?>" value
="<%= _.escape(item.get('careTeam') || '') %>"></select
>
474 <span
class="help-inline"></span
>
477 <div
class="form-group inline dynhide" id
="noteInputContainer">
478 <label
class="control-label" style
="color:green" for="note"><?php
echo xlt('Message to Reviewer')?
></label
>
479 <div
class="controls inline-inputs">
480 <textarea
class="form-control" id
="note" rows
="1" style
='min-width:180px'><%
= _
.escape("To Admin: ") %
></textarea
>
481 <span
class="help-inline"></span
>
489 <div id
="collectionAlert"></div
>
490 <div id
="modelAlert"></div
>
491 <div id
="patientCollectionContainer" class="collectionContainer"></div
><!-- -->
492 <div id
="patientModelContainer" class="modelContainer"></div
>
493 </div
> <!-- /container
-->
494 <?php
//$this->display('_Footer.tpl.php');?>
497 <!-- <div
class="form-group inline" id
="ethnoracialInputContainer">
498 <label
class="control-label" for="ethnoracial"><?php
echo xlt('Ethnoracial')?
></label
><br
>
499 <div
class="controls inline-inputs">
501 # Generate drop down list for Ethnoracial
502 //echo generate_select_list('ethnoracial', 'ethrace', $row['ethnoracial'], xl('Ethnoracial'), 'Unassigned', "form-control");
504 <span
class="help-inline"></span
>
507 <!-- <div
class="form-group inline" id
="interpretterInputContainer">
508 <label
class="control-label" for="interpretter"><?php
//echo xlt('Interpreter')?></label>
509 <div
class="controls inline-inputs">
510 <input type
="text" class="form-control" id
="interpretter" placeholder
="<?php //echo xla('Interpreter')?>" value
="<%= _.escape(item.get('interpretter') || '') %>">
511 <span
class="help-inline"></span
>
514 <div
class="form-group inline" id
="migrantseasonalInputContainer">
515 <label
class="control-label" for="migrantseasonal"><?php
//echo xlt('Migrantseasonal')?></label>
516 <div
class="controls inline-inputs">
517 <input type
="text" class="form-control" id
="migrantseasonal" placeholder
="<?php //echo xla('Migrantseasonal')?>" value
="<%= _.escape(item.get('migrantseasonal') || '') %>">
518 <span
class="help-inline"></span
>
521 <!-- <div
class="form-group inline" id
="industryInputContainer">
522 <label
class="control-label" for="industry"><?php
//echo xlt('Industry')?></label>
523 <div
class="controls inline-inputs">
524 <input type
="text" class="form-control" id
="industry" placeholder
="<?php //echo xla('Industry')?>" value
="<%= _.escape(item.get('industry') || '') %>">
525 <span
class="help-inline"></span
>
528 <div
class="form-group inline" id
="occupationInputContainer">
529 <label
class="control-label" for="occupation"><?php
//echo xlt('Occupation')?></label>
530 <div
class="controls inline-inputs">
531 <textarea
class="form-control" id
="occupation" rows
="1" style
='min-width:90px'><%
= _
.escape(item
.get('occupation') ||
'') %
></textarea
>
532 <span
class="help-inline"></span
>
535 <!--<div
class="form-group inline" id
="referrerInputContainer">
536 <label
class="control-label" for="referrer"><?php
//echo xlt('Referrer')?></label>
537 <div
class="controls inline-inputs">
538 <input type
="text" class="form-control" id
="referrer" placeholder
="<?php //echo xla('Referrer')?>" value
="<%= _.escape(item.get('referrer') || '') %>">
539 <span
class="help-inline"></span
>
542 <div
class="form-group inline" id
="referreridInputContainer">
543 <label
class="control-label" for="referrerid"><?php
//echo xlt('Referrerid')?></label>
544 <div
class="controls inline-inputs">
545 <input type
="text" class="form-control" id
="referrerid" placeholder
="<?php //echo xla('Referrerid')?>" value
="<%= _.escape(item.get('referrerid') || '') %>">
546 <span
class="help-inline"></span
>
549 <!-- <div
class="form-group inline" id
="monthlyIncomeInputContainer">
550 <label
class="control-label" for="monthlyIncome"><?php
//echo xlt('Monthly Income')?></label>
551 <div
class="controls inline-inputs">
