interface/patient_file/summary/demographics_full.php

   1 <?php
   2 // This program is free software; you can redistribute it and/or
   3 // modify it under the terms of the GNU General Public License
   4 // as published by the Free Software Foundation; either version 2
   5 // of the License, or (at your option) any later version.
   6
   7 require_once("../../globals.php");
   8 require_once("$srcdir/acl.inc");
   9 require_once("$srcdir/options.inc.php");
  10 require_once("$srcdir/formatting.inc.php");
  11 require_once("$srcdir/erx_javascript.inc.php");
  12 require_once("$srcdir/validation/LBF_Validation.php");
  13
  14  // Session pid must be right or bad things can happen when demographics are saved!
  15  //
  16  include_once("$srcdir/pid.inc");
  17  $set_pid = $_GET["set_pid"] ? $_GET["set_pid"] : $_GET["pid"];
  18  if ($set_pid && $set_pid != $_SESSION["pid"]) {
  19   setpid($set_pid);
  20  }
  21
  22  include_once("$srcdir/patient.inc");
  23
  24  $result = getPatientData($pid, "*, DATE_FORMAT(DOB,'%Y-%m-%d') as DOB_YMD");
  25  $result2 = getEmployerData($pid);
  26
  27  // Check authorization.
  28  if ($pid) {
  29   if (!acl_check('patients', 'demo', '', 'write'))
  30    die(xl('Updating demographics is not authorized.'));
  31   if ($result['squad'] && ! acl_check('squads', $result['squad']))
  32    die(xl('You are not authorized to access this squad.'));
  33  } else {
  34   if (!acl_check('patients', 'demo', '', array('write','addonly') ))
  35    die(xl('Adding demographics is not authorized.'));
  36  }
  37
  38 $CPR = 4; // cells per row
  39
  40 // $statii = array('married','single','divorced','widowed','separated','domestic partner');
  41 // $langi = getLanguages();
  42 // $ethnoraciali = getEthnoRacials();
  43 // $provideri = getProviderInfo();
  44 if ($GLOBALS['insurance_information'] != '0') {
  45     $insurancei = getInsuranceProvidersExtra();
  46 }else{
  47         $insurancei = getInsuranceProviders();
  48 }
  49
  50 $fres = sqlStatement("SELECT * FROM layout_options " .
  51   "WHERE form_id = 'DEM' AND uor > 0 " .
  52   "ORDER BY group_name, seq");
  53 ?>
  54 <html>
  55 <head>
  56 <?php html_header_show();?>
  57
  58 <link rel="stylesheet" href="<?php echo $css_header; ?>" type="text/css">
  59
  60 <style type="text/css">@import url(../../../library/dynarch_calendar.css);</style>
  61
  62 <script type="text/javascript" src="../../../library/dialog.js"></script>
  63 <script type="text/javascript" src="../../../library/textformat.js"></script>
  64 <script type="text/javascript" src="../../../library/dynarch_calendar.js"></script>
  65 <?php include_once("{$GLOBALS['srcdir']}/dynarch_calendar_en.inc.php"); ?>
  66 <script type="text/javascript" src="../../../library/dynarch_calendar_setup.js"></script>
  67 <script type="text/javascript" src="../../../library/js/jquery-1.9.1.min.js"></script>
  68 <script type="text/javascript" src="../../../library/js/common.js"></script>
  69 <script type="text/javascript" src="../../../library/js/fancybox/jquery.fancybox-1.2.6.js"></script>
  70
  71 <?php include_once("{$GLOBALS['srcdir']}/options.js.php"); ?>
  72
  73 <link rel="stylesheet" type="text/css" href="../../../library/js/fancybox/jquery.fancybox-1.2.6.css" media="screen" />
  74
  75 <script type="text/javascript">
  76
  77 // Support for beforeunload handler.
  78 var somethingChanged = false;
  79
  80 $(document).ready(function(){
  81     tabbify();
  82     enable_modals();
  83
  84     // special size for
  85         $(".medium_modal").fancybox( {
  86                 'overlayOpacity' : 0.0,
  87                 'showCloseButton' : true,
  88                 'frameHeight' : 460,
  89                 'frameWidth' : 650
  90         });
  91
  92   // Support for beforeunload handler.
