interface/new/new_comprehensive.php

   1 <?php
   2 // Copyright (C) 2009-2010 Rod Roark <rod@sunsetsystems.com>
   3 //
   4 // This program is free software; you can redistribute it and/or
   5 // modify it under the terms of the GNU General Public License
   6 // as published by the Free Software Foundation; either version 2
   7 // of the License, or (at your option) any later version.
   8
   9 require_once("../globals.php");
  10 require_once("$srcdir/acl.inc");
  11 require_once("$srcdir/options.inc.php");
  12 require_once("$srcdir/patient.inc");
  13 require_once("$srcdir/erx_javascript.inc.php");
  14
  15 // Check authorization.
  16 $thisauth = acl_check('patients', 'demo');
  17 if ($thisauth != 'write' && $thisauth != 'addonly')
  18   die("Adding demographics is not authorized.");
  19
  20 $CPR = 4; // cells per row
  21
  22 $searchcolor = empty($GLOBALS['layout_search_color']) ?
  23   '#ffff55' : $GLOBALS['layout_search_color'];
  24
  25 $WITH_SEARCH = ($GLOBALS['full_new_patient_form'] == '1' || $GLOBALS['full_new_patient_form'] == '2');
  26 $SHORT_FORM  = ($GLOBALS['full_new_patient_form'] == '2' || $GLOBALS['full_new_patient_form'] == '3');
  27
  28 function getLayoutRes() {
  29   global $SHORT_FORM;
  30   return sqlStatement("SELECT * FROM layout_options " .
  31     "WHERE form_id = 'DEM' AND uor > 0 AND field_id != '' " .
  32     ($SHORT_FORM ? "AND ( uor > 1 OR edit_options LIKE '%N%' ) " : "") .
  33     "ORDER BY group_name, seq");
  34 }
  35
  36 // Determine layout field search treatment from its data type:
  37 // 1 = text field
  38 // 2 = select list
  39 // 0 = not searchable
  40 //
  41 function getSearchClass($data_type) {
  42   switch($data_type) {
  43     case  1: // single-selection list
  44     case 10: // local provider list
  45     case 11: // provider list
  46     case 12: // pharmacy list
  47     case 13: // squads
  48     case 14: // address book list
  49     case 26: // single-selection list with add
  50     case 35: // facilities
  51       return 2;
  52     case  2: // text field
  53     case  3: // textarea
  54     case  4: // date
  55       return 1;
  56   }
  57   return 0;
  58 }
  59
  60 $fres = getLayoutRes();
  61 ?>
  62 <html>
  63 <head>
  64 <?php html_header_show(); ?>
  65
  66 <link rel="stylesheet" href="<?php echo $css_header; ?>" type="text/css">
  67
  68 <style>
  69 body, td, input, select, textarea {
  70  font-family: Arial, Helvetica, sans-serif;
  71  font-size: 10pt;
  72 }
  73
  74 body {
  75  padding: 5pt 5pt 5pt 5pt;
  76 }
  77
  78 div.section {
  79  border: solid;
  80  border-width: 1px;
  81  border-color: #0000ff;
  82  margin: 0 0 0 10pt;
  83  padding: 5pt;
  84 }
  85
  86 </style>
  87
  88 <style type="text/css">@import url(../../library/dynarch_calendar.css);</style>
  89
  90 <script type="text/javascript" src="../../library/dialog.js"></script>
  91 <script type="text/javascript" src="../../library/textformat.js"></script>
  92 <script type="text/javascript" src="../../library/dynarch_calendar.js"></script>
  93 <?php include_once("{$GLOBALS['srcdir']}/dynarch_calendar_en.inc.php"); ?>
  94 <script type="text/javascript" src="../../library/dynarch_calendar_setup.js"></script>
  95 <script type="text/javascript" src="<?php echo $GLOBALS['webroot']; ?>/library/js/jquery.js"></script>
  96
  97 <SCRIPT LANGUAGE="JavaScript"><!--
  98 //Visolve - sync the radio buttons - Start
  99 if((top.window.parent) && (parent.window)){
 100         var wname = top.window.parent.left_nav;
 101         fname = (parent.window.name)?parent.window.name:window.name;
 102         wname.syncRadios();
 103         wname.setRadio(fname, "new");
 104 }//Visolve - sync the radio buttons - End
 105
 106 var mypcc = '<?php echo $GLOBALS['phone_country_code'] ?>';
 107
 108 // This may be changed to true by the AJAX search script.