552 <input type
="text" class="form-control" id
="monthlyIncome" placeholder
="<?php //echo xla('Monthly Income')?>" value
="<%= _.escape(item.get('monthlyIncome') || '') %>">
553 <span
class="help-inline"></span
>
556 <div
class="form-group inline" id
="billingNoteInputContainer">
557 <label
class="control-label" for="billingNote"><?php
//echo xlt('Billing Note')?></label>
558 <div
class="controls inline-inputs">
559 <input type
="text" class="form-control" id
="billingNote" placeholder
="<?php //echo xla('Billing Note')?>" value
="<%= _.escape(item.get('billingNote') || '') %>">
560 <span
class="help-inline"></span
>
563 <div
class="form-group inline" id
="homelessInputContainer">
564 <label
class="control-label" for="homeless"><?php
//echo xlt('Homeless')?></label>
565 <div
class="controls inline-inputs">
566 <input type
="text" class="form-control" id
="homeless" placeholder
="<?php //echo xla('Homeless')?>" value
="<%= _.escape(item.get('homeless') || '') %>">
567 <span
class="help-inline"></span
>
570 <div
class="form-group inline" id
="financialReviewInputContainer">
571 <label
class="control-label" for="financialReview"><?php
//echo xlt('Financial Review')?></label>
572 <div
class="controls inline-inputs">
573 <div
class="input-group">
574 <input id
="financialReview" type
="text" class="form-control jquery-date-time-picker" value
="<%= item.get('financialReview') %>" />
576 <span
class="help-inline"></span
>
579 <div
class="form-group inline" id
="pubpidInputContainer">
580 <label
class="control-label" for="pubpid"><?php
//echo xlt('Pubpid')?></label>
581 <div
class="controls inline-inputs">
582 <input type
="text" class="form-control" id
="pubpid" placeholder
="<?php //echo xla('Pubpid')?>" value
="<%= _.escape(item.get('pubpid') || '') %>">
583 <span
class="help-inline"></span
>
587 <div
class="form-group inline" id
="genericname1InputContainer">
588 <label
class="control-label" for="genericname1"><?php
//echo xlt('Genericname1')?></label>
589 <div
class="controls inline-inputs">
590 <input type
="text" class="form-control" id
="genericname1" placeholder
="<?php //echo xla('Genericname1')?>" value
="<%= _.escape(item.get('genericname1') || '') %>">
591 <span
class="help-inline"></span
>
594 <div
class="form-group inline" id
="genericval1InputContainer">
595 <label
class="control-label" for="genericval1"><?php
//echo xlt('Genericval1')?></label>
596 <div
class="controls inline-inputs">
597 <input type
="text" class="form-control" id
="genericval1" placeholder
="<?php //echo xla('Genericval1')?>" value
="<%= _.escape(item.get('genericval1') || '') %>">
598 <span
class="help-inline"></span
>
601 <div
class="form-group inline" id
="genericname2InputContainer">
602 <label
class="control-label" for="genericname2"><?php
//echo xlt('Genericname2')?></label>
603 <div
class="controls inline-inputs">
604 <input type
="text" class="form-control" id
="genericname2" placeholder
="<?php //echo xla('Genericname2')?>" value
="<%= _.escape(item.get('genericname2') || '') %>">
605 <span
class="help-inline"></span
>
608 <div
class="form-group inline" id
="genericval2InputContainer">
609 <label
class="control-label" for="genericval2"><?php
//echo xlt('Genericval2')?></label>
610 <div
class="controls inline-inputs">
611 <input type
="text" class="form-control" id
="genericval2" placeholder
="<?php //echo xla('Genericval2')?>" value
="<%= _.escape(item.get('genericval2') || '') %>">
612 <span
class="help-inline"></span
>
615 <!-- <div
class="form-group inline" id
="squadInputContainer">
616 <label
class="control-label" for="squad"><?php
//echo xlt('Squad')?></label>
617 <div
class="controls inline-inputs">
618 <input type
="text" class="form-control" id
="squad" placeholder
="<?php //echo xla('Squad')?>" value
="<%= _.escape(item.get('squad') || '') %>">
619 <span
class="help-inline"></span
>
622 <div