  93   $('.tab input, .tab select, .tab textarea').change(function() {
  94     somethingChanged = true;
  95   });
  96   window.addEventListener("beforeunload", function (e) {
  97     if (somethingChanged && !top.timed_out) {
  98       var msg = "<?php echo xls('You have unsaved changes.'); ?>";
  99       e.returnValue = msg;     // Gecko, Trident, Chrome 34+
 100       return msg;              // Gecko, WebKit, Chrome <34
 101     }
 102   });
 103 });
 104
 105 var mypcc = '<?php echo $GLOBALS['phone_country_code'] ?>';
 106
 107 //code used from http://tech.irt.org/articles/js037/
 108 function replace(string,text,by) {
 109  // Replaces text with by in string
 110  var strLength = string.length, txtLength = text.length;
 111  if ((strLength == 0) || (txtLength == 0)) return string;
 112
 113  var i = string.indexOf(text);
 114  if ((!i) && (text != string.substring(0,txtLength))) return string;
 115  if (i == -1) return string;
 116
 117  var newstr = string.substring(0,i) + by;
 118
 119  if (i+txtLength < strLength)
 120   newstr += replace(string.substring(i+txtLength,strLength),text,by);
 121
 122  return newstr;
 123 }
 124
 125 function upperFirst(string,text) {
 126  return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
 127 }
 128
 129 <?php for ($i=1;$i<=3;$i++) { ?>
 130 function auto_populate_employer_address<?php echo $i ?>(){
 131  var f = document.demographics_form;
 132  if (f.form_i<?php echo $i?>subscriber_relationship.options[f.form_i<?php echo $i?>subscriber_relationship.selectedIndex].value == "self")
 133  {
 134   f.i<?php echo $i?>subscriber_fname.value=f.form_fname.value;
 135   f.i<?php echo $i?>subscriber_mname.value=f.form_mname.value;
 136   f.i<?php echo $i?>subscriber_lname.value=f.form_lname.value;
 137   f.i<?php echo $i?>subscriber_street.value=f.form_street.value;
 138   f.i<?php echo $i?>subscriber_city.value=f.form_city.value;
 139   f.form_i<?php echo $i?>subscriber_state.value=f.form_state.value;
 140   f.i<?php echo $i?>subscriber_postal_code.value=f.form_postal_code.value;
 141   if (f.form_country_code)
 142     f.form_i<?php echo $i?>subscriber_country.value=f.form_country_code.value;
 143   f.i<?php echo $i?>subscriber_phone.value=f.form_phone_home.value;
 144   f.i<?php echo $i?>subscriber_DOB.value=f.form_DOB.value;
 145   if(typeof f.form_ss!="undefined")
 146     {
 147         f.i<?php echo $i?>subscriber_ss.value=f.form_ss.value;
 148     }
 149   f.form_i<?php echo $i?>subscriber_sex.value = f.form_sex.value;
 150   f.i<?php echo $i?>subscriber_employer.value=f.form_em_name.value;
 151   f.i<?php echo $i?>subscriber_employer_street.value=f.form_em_street.value;
 152   f.i<?php echo $i?>subscriber_employer_city.value=f.form_em_city.value;
 153   f.form_i<?php echo $i?>subscriber_employer_state.value=f.form_em_state.value;
 154   f.i<?php echo $i?>subscriber_employer_postal_code.value=f.form_em_postal_code.value;
 155   if (f.form_em_country)
 156     f.form_i<?php echo $i?>subscriber_employer_country.value=f.form_em_country.value;
 157  }
 158 }
 159
 160 <?php } ?>
 161
 162 function popUp(URL) {
 163  day = new Date();
 164  id = day.getTime();
 165  top.restoreSession();
 166  eval("page" + id + " = window.open(URL, '" + id + "', 'toolbar=0,scrollbars=1,location=0,statusbar=0,menubar=0,resizable=1,width=400,height=300,left = 440,top = 362');");
 167 }
 168
 169 function checkNum () {
 170  var re= new RegExp();
 171  re = /^\d*\.?\d*$/;
 172  str=document.demographics_form.monthly_income.value;
 173  if(re.exec(str))
 174  {
 175  }else{
 176   alert("<?php xl('Please enter a monetary amount using only numbers and a decimal point.','e'); ?>");
 177  }
 178 }
 179
 180 // Indicates which insurance slot is being updated.
 181 var insurance_index = 0;
 182
 183 // The OnClick handler for searching/adding the insurance company.
 184 function ins_search(ins) {
 185         insurance_index = ins;
 186         return false;
 187 }
 188
 189 // The ins_search.php window calls this to set the selected insurance.
 190 function set_insurance(ins_id, ins_name) {
 191  var thesel = document.forms[0]['i' + insurance_index + 'provider'];
 192  var theopts = thesel.options; // the array of Option objects
 193  var i = 0;
 194  for (; i < theopts.length; ++i) {
 195   if (theopts[i].value == ins_id) {
 196    theopts[i].selected = true;
 197    return;
 198   }
 199  }
 200  // no matching option was found so create one, append it to the
 201  // end of the list, and select it.