 109 var force_submit = false;
 110
 111 //code used from http://tech.irt.org/articles/js037/
 112 function replace(string,text,by) {
 113  // Replaces text with by in string
 114  var strLength = string.length, txtLength = text.length;
 115  if ((strLength == 0) || (txtLength == 0)) return string;
 116
 117  var i = string.indexOf(text);
 118  if ((!i) && (text != string.substring(0,txtLength))) return string;
 119  if (i == -1) return string;
 120
 121  var newstr = string.substring(0,i) + by;
 122
 123  if (i+txtLength < strLength)
 124   newstr += replace(string.substring(i+txtLength,strLength),text,by);
 125
 126  return newstr;
 127 }
 128
 129 <?php for ($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   f.i<?php echo $i?>subscriber_fname.value=f.form_fname.value;
 134   f.i<?php echo $i?>subscriber_mname.value=f.form_mname.value;
 135   f.i<?php echo $i?>subscriber_lname.value=f.form_lname.value;
 136   f.i<?php echo $i?>subscriber_street.value=f.form_street.value;
 137   f.i<?php echo $i?>subscriber_city.value=f.form_city.value;
 138   f.form_i<?php echo $i?>subscriber_state.value=f.form_state.value;
 139   f.i<?php echo $i?>subscriber_postal_code.value=f.form_postal_code.value;
 140   if (f.form_country_code)
 141     f.form_i<?php echo $i?>subscriber_country.value=f.form_country_code.value;
 142   f.i<?php echo $i?>subscriber_phone.value=f.form_phone_home.value;
 143   f.i<?php echo $i?>subscriber_DOB.value=f.form_DOB.value;
 144   f.i<?php echo $i?>subscriber_ss.value=f.form_ss.value;
 145   f.form_i<?php echo $i?>subscriber_sex.value = f.form_sex.value;
 146   f.i<?php echo $i?>subscriber_employer.value=f.form_em_name.value;
 147   f.i<?php echo $i?>subscriber_employer_street.value=f.form_em_street.value;
 148   f.i<?php echo $i?>subscriber_employer_city.value=f.form_em_city.value;
 149   f.form_i<?php echo $i?>subscriber_employer_state.value=f.form_em_state.value;
 150   f.i<?php echo $i?>subscriber_employer_postal_code.value=f.form_em_postal_code.value;
 151   if (f.form_em_country)
 152     f.form_i<?php echo $i?>subscriber_employer_country.value=f.form_em_country.value;
 153  }
 154 }
 155
 156 <?php } ?>
 157
 158 function upperFirst(string,text) {
 159  return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
 160 }
 161
 162 // The ins_search.php window calls this to set the selected insurance.
 163 function set_insurance(ins_id, ins_name) {
 164  var thesel = document.forms[0]['i' + insurance_index + 'provider'];
 165  var theopts = thesel.options; // the array of Option objects
 166  var i = 0;
 167  for (; i < theopts.length; ++i) {
 168   if (theopts[i].value == ins_id) {
 169    theopts[i].selected = true;
 170    return;
 171   }
 172  }
 173  // no matching option was found so create one, append it to the
 174  // end of the list, and select it.
 175  theopts[i] = new Option(ins_name, ins_id, false, true);
 176 }
 177
 178 // Indicates which insurance slot is being updated.
 179 var insurance_index = 0;
 180
 181 // The OnClick handler for searching/adding the insurance company.