class="form-group inline" id
="fitnessInputContainer">
623 <label
class="control-label" for="fitness"><?php
//echo xlt('Fitness')?></label>
624 <div
class="controls inline-inputs">
625 <input type
="text" class="form-control" id
="fitness" placeholder
="<?php //echo xla('Fitness')?>" value
="<%= _.escape(item.get('fitness') || '') %>">
626 <span
class="help-inline"></span
>
629 <!-- <div
class="form-group inline" id
="allowPatientPortalInputContainer">
630 <label
class="control-label" for="allowPatientPortal"><?php
//echo xlt('Allow Patient Portal')?></label>
631 <div
class="controls inline-inputs">
632 <label
class="btn btn-default btn-gradient btn-sm"><input id
="allowPatientPortal0" name
="allowPatientPortal" type
="radio" value
="NO"<%
if (item
.get('allowPatientPortal')=="NO") { %
> checked
="checked"<%
} %
>><?php
//echo xlt('NO'); ?></label>
633 <label
class="btn btn-default btn-gradient btn-sm"><input id
="allowPatientPortal1" name
="allowPatientPortal" type
="radio" value
="YES"<%
if (item
.get('allowPatientPortal')=="YES") { %
> checked
="checked"<%
} %
>><?php
//echo xlt('YES'); ?></label>
634 <label
class="btn btn-default btn-gradient btn-sm"><input id
="allowPatientPortal2" name
="allowPatientPortal" type
="radio" value
=""<%
if (item
.get('allowPatientPortal')=="") { %
> checked
="checked"<%
} %
>><?php
//echo xlt('Unassigned'); ?></label>
635 <span
class="help-inline"></span
>
638 <div
class="form-group inline" id
="deceasedDateInputContainer">
639 <label
class="control-label" for="deceasedDate"><?php
//echo xlt('Deceased Date')?></label>
640 <div
class="controls inline-inputs">
641 <div
class="input-group">
642 <input id
="deceasedDate" type
="text" class="form-control jquery-date-time-picker" value
="<%= item.get('deceasedDate') %>" />
644 <span
class="help-inline"></span
>
647 <div
class="form-group inline" id
="deceasedReasonInputContainer">
648 <label
class="control-label" for="deceasedReason"><?php
//echo xlt('Deceased Reason')?></label>
649 <div
class="controls inline-inputs">
650 <input type
="text" class="form-control" id
="deceasedReason" placeholder
="<?php //echo xla('Deceased Reason')?>" value
="<%= _.escape(item.get('deceasedReason') || '') %>">
651 <span
class="help-inline"></span
>
654 <div
class="form-group inline" id
="soapImportStatusInputContainer">
655 <label
class="control-label" for="soapImportStatus"><?php
//echo xlt('Soap Import Status')?></label>
656 <div
class="controls inline-inputs">
657 <input type
="text" class="form-control" id
="soapImportStatus" placeholder
="<?php //echo xla('Soap Import Status')?>" value
="<%= _.escape(item.get('soapImportStatus') || '') %>">
658 <span
class="help-inline"></span
>
661 <div
class="form-group inline" id
="cmsportalLoginInputContainer">
662 <label
class="control-label" for="cmsportalLogin"><?php
//echo xlt('Cmsportal Login')?></label>
663 <div
class="controls inline-inputs">
664 <input type
="text" class="form-control" id
="cmsportalLogin" placeholder
="<?php //echo xla('Cmsportal Login')?>" value
="<%= _.escape(item.get('cmsportalLogin') || '') %>">
665 <span
class="help-inline"></span
>
668 <!-- <div
class="form-group inline" id
="contrastartInputContainer">
669 <label
class="control-label" for="contrastart"><?php
//echo xlt('Contrastart')?></label>
670 <div
class="controls inline-inputs">
671 <div
class="input-group">
672 <input id
="contrastart" type
="text" class="form-control jquery-date-time-picker" value
="<%= item.get('contrastart') %>" />
674 <span
class="help-inline"></span
>
677 <div
class="form-group inline" id
="completedAdInputContainer">
678 <label
class="control-label" for="completedAd"><?php
//echo xlt('Completed Ad')?></label>
679 <div
class="controls inline-inputs">
680 <label
class="btn btn-default btn-gradient btn-sm"><input id
="completedAd0" name
="completedAd" type
="radio" value
="NO"<%
if (item