 202  theopts[i] = new Option(ins_name, ins_id, false, true);
 203 }
 204
 205 // This capitalizes the first letter of each word in the passed input
 206 // element.  It also strips out extraneous spaces.
 207 function capitalizeMe(elem) {
 208  var a = elem.value.split(' ');
 209  var s = '';
 210  for(var i = 0; i < a.length; ++i) {
 211   if (a[i].length > 0) {
 212    if (s.length > 0) s += ' ';
 213    s += a[i].charAt(0).toUpperCase() + a[i].substring(1);
 214   }
 215  }
 216  elem.value = s;
 217 }
 218
 219 function divclick(cb, divid) {
 220  var divstyle = document.getElementById(divid).style;
 221  if (cb.checked) {
 222   divstyle.display = 'block';
 223  } else {
 224   divstyle.display = 'none';
 225  }
 226  return true;
 227 }
 228
 229 // Compute the length of a string without leading and trailing spaces.
 230 function trimlen(s) {
 231  var i = 0;
 232  var j = s.length - 1;
 233  for (; i <= j && s.charAt(i) == ' '; ++i);
 234  for (; i <= j && s.charAt(j) == ' '; --j);
 235  if (i > j) return 0;
 236  return j + 1 - i;
 237 }
 238
 239 function validate(f) {
 240  var errCount = 0;
 241  var errMsgs = new Array();
 242 <?php generate_layout_validation('DEM'); ?>
 243
 244  var msg = "";
 245  msg += "<?php xl('The following fields are required', 'e' ); ?>:\n\n";
 246  for ( var i = 0; i < errMsgs.length; i++ ) {
 247         msg += errMsgs[i] + "\n";
 248  }
 249  msg += "\n<?php xl('Please fill them in before continuing.', 'e'); ?>";
 250
 251  if ( errMsgs.length > 0 ) {
 252         alert(msg);
 253  }
 254
 255  //Misc  Deceased Date Validation for Future Date
 256 var dateVal = document.getElementById("form_deceased_date").value;
 257 var currentDate;
 258 var d = new Date();
 259 month = '' + (d.getMonth() + 1),
 260 day = '' + d.getDate(),
 261 year = d.getFullYear();
 262 if (month.length < 2) month = '0' + month;
 263 if (day.length < 2) day = '0' + day;
 264 currentDate = year+'-'+month+'-'+day;
 265 if(dateVal > currentDate)
 266 {
 267         alert ('<?php echo xls("Deceased Date should not be greater than Today"); ?>');
 268         return false;
 269 }
 270
 271 //Patient Data validations
 272  <?php if($GLOBALS['erx_enable']){ ?>
 273  alertMsg='';
 274  for(i=0;i<f.length;i++){
 275   if(f[i].type=='text' && f[i].value)
 276   {
 277    if(f[i].name == 'form_fname' || f[i].name == 'form_mname' || f[i].name == 'form_lname')
 278    {
 279     alertMsg += checkLength(f[i].name,f[i].value,35);
 280     alertMsg += checkUsername(f[i].name,f[i].value);
 281    }
 282    else if(f[i].name == 'form_street' || f[i].name == 'form_city')
 283    {
 284     alertMsg += checkLength(f[i].name,f[i].value,35);
 285     alertMsg += checkAlphaNumericExtended(f[i].name,f[i].value);
 286    }
 287    else if(f[i].name == 'form_phone_home')
 288    {
 289     alertMsg += checkPhone(f[i].name,f[i].value);
 290    }
 291   }
 292  }
 293  if(alertMsg)
 294  {
 295    alert(alertMsg);
 296    return false;
 297  }
 298  <?php } ?>
 299  //return false;
 300
 301 // Some insurance validation.