 182 function ins_search(ins) {
 183  insurance_index = ins;
 184  dlgopen('../../interface/practice/ins_search.php', '_blank', 550, 400);
 185  return false;
 186 }
 187
 188 function checkNum () {
 189  var re= new RegExp();
 190  re = /^\d*\.?\d*$/;
 191  str=document.forms[0].monthly_income.value;
 192  if(re.exec(str))
 193  {
 194  }else{
 195   alert("Please enter a dollar amount using only numbers and a decimal point.");
 196  }
 197 }
 198
 199 // This capitalizes the first letter of each word in the passed input
 200 // element.  It also strips out extraneous spaces.
 201 function capitalizeMe(elem) {
 202  var a = elem.value.split(' ');
 203  var s = '';
 204  for(var i = 0; i < a.length; ++i) {
 205   if (a[i].length > 0) {
 206    if (s.length > 0) s += ' ';
 207    s += a[i].charAt(0).toUpperCase() + a[i].substring(1);
 208   }
 209  }
 210  elem.value = s;
 211 }
 212
 213 // Onkeyup handler for policy number.  Allows only A-Z and 0-9.
 214 function policykeyup(e) {
 215  var v = e.value.toUpperCase();
 216  for (var i = 0; i < v.length; ++i) {
 217   var c = v.charAt(i);
 218   if (c >= '0' && c <= '9') continue;
 219   if (c >= 'A' && c <= 'Z') continue;
 220   if (c == '*') continue;
 221   if (c == '-') continue;
 222   if (c == '_') continue;
 223   if (c == '(') continue;
 224   if (c == ')') continue;
 225   if (c == '#') continue;
 226   v = v.substring(0, i) + v.substring(i + i);
 227   --i;
 228  }
 229  e.value = v;
 230  return;
 231 }
 232
 233 function divclick(cb, divid) {
 234  var divstyle = document.getElementById(divid).style;
 235  if (cb.checked) {
 236   divstyle.display = 'block';
 237  } else {
 238   divstyle.display = 'none';
 239  }
 240  return true;
 241 }
 242
 243 // Compute the length of a string without leading and trailing spaces.
 244 function trimlen(s) {
 245  var i = 0;
 246  var j = s.length - 1;
 247  for (; i <= j && s.charAt(i) == ' '; ++i);
 248  for (; i <= j && s.charAt(j) == ' '; --j);
 249  if (i > j) return 0;
 250  return j + 1 - i;
 251 }
 252
 253 function validate(f) {
 254 <?php generate_layout_validation('DEM'); ?>
 255   <?php if($GLOBALS['erx_enable']){ ?>
 256   alertMsg='';
 257   for(i=0;i<f.length;i++){
 258     if(f[i].type=='text' && f[i].value)
 259     {
 260       if(f[i].name == 'form_fname' || f[i].name == 'form_mname' || f[i].name == 'form_lname')
 261       {
 262         alertMsg += checkLength(f[i].name,f[i].value,35);
 263         alertMsg += checkUsername(f[i].name,f[i].value);
 264       }
 265       else if(f[i].name == 'form_street' || f[i].name == 'form_city')
 266       {
 267         alertMsg += checkLength(f[i].name,f[i].value,35);
 268         alertMsg += checkAlphaNumericExtended(f[i].name,f[i].value);
 269       }
 270       else if(f[i].name == 'form_phone_home')
 271       {
 272        alertMsg += checkPhone(f[i].name,f[i].value);
 273       }
 274     }
 275   }
 276   if(alertMsg)
 277   {
 278     alert(alertMsg);
 279     return false;
 280   }
 281   <?php } ?>
 282  return true;
 283 }
 284
 285 function toggleSearch(elem) {
 286  var f = document.forms[0];
 287 <?php if ($WITH_SEARCH) { ?>
 288  // Toggle background color.
 289  if (elem.style.backgroundColor == '')
 290   elem.style.backgroundColor = '<?php echo $searchcolor; ?>';
 291  else
 292   elem.style.backgroundColor = '';
 293 <?php } ?>
 294  if (force_submit) {
 295   force_submit = false;
 296   f.create.value = '<?php xl('Create New Patient','e'); ?>';
 297  }
 298  return true;
 299 }
 300
 301 // If a <select> list is dropped down, this is its name.