.get('completedAd')=="NO") { %
> checked
="checked"<%
} %
>><?php
//echo xlt('NO'); ?></label>
681 <label
class="btn btn-default btn-gradient btn-sm"><input id
="completedAd1" name
="completedAd" type
="radio" value
="YES"<%
if (item
.get('completedAd')=="YES") { %
> checked
="checked"<%
} %
>><?php
//echo xlt('YES'); ?></label>
682 <label
class="btn btn-default btn-gradient btn-sm"><input id
="completedAd2" name
="completedAd" type
="radio" value
=""<%
if (item
.get('completedAd')=="") { %
> checked
="checked"<%
} %
>><?php
//echo xlt('Unassigned'); ?></label>
683 <span
class="help-inline"></span
>
686 <div
class="form-group inline" id
="adReviewedInputContainer">
687 <label
class="control-label" for="adReviewed"><?php
//echo xlt('Ad Reviewed')?></label>
688 <div
class="controls inline-inputs">
689 <div
class="input-group">
690 <input id
="adReviewed" type
="text" class="form-control jquery-date-time-picker" value
="<%= item.get('adReviewed') %>" />
692 <span
class="help-inline"></span
>
695 <div
class="form-group inline" id
="vfcInputContainer">
696 <label
class="control-label" for="vfc"><?php
//echo xlt('Vfc')?></label>
697 <div
class="controls inline-inputs">
698 <input type
="text" class="form-control" id
="vfc" placeholder
="<?php //echo xla('Vfc')?>" value
="<%= _.escape(item.get('vfc') || '') %>">
699 <span
class="help-inline"></span
>
702 <!-- <div
class="form-group inline" id
="usertext1InputContainer">
703 <label
class="control-label" for="usertext1"><?php
//echo xlt('Usertext1')?></label>
704 <div
class="controls inline-inputs">
705 <input type
="text" class="form-control" id
="usertext1" placeholder
="<?php //echo xla('Usertext1')?>" value
="<%= _.escape(item.get('usertext1') || '') %>">
706 <span
class="help-inline"></span
>
709 <div
class="form-group inline" id
="usertext2InputContainer">
710 <label
class="control-label" for="usertext2"><?php
//echo xlt('Usertext2')?></label>
711 <div
class="controls inline-inputs">
712 <input type
="text" class="form-control" id
="usertext2" placeholder
="<?php //echo xla('Usertext2')?>" value
="<%= _.escape(item.get('usertext2') || '') %>">
713 <span
class="help-inline"></span
>
716 <div
class="form-group inline" id
="usertext3InputContainer">
717 <label
class="control-label" for="usertext3"><?php
//echo xlt('Usertext3')?></label>
718 <div
class="controls inline-inputs">
719 <input type
="text" class="form-control" id
="usertext3" placeholder
="<?php //echo xla('Usertext3')?>" value
="<%= _.escape(item.get('usertext3') || '') %>">
720 <span
class="help-inline"></span
>
723 <div
class="form-group inline" id
="usertext4InputContainer">
724 <label
class="control-label" for="usertext4"><?php
//echo xlt('Usertext4')?></label>
725 <div
class="controls inline-inputs">
726 <input type
="text" class="form-control" id
="usertext4" placeholder
="<?php //echo xla('Usertext4')?>" value
="<%= _.escape(item.get('usertext4') || '') %>">
727 <span
class="help-inline"></span
>
730 <div
class="form-group inline" id
="usertext5InputContainer">
731 <label
class="control-label" for="usertext5"><?php
//echo xlt('Usertext5')?></label>
732 <div
class="controls inline-inputs">
733 <input type
="text" class="form-control" id
="usertext5" placeholder
="<?php //echo xla('Usertext5')?>" value
="<%= _.escape(item.get('usertext5') || '') %>">
734 <span
class="help-inline"></span
>
737 <div
class="form-group inline" id
="usertext6InputContainer">
738 <label
class="control-label" for="usertext6"><?php
//echo xlt('Usertext6')?></label>
739 <div
class="controls inline-inputs">
740 <input type
="text" class="form-control" id
="usertext6" placeholder
="<?php //echo xla('Usertext6')?>" value
="<%= _.escape(item.get('usertext6') || '') %>">
741 <span
class="help-inline"></span
>
744 <div
class="form-group inline" id
="usertext7InputContainer">
745 <label
class="control-label" for="usertext7"><?php