 302  for (var i = 1; i <= 3; ++i) {
 303   subprov = 'i' + i + 'provider';
 304   if (!f[subprov] || f[subprov].selectedIndex <= 0) continue;
 305   var subpfx = 'i' + i + 'subscriber_';
 306   var subrelat = f['form_' + subpfx + 'relationship'];
 307   var samename =
 308    f[subpfx + 'fname'].value == f.form_fname.value &&
 309    f[subpfx + 'mname'].value == f.form_mname.value &&
 310    f[subpfx + 'lname'].value == f.form_lname.value;
 311   var ss_regexp=/[0-9][0-9][0-9]-?[0-9][0-9]-?[0-9][0-9][0-9][0-9]/;
 312   var samess=true;
 313   var ss_valid=false;
 314   if(typeof f.form_ss!="undefined")
 315       {
 316         samess = f[subpfx + 'ss'].value == f.form_ss.value;
 317         ss_valid=ss_regexp.test(f[subpfx + 'ss'].value) && ss_regexp.test(f.form_ss.value);
 318       }
 319   if (subrelat.options[subrelat.selectedIndex].value == "self") {
 320    if (!samename) {
 321     if (!confirm("<?php echo xls('Subscriber relationship is self but name is different! Is this really OK?'); ?>"))
 322      return false;
 323    }
 324    if (!samess && ss_valid) {
 325     if(!confirm("<?php echo xls('Subscriber relationship is self but SS number is different!')." ". xls("Is this really OK?"); ?>"))
 326     return false;
 327    }
 328   } // end self
 329   else {
 330    if (samename) {
 331     if (!confirm("<?php echo xls('Subscriber relationship is not self but name is the same! Is this really OK?'); ?>"))
 332      return false;
 333    }
 334    if (samess && ss_valid)  {
 335     if(!confirm("<?php echo xls('Subscriber relationship is not self but SS number is the same!') ." ". xls("Is this really OK?"); ?>"))
 336     return false;
 337    }
 338   } // end not self
 339  } // end for
 340
 341  return errMsgs.length < 1;
 342 }
 343
 344
 345
 346 // Onkeyup handler for policy number.  Allows only A-Z and 0-9.
 347 function policykeyup(e) {
 348  var v = e.value.toUpperCase();
 349  var filteredString="";
 350  for (var i = 0; i < v.length; ++i) {
 351   var c = v.charAt(i);
 352   if ((c >= '0' && c <= '9') ||
 353      (c >= 'A' && c <= 'Z') ||
 354      (c == '*') ||
 355      (c == '-') ||
 356      (c == '_') ||
 357      (c == '(') ||
 358      (c == ')') ||
 359      (c == '#'))
 360      {
 361          filteredString+=c;
 362      }
 363  }
 364  e.value = filteredString;
 365  return;
 366 }
 367
 368 // Added 06/2009 by BM to make compatible with list_options table and functions - using jquery
 369 $(document).ready(function() {
 370
 371  <?php for ($i=1;$i<=3;$i++) { ?>
 372   $("#form_i<?php echo $i?>subscriber_relationship").change(function() { auto_populate_employer_address<?php echo $i?>(); });
 373  <?php } ?>
 374
 375 });
 376
 377 </script>
 378 </head>
 379
 380 <?php
 381 /*Get the constraint from the DB-> LBF forms accordinf the form_id*/
 382 $constraints = LBF_Validation::generate_validate_constraints("DEM");
 383 ?>
 384 <script> var constraints = <?php echo $constraints;?>; </script>
 385
 386 <body class="body_top">
 387 <form action='demographics_save.php' name='demographics_form' id="DEM" method='post' onsubmit="submitme(<?php echo $GLOBALS['new_validate'] ? 1 : 0;?>,event,'DEM',constraints)">
 388 <input type='hidden' name='mode' value='save' />
 389 <input type='hidden' name='db_id' value="<?php echo $result['id']?>" />
 390 <table cellpadding='0' cellspacing='0' border='0'>
 391         <tr>
 392                 <td>
 393                         <?php if ($GLOBALS['concurrent_layout']) { ?>
 394                         <a href="demographics.php" onclick="top.restoreSession()">
 395                         <?php } else { ?>
 396                         <a href="patient_summary.php" target="Main" onclick="top.restoreSession()">
 397                         <?php } ?>
 398                         <font class=title><?php xl('Current Patient','e'); ?></font>
 399                         </a>
 400                         &nbsp;&nbsp;
 401                 </td>
 402         <td>
 403             <input id="submit_btn" class="css_btn" type="submit" disabled="disabled" value="<?php xl('Save','e'); ?>">
 404         </td>
 405                 <td>
 406                         <?php if ($GLOBALS['concurrent_layout']) { ?>
 407                         <a class="css_button" href="demographics.php" onclick="top.restoreSession()">
 408                         <?php } else { ?>
 409                         <a href="patient_summary.php" target="Main" onclick="top.restoreSession()">
 410                         <?php } ?>
 411                         <span><?php xl('Cancel','e'); ?></span>
 412                         </a>
 413                 </td>
 414         </tr>
 415 </table>
 416 <?php
 417
 418 function end_cell() {
 419   global $item_count, $cell_count;
 420   if ($item_count > 0) {
 421     echo "</td>";
 422     $item_count = 0;
 423   }
 424 }
 425
 426 function end_row() {
 427   global $cell_count, $CPR;
 428   end_cell();
 429   if ($cell_count > 0) {
 430     for (; $cell_count < $CPR; ++$cell_count) echo "<td></td>";
 431     echo "</tr>\n";
 432     $cell_count = 0;
 433   }
 434 }
 435
 436 function end_group() {
 437   global $last_group;