 302 var open_sel_name = '';
 303
 304 function selClick(elem) {
 305  if (open_sel_name == elem.name) {
 306   open_sel_name = '';
 307  }
 308  else {
 309   open_sel_name = elem.name;
 310   toggleSearch(elem);
 311  }
 312  return true;
 313 }
 314
 315 function selBlur(elem) {
 316  if (open_sel_name == elem.name) {
 317   open_sel_name = '';
 318  }
 319  return true;
 320 }
 321
 322 // This invokes the patient search dialog.
 323 function searchme() {
 324  var f = document.forms[0];
 325  var url = '../main/finder/patient_select.php?popup=1';
 326
 327 <?php
 328 $lres = getLayoutRes();
 329
 330 while ($lrow = sqlFetchArray($lres)) {
 331   $field_id  = $lrow['field_id'];
 332   if (strpos($field_id, 'em_') === 0) continue;
 333   $data_type = $lrow['data_type'];
 334   $fldname = "form_$field_id";
 335   switch(getSearchClass($data_type)) {
 336     case  1:
 337       echo
 338       " if (f.$fldname.style.backgroundColor != '' && trimlen(f.$fldname.value) > 0) {\n" .
 339       "  url += '&$field_id=' + encodeURIComponent(f.$fldname.value);\n" .
 340       " }\n";
 341       break;
 342     case 2:
 343       echo
 344       " if (f.$fldname.style.backgroundColor != '' && f.$fldname.selectedIndex > 0) {\n" .
 345       "  url += '&$field_id=' + encodeURIComponent(f.$fldname.options[f.$fldname.selectedIndex].value);\n" .
 346       " }\n";
 347       break;
 348   }
 349 }
 350 ?>
 351
 352  dlgopen(url, '_blank', 700, 500);
 353 }
 354
 355 //-->
 356
 357 </script>
 358 </head>
 359
 360 <body class="body_top">
 361
 362 <form action='new_comprehensive_save.php' name='demographics_form' method='post' onsubmit='return validate(this)'>
 363
 364 <span class='title'><?php xl('Search or Add Patient','e'); ?></span>
 365
 366 <table width='100%' cellpadding='0' cellspacing='8'>
 367  <tr>
 368   <td align='left' valign='top'>
 369 <?php if ($SHORT_FORM) echo "  <center>\n"; ?>
 370 <?php
 371
 372 function end_cell() {
 373   global $item_count, $cell_count;
 374   if ($item_count > 0) {
 375     echo "</td>";
 376     $item_count = 0;
 377   }
 378 }
 379
 380 function end_row() {
 381   global $cell_count, $CPR;
 382   end_cell();
 383   if ($cell_count > 0) {
 384     for (; $cell_count < $CPR; ++$cell_count) echo "<td></td>";
 385     echo "</tr>\n";
 386     $cell_count = 0;
 387   }
 388 }
 389
 390 function end_group() {
 391   global $last_group, $SHORT_FORM;
 392   if (strlen($last_group) > 0) {
 393     end_row();
 394     echo " </table>\n";
 395     if (!$SHORT_FORM) echo "</div>\n";
 396   }
 397 }
 398
 399 $last_group    = '';
 400 $cell_count    = 0;
 401 $item_count    = 0;
 402 $display_style = 'block';
 403 $group_seq     = 0; // this gives the DIV blocks unique IDs
 404
 405 while ($frow = sqlFetchArray($fres)) {
 406   $this_group = $frow['group_name'];
 407   $titlecols  = $frow['titlecols'];
 408   $datacols   = $frow['datacols'];
 409   $data_type  = $frow['data_type'];
 410   $field_id   = $frow['field_id'];
 411   $list_id    = $frow['list_id'];
 412   $currvalue  = '';
 413
 414   if (strpos($field_id, 'em_') === 0) {
 415     $tmp = substr($field_id, 3);
 416     if (isset($result2[$tmp])) $currvalue = $result2[$tmp];
 417   }
 418   else {
 419     if (isset($result[$field_id])) $currvalue = $result[$field_id];
 420   }
 421
 422   // Handle a data category (group) change.