//echo xlt('Usertext7')?></label>
746 <div
class="controls inline-inputs">
747 <input type
="text" class="form-control" id
="usertext7" placeholder
="<?php //echo xla('Usertext7')?>" value
="<%= _.escape(item.get('usertext7') || '') %>">
748 <span
class="help-inline"></span
>
751 <div
class="form-group inline" id
="usertext8InputContainer">
752 <label
class="control-label" for="usertext8"><?php
//echo xlt('Usertext8')?></label>
753 <div
class="controls inline-inputs">
754 <input type
="text" class="form-control" id
="usertext8" placeholder
="<?php //echo xla('Usertext8')?>" value
="<%= _.escape(item.get('usertext8') || '') %>">
755 <span
class="help-inline"></span
>
758 <div
class="form-group inline" id
="userlist1InputContainer">
759 <label
class="control-label" for="userlist1"><?php
//echo xlt('Userlist1')?></label>
760 <div
class="controls inline-inputs">
761 <input type
="text" class="form-control" id
="userlist1" placeholder
="<?php //echo xla('Userlist1')?>" value
="<%= _.escape(item.get('userlist1') || '') %>">
762 <span
class="help-inline"></span
>
765 <div
class="form-group inline" id
="userlist2InputContainer">
766 <label
class="control-label" for="userlist2"><?php
//echo xlt('Userlist2')?></label>
767 <div
class="controls inline-inputs">
768 <input type
="text" class="form-control" id
="userlist2" placeholder
="<?php //echo xla('Userlist2')?>" value
="<%= _.escape(item.get('userlist2') || '') %>">
769 <span
class="help-inline"></span
>
772 <div
class="form-group inline" id
="userlist3InputContainer">
773 <label
class="control-label" for="userlist3"><?php
//echo xlt('Userlist3')?></label>
774 <div
class="controls inline-inputs">
775 <input type
="text" class="form-control" id
="userlist3" placeholder
="<?php //echo xla('Userlist3')?>" value
="<%= _.escape(item.get('userlist3') || '') %>">
776 <span
class="help-inline"></span
>
779 <div
class="form-group inline" id
="userlist4InputContainer">
780 <label
class="control-label" for="userlist4"><?php
//echo xlt('Userlist4')?></label>
781 <div
class="controls inline-inputs">
782 <input type
="text" class="form-control" id
="userlist4" placeholder
="<?php //echo xla('Userlist4')?>" value
="<%= _.escape(item.get('userlist4') || '') %>">
783 <span
class="help-inline"></span
>
786 <div
class="form-group inline" id
="userlist5InputContainer">
787 <label
class="control-label" for="userlist5"><?php
//echo xlt('Userlist5')?></label>
788 <div
class="controls inline-inputs">
789 <input type
="text" class="form-control" id
="userlist5" placeholder
="<?php //echo xla('Userlist5')?>" value
="<%= _.escape(item.get('userlist5') || '') %>">
790 <span
class="help-inline"></span
>
793 <div
class="form-group inline" id
="userlist6InputContainer">
794 <label
class="control-label" for="userlist6"><?php
//echo xlt('Userlist6')?></label>
795 <div
class="controls inline-inputs">
796 <input type
="text" class="form-control" id
="userlist6" placeholder
="<?php //echo xla('Userlist6')?>" value
="<%= _.escape(item.get('userlist6') || '') %>">
797 <span
class="help-inline"></span
>
800 <div
class="form-group inline" id
="userlist7InputContainer">
801 <label
class="control-label" for="userlist7"><?php
//echo xlt('Userlist7')?></label>
802 <div
class="controls inline-inputs">
803 <input type
="text" class="form-control" id
="userlist7" placeholder
="<?php //echo xla('Userlist7')?>" value
="<%= _.escape(item.get('userlist7') || '') %>">
804 <span
class="help-inline"></span
>
807 <div
class="form-group inline" id
="pricelevelInputContainer">
808 <label
class="control-label" for="pricelevel"><?php
//echo xlt('Pricelevel')?></label>
809 <div
class="controls inline-inputs">
810 <input type
="text" class="form-control" id
="pricelevel" placeholder
="<?php //echo xla('Pricelevel')?>" value
="<%= _.escape(item.get('pricelevel') || '') %>">
811 <span
class="help-inline"></span
>