 438   if (strlen($last_group) > 0) {
 439     end_row();
 440     echo " </table>\n";
 441     echo "</div>\n";
 442   }
 443 }
 444
 445 $last_group = '';
 446 $cell_count = 0;
 447 $item_count = 0;
 448 $display_style = 'block';
 449
 450 $group_seq=0; // this gives the DIV blocks unique IDs
 451
 452 ?>
 453 <br>
 454   <div class="section-header">
 455    <span class="text"><b> <?php xl("Demographics", "e" )?></b></span>
 456 </div>
 457
 458 <div id="DEM" >
 459
 460         <ul class="tabNav">
 461            <?php display_layout_tabs('DEM', $result, $result2); ?>
 462         </ul>
 463
 464         <div class="tabContainer">
 465                 <?php display_layout_tabs_data_editable('DEM', $result, $result2); ?>
 466         </div>
 467 </div>
 468 <br>
 469
 470 <div id="DEM" >
 471
 472
 473 <?php
 474  if (! $GLOBALS['simplified_demographics']) {
 475
 476           $insurance_headings = array(xl("Primary Insurance Provider"), xl("Secondary Insurance Provider"), xl("Tertiary Insurance provider"));
 477           $insurance_info = array();
 478           $insurance_info[1] = getInsuranceData($pid,"primary");
 479           $insurance_info[2] = getInsuranceData($pid,"secondary");
 480           $insurance_info[3] = getInsuranceData($pid,"tertiary");
 481
 482         ?>
 483      <div class="section-header">
 484          <span class="text"><b><?php xl("Insurance", "e" )?></b></span>
 485      </div>
 486         <div id="INSURANCE" >
 487                 <ul class="tabNav">
 488                 <?php
 489                 foreach (array('primary','secondary','tertiary') as $instype) {
 490                         ?><li <?php echo $instype == 'primary' ? 'class="current"' : '' ?>><a href="#"><?php $CapInstype=ucfirst($instype); xl($CapInstype,'e'); ?></a></li><?php
 491                 }
 492                 ?>
 493                 </ul>
 494
 495         <div class="tabContainer">
 496
 497         <?php
 498           for($i=1;$i<=3;$i++) {
 499            $result3 = $insurance_info[$i];
 500         ?>
 501
 502                 <div class="tab <?php echo $i == 1 ? 'current': '' ?>" style='height:auto;width:auto'>          <!---display icky, fix to auto-->
 503
 504                 <table border="0">
 505
 506                  <tr>
 507                   <td valign=top width="430">
 508                    <table border="0">
 509
 510                          <tr>
 511                           <td valign='top'>
 512                            <span class='required'><?php echo $insurance_headings[$i -1]."&nbsp;"?></span>
 513                           </td>
 514                           <td class='required'>:</td>
 515                           <td>
 516                            <a href="../../practice/ins_search.php" class="iframe medium_modal css_button" onclick="ins_search(<?php echo $i?>)">
 517                                 <span><?php echo xl('Search/Add') ?></span>
 518                                 </a>
 519                                 <select name="i<?php echo $i?>provider">
 520                                 <option value=""><?php xl('Unassigned','e'); ?></option>
 521                                 <?php
 522                                  foreach ($insurancei as $iid => $iname) {
 523                                   echo "<option value='" . $iid . "'";
 524                                   if (strtolower($iid) == strtolower($result3{"provider"}))
 525                                    echo " selected";
 526                                   echo ">" . $iname . "</option>\n";
 527                                  }
 528                                 ?>
 529                            </select>
 530
 531                           </td>
 532                          </tr>
 533
 534                         <tr>
 535                          <td>
 536                           <span class='required'><?php xl('Plan Name','e'); ?> </span>
 537                          </td>
 538                          <td class='required'>:</td>
 539                          <td>
 540                           <input type='entry' size='20' name='i<?php echo $i?>plan_name' value="<?php echo $result3{"plan_name"} ?>"
 541                            onchange="capitalizeMe(this);" />&nbsp;&nbsp;
 542                          </td>
 543                         </tr>
 544
 545                         <tr>
 546                          <td>
 547                           <span class='required'><?php xl('Effective Date','e'); ?></span>
 548                          </td>
 549                          <td class='required'>:</td>
 550                          <td>
 551                           <input type='entry' size='16' id='i<?php echo $i ?>effective_date' name='i<?php echo $i ?>effective_date'
 552                            value='<?php echo $result3['date'] ?>'
 553                            onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)'
 554                            title='yyyy-mm-dd' />
 555                           <img src='../../pic/show_calendar.gif' align='absbottom' width='24' height='22' id='img_i<?php echo $i ?>effective_date' border='0' alt='[?]' style='cursor:pointer' title='<?php xl('Click here to choose a date','e'); ?>'>