 423   if (strcmp($this_group, $last_group) != 0) {
 424     if (!$SHORT_FORM) {
 425       end_group();
 426       $group_seq++;    // ID for DIV tags
 427       $group_name = substr($this_group, 1);
 428       if (strlen($last_group) > 0) echo "<br />";
 429       echo "<span class='bold'><input type='checkbox' name='form_cb_$group_seq' id='form_cb_$group_seq' value='1' " .
 430         "onclick='return divclick(this,\"div_$group_seq\");'";
 431       if ($display_style == 'block') echo " checked";
 432
 433       // Modified 6-09 by BM - Translate if applicable
 434       echo " /><b>" . xl_layout_label($group_name) . "</b></span>\n";
 435
 436       echo "<div id='div_$group_seq' class='section' style='display:$display_style;'>\n";
 437       echo " <table border='0' cellpadding='0'>\n";
 438       $display_style = 'none';
 439     }
 440     else if (strlen($last_group) == 0) {
 441       echo " <table border='0' cellpadding='0'>\n";
 442     }
 443     $last_group = $this_group;
 444   }
 445
 446   // Handle starting of a new row.
 447   if (($titlecols > 0 && $cell_count >= $CPR) || $cell_count == 0) {
 448     end_row();
 449     echo "  <tr>";
 450   }
 451
 452   if ($item_count == 0 && $titlecols == 0) $titlecols = 1;
 453
 454   // Handle starting of a new label cell.
 455   if ($titlecols > 0) {
 456     end_cell();
 457     echo "<td colspan='$titlecols'";
 458     echo ($frow['uor'] == 2) ? " class='required'" : " class='bold'";
 459     if ($cell_count == 2) echo " style='padding-left:10pt'";
 460     echo ">";
 461     $cell_count += $titlecols;
 462   }
 463   ++$item_count;
 464
 465   echo "<b>";
 466
 467   // Modified 6-09 by BM - Translate if applicable
 468   if ($frow['title']) echo (xl_layout_label($frow['title']).":"); else echo "&nbsp;";
 469
 470   echo "</b>";
 471
 472   // Handle starting of a new data cell.
 473   if ($datacols > 0) {
 474     end_cell();
 475     echo "<td colspan='$datacols' class='text'";
 476     if ($cell_count > 0) echo " style='padding-left:5pt'";
 477     echo ">";
 478     $cell_count += $datacols;
 479   }
 480
 481   ++$item_count;
 482   generate_form_field($frow, $currvalue);
 483 }
 484
 485 end_group();
 486 ?>
 487
 488 <?php
 489 if (! $GLOBALS['simplified_demographics']) {
 490   $insurancei = getInsuranceProviders();
 491   $pid = 0;
 492   $insurance_headings = array(xl("Primary Insurance Provider"), xl("Secondary Insurance Provider"), xl("Tertiary Insurance provider"));
 493   $insurance_info = array();
 494   $insurance_info[1] = getInsuranceData($pid,"primary");
 495   $insurance_info[2] = getInsuranceData($pid,"secondary");
 496   $insurance_info[3] = getInsuranceData($pid,"tertiary");
 497
 498   echo "<br /><span class='bold'><input type='checkbox' name='form_cb_ins' value='1' " .