 556                          </td>
 557                         </tr>
 558
 559                         <tr>
 560                          <td><span class=required><?php xl('Policy Number','e'); ?></span></td>
 561                          <td class='required'>:</td>
 562                          <td><input type='entry' size='16' name='i<?php echo $i?>policy_number' value="<?php echo $result3{"policy_number"}?>"
 563                           onkeyup='policykeyup(this)'></td>
 564                         </tr>
 565
 566                         <tr>
 567                          <td><span class=required><?php xl('Group Number','e'); ?></span></td>
 568                          <td class='required'>:</td>
 569                          <td><input type=entry size=16 name=i<?php echo $i?>group_number value="<?php echo $result3{"group_number"}?>" onkeyup='policykeyup(this)'></td>
 570                         </tr>
 571
 572                         <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 573                          <td class='required'><?php xl('Subscriber Employer (SE)','e'); ?><br><span style='font-weight:normal'>
 574                           (<?php xl('if unemployed enter Student','e'); ?>,<br><?php xl('PT Student, or leave blank','e'); ?>) </span></td>
 575                           <td class='required'>:</td>
 576                          <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer
 577                           value="<?php echo $result3{"subscriber_employer"}?>"
 578                            onchange="capitalizeMe(this);" /></td>
 579                         </tr>
 580
 581                         <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 582                          <td><span class=required><?php xl('SE Address','e'); ?></span></td>
 583                          <td class='required'>:</td>
 584                          <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer_street
 585                           value="<?php echo $result3{"subscriber_employer_street"}?>"
 586                            onchange="capitalizeMe(this);" /></td>
 587                         </tr>
 588
 589                         <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 590                          <td colspan="3">
 591                           <table>
 592                            <tr>
 593                                 <td><span class=required><?php xl('SE City','e'); ?>: </span></td>
 594                                 <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_city
 595                                  value="<?php echo $result3{"subscriber_employer_city"}?>"
 596                                   onchange="capitalizeMe(this);" /></td>
 597                                 <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE State','e') : xl('SE Locality','e') ?>: </span></td>
 598                         <td>
 599                                  <?php
 600                                   // Modified 7/2009 by BM to incorporate data types
 601                           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'), $result3['subscriber_employer_state']);
 602                                  ?>
 603                                 </td>
 604                            </tr>
 605                            <tr>
 606                                 <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE Zip Code','e') : xl('SE Postal Code','e') ?>: </span></td>
 607                                 <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_postal_code value="<?php echo $result3{"subscriber_employer_postal_code"}?>"></td>
 608                                 <td><span class=required><?php xl('SE Country','e'); ?>: </span></td>
 609                         <td>
 610                                  <?php
 611                                   // Modified 7/2009 by BM to incorporate data types
 612                           generate_form_field(array('data_type'=>$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'), $result3['subscriber_employer_country']);
 613                                  ?>
 614                         </td>
 615                            </tr>
 616                           </table>
 617                          </td>
 618                         </tr>
 619
 620                    </table>
 621                   </td>
 622
 623                   <td valign=top>
 624                 <table border="0">
 625                         <tr>
 626                                 <td><span class=required><?php xl('Relationship','e'); ?></span></td>
 627                                 <td class=required>:</td>
 628                                 <td colspan=3><?php
 629                                         // Modified 6/2009 by BM to use list_options and function
 630                                         generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_relationship'),'list_id'=>'sub_relation','empty_title'=>' '), $result3['subscriber_relationship']);
 631                                         ?>
 632
 633                                 <a href="javascript:popUp('browse.php?browsenum=<?php echo $i?>')" class=text>(<?php xl('Browse','e'); ?>)</a></td>
 634                                 <td></td><td></td><td></td><td></td>
 635                         </tr>
 636                         <tr>
 637                                 <td width=120><span class=required><?php xl('Subscriber','e'); ?> </span></td>
 638                                 <td class=required>:</td>
 639                                 <td colspan=3><input type=entry size=10 name=i<?php echo $i?>subscriber_fname   value="<?php echo $result3{"subscriber_fname"}?>" onchange="capitalizeMe(this);" />
 640                                 <input type=entry size=3 name=i<?php echo $i?>subscriber_mname value="<?php echo $result3{"subscriber_mname"}?>" onchange="capitalizeMe(this);" />
 641                                 <input type=entry size=10 name=i<?php echo $i?>subscriber_lname value="<?php echo $result3{"subscriber_lname"}?>" onchange="capitalizeMe(this);" /></td>
 642                                 <td></td><td></td><td></td><td></td>
 643                         </tr>
 644                         <tr>
 645                                 <td><span class=bold><?php xl('D.O.B.','e'); ?> </span></td>
 646                                 <td class=required>:</td>
 647                                 <td><input type='entry' size='11' id='i<?php echo $i?>subscriber_DOB' name='i<?php echo $i?>subscriber_DOB' value='<?php echo $result3['subscriber_DOB'] ?>' onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)' title='yyyy-mm-dd' /><img src='../../pic/show_calendar.gif' align='absbottom' width='24' height='22' id='img_i<?php echo $i; ?>dob_date' border='0' alt='[?]' style='cursor:pointer' title='<?php xl('Click here to choose a date','e'); ?>'></td>
 648
 649                                 <td><span class=bold><?php xl('Sex','e'); ?>: </span></td>
 650                                 <td><?php
 651                                         // Modified 6/2009 by BM to use list_options and function
 652                                         generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_sex'),'list_id'=>'sex'), $result3['subscriber_sex']);
 653                                         ?>
 654                                 </td>
 655                                 <td></td><td></td> <td></td><td></td>
 656                         </tr>
 657                         <tr>
 658                                 <td class=leftborder><span class=bold><?php xl('S.S.','e'); ?> </span></td>
 659                                 <td class=required>:</td>
 660                                 <td><input type=entry size=11 name=i<?php echo $i?>subscriber_ss value="<?php echo trim($result3{"subscriber_ss"})?>"></td>
 661                         </tr>
 662
 663                         <tr>
 664                                 <td><span class=required><?php xl('Subscriber Address','e'); ?> </span></td>
 665                                 <td class=required>:</td>
 666                                 <td><input type=entry size=20 name=i<?php echo $i?>subscriber_street value="<?php echo $result3{"subscriber_street"}?>" onchange="capitalizeMe(this);" /></td>
 667
 668                                 <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('State','e') : xl('Locality','e') ?>: </span></td>
 669                                 <td>
 670                                         <?php
 671                                         // Modified 7/2009 by BM to incorporate data types
 672                                         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']);
 673                                 ?>
 674                                 </td>
 675                         </tr>
 676                         <tr>
 677                                 <td class=leftborder><span class=required><?php xl('City','e'); ?></span></td>
 678                                 <td class=required>:</td>
 679                                 <td><input type=entry size=11 name=i<?php echo $i?>subscriber_city value="<?php echo $result3{"subscriber_city"}?>" onchange="capitalizeMe(this);" /></td><td class=leftborder><span class='required'<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>><?php xl('Country','e'); ?>: </span></td><td>
 680                                         <?php
 681                                         // Modified 7/2009 by BM to incorporate data types
 682                                         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'), $result3['subscriber_country']);
 683                                         ?>
 684                                 </td>
 685 </tr>
 686                         <tr>
 687                                 <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('Zip Code','e') : xl('Postal Code','e') ?> </span></td><td class=required>:</td><td><input type=entry size=10 name=i<?php echo $i?>subscriber_postal_code value="<?php echo $result3{"subscriber_postal_code"}?>"></td>
 688
 689                                 <td colspan=2>
 690                                 </td><td></td>
 691                         </tr>
 692                         <tr>
 693                                 <td><span class=bold><?php xl('Subscriber Phone','e'); ?></span></td>
 694                                 <td class=required>:</td>
 695                                 <td><input type='text' size='20' name='i<?php echo $i?>subscriber_phone' value='<?php echo $result3["subscriber_phone"] ?>' onkeyup='phonekeyup(this,mypcc)' /></td>
 696                                 <td colspan=2><span class=bold><?php xl('CoPay','e'); ?>: <input type=text size="6" name=i<?php echo $i?>copay value="<?php echo $result3{"copay"}?>"></span></td>
 697                                 <td colspan=2>
 698                                 </td><td></td><td></td>
 699                         </tr>
 700                         <tr>
 701                                 <td colspan=0><span class='required'><?php xl('Accept Assignment','e'); ?></span></td>
 702                                 <td class=required>:</td>
 703                                 <td colspan=2>
 704                                         <select name=i<?php echo $i?>accept_assignment>
 705                                                 <option value="TRUE" <?php if (strtoupper($result3{"accept_assignment"}) == "TRUE") echo "selected"?>><?php xl('YES','e'); ?></option>
 706                                                 <option value="FALSE" <?php if (strtoupper($result3{"accept_assignment"}) == "FALSE") echo "selected"?>><?php xl('NO','e'); ?></option>
 707                                         </select>
 708                                 </td>
 709                                 <td></td><td></td>
 710                                 <td colspan=2>
 711                                 </td><td></td>
 712                         </tr>
 713       <tr>
 714         <td><span class='bold'><?php xl('Secondary Medicare Type','e'); ?></span></td>
 715         <td class='bold'>:</td>
 716         <td colspan='6'>
 717           <select name=i<?php echo $i?>policy_type>
 718 <?php
 719   foreach ($policy_types AS $key => $value) {
 720     echo "            <option value ='$key'";
 721     if ($key == $result3['policy_type']) echo " selected";
 722     echo ">" . htmlspecialchars($value) . "</option>\n";
 723   }
 724 ?>
 725           </select>
 726         </td>
 727       </tr>
 728                 </table>
 729
 730                   </td>
 731                  </tr>
 732                 </table>
 733
 734                 </div>
 735
 736         <?php } //end insurer for loop ?>
 737
 738         </div>
 739 </div>
 740
 741 <?php } // end of "if not simplified_demographics" ?>
 742 </div></div>
 743
 744 </form>
 745
 746 <br>
 747
 748 <script language="JavaScript">
 749 // hard code validation for old validation, in the new validation possible to add match rules
 750 <?php if($GLOBALS['new_validate'] == 0) { ?>
 751  // fix inconsistently formatted phone numbers from the database
 752  var f = document.forms[0];
 753  if (f.form_phone_contact) phonekeyup(f.form_phone_contact,mypcc);
 754  if (f.form_phone_home   ) phonekeyup(f.form_phone_home   ,mypcc);
 755  if (f.form_phone_biz    ) phonekeyup(f.form_phone_biz    ,mypcc);
 756  if (f.form_phone_cell   ) phonekeyup(f.form_phone_cell   ,mypcc);
 757
 758 <?php if (! $GLOBALS['simplified_demographics']) { ?>
 759  phonekeyup(f.i1subscriber_phone,mypcc);
 760  phonekeyup(f.i2subscriber_phone,mypcc);
 761  phonekeyup(f.i3subscriber_phone,mypcc);
 762 <?php } ?>
 763
 764 <?php }?>
 765
 766 <?php if ($GLOBALS['concurrent_layout'] && $set_pid) { ?>
 767  parent.left_nav.setPatient(<?php echo "'" . addslashes($result['fname']) . " " . addslashes($result['lname']) . "',$pid,'" . addslashes($result['pubpid']) . "','', ' " . xl('DOB') . ": " . oeFormatShortDate($result['DOB_YMD']) . " " . xl('Age') . ": " . getPatientAgeDisplay($result['DOB_YMD']) . "'"; ?>);
 768  parent.left_nav.setRadio(window.name, 'dem');
 769 <?php } ?>
 770
 771 <?php echo $date_init; ?>
 772 <?php if (! $GLOBALS['simplified_demographics']) { for ($i=1; $i<=3; $i++): ?>
 773  Calendar.setup({inputField:"i<?php echo $i?>effective_date", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i?>effective_date"});
 774  Calendar.setup({inputField:"i<?php echo $i?>subscriber_DOB", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i?>dob_date"});
 775 <?php endfor; } ?>
 776 </script>
 777
 778 <!-- include support for the list-add selectbox feature -->
 779 <?php include $GLOBALS['fileroot']."/library/options_listadd.inc"; ?>
 780
 781 <?php /*Include the validation script and rules for this form*/
 782 $form_id="DEM";
 783 ?>
 784 <?php  include_once("$srcdir/validation/validation_script.js.php");?>
 785
 786
 787 </body>
 788 <script language='JavaScript'>
 789     // Array of skip conditions for the checkSkipConditions() function.
 790     var skipArray = [
 791         <?php echo $condition_str; ?>
 792     ];
 793     checkSkipConditions();
 794     $("input").change(function() {
 795         checkSkipConditions();
 796     });
 797     $("select").change(function() {
 798         checkSkipConditions();
 799     });
 800 </script>
 801
 802
 803 </html>