 499     "onclick='return divclick(this,\"div_ins\");'";
 500   if ($display_style == 'block') echo " checked";
 501   echo " /><b>" . xl('Insurance') . "</b></span>\n";
 502   echo "<div id='div_ins' class='section' style='display:$display_style;'>\n";
 503
 504   for($i=1;$i<=3;$i++) {
 505    $result3 = $insurance_info[$i];
 506 ?>
 507 <table border="0">
 508  <tr>
 509   <td valign='top' colspan='2'>
 510    <span class='required'><?php echo $insurance_headings[$i -1].":"?></span>
 511    <select name="i<?php echo $i?>provider">
 512     <option value=""><?php xl('Unassigned','e'); ?></option>
 513 <?php
 514  foreach ($insurancei as $iid => $iname) {
 515   echo "<option value='" . $iid . "'";
 516   if (strtolower($iid) == strtolower($result3{"provider"}))
 517    echo " selected";
 518   echo ">" . $iname . "</option>\n";
 519  }
 520 ?>
 521    </select>&nbsp;<a href='' onclick='return ins_search(<?php echo $i?>)'>
 522    <?php xl('Search/Add Insurer','e'); ?></a>
 523   </td>
 524  </tr>
 525  <tr>
 526   <td valign=top>
 527    <table border="0">
 528
 529     <tr>
 530      <td>
 531       <span class='required'><?php xl('Plan Name','e'); ?>: </span>
 532      </td>
 533      <td>
 534       <input type='entry' size='20' name='i<?php echo $i?>plan_name' value="<?php echo $result3{"plan_name"} ?>"
 535        onchange="capitalizeMe(this);" />&nbsp;&nbsp;
 536      </td>
 537     </tr>
 538
 539     <tr>
 540      <td>
 541       <span class='required'><?php xl('Effective Date','e'); ?>: </span>
 542      </td>
 543      <td>
 544       <input type='entry' size='11' name='i<?php echo $i ?>effective_date'
 545        id='i<?php echo $i ?>effective_date'
 546        value='<?php echo $result3['date'] ?>'
 547        onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)'
 548        title='yyyy-mm-dd' />
 549
 550       <img src='../../interface/pic/show_calendar.gif' align='absbottom' width='24' height='22'
 551       id='img_i<?php echo $i ?>effective_date' border='0' alt='[?]' style='cursor:pointer'
 552       title='<?php xl('Click here to choose a date','e'); ?>'>
 553
 554       <script LANGUAGE="JavaScript">
 555       Calendar.setup({inputField:"i<?php echo $i ?>effective_date", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i; ?>effective_date"});
 556       </script>
 557
 558
 559      </td>
 560     </tr>
 561
 562     <tr>
 563      <td><span class=required><?php xl('Policy Number','e'); ?>: </span></td>
 564      <td><input type='entry' size='16' name='i<?php echo $i?>policy_number' value="<?php echo $result3{"policy_number"}?>"
 565       onkeyup='policykeyup(this)'></td>
 566     </tr>
 567
 568     <tr>
 569      <td><span class=required><?php xl('Group Number','e'); ?>: </span></td><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><input type=entry size=25 name=i<?php echo $i?>subscriber_employer
 576       value="<?php echo $result3{"subscriber_employer"}?>"
 577        onchange="capitalizeMe(this);" /></td>
 578     </tr>
 579
 580     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 581      <td><span class=required><?php xl('SE Address','e'); ?>: </span></td>
 582      <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer_street
 583       value="<?php echo $result3{"subscriber_employer_street"}?>"
 584        onchange="capitalizeMe(this);" /></td>
 585     </tr>
 586
 587     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 588      <td colspan="2">
 589       <table>
 590        <tr>
 591         <td><span class=required><?php xl('SE City','e'); ?>: </span></td>
 592         <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_city
 593          value="<?php echo $result3{"subscriber_employer_city"}?>"
 594           onchange="capitalizeMe(this);" /></td>
 595         <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE State','e') : xl('SE Locality','e') ?>: </span></td>
 596         <td>
 597          <?php
 598           // Modified 7/2009 by BM to incorporate data types
 599           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'), $result3['subscriber_employer_state']);
 600          ?>
 601         </td>
 602        </tr>
 603        <tr>
 604         <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE Zip Code','e') : xl('SE Postal Code','e') ?>: </span></td>
 605         <td><input type=entry size=10 name=i<?php echo $i?>subscriber_employer_postal_code value="<?php echo $result3{"subscriber_employer_postal_code"}?>"></td>
 606         <td><span class=required><?php xl('SE Country','e'); ?>: </span></td>
 607         <td>
 608          <?php
 609           // Modified 7/2009 by BM to incorporate data types
 610           generate_form_field(array('data_type'=>$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']);
 611          ?>
 612         </td>
 613        </tr>
 614       </table>
 615      </td>
 616     </tr>
 617
 618    </table>
 619   </td>
 620
 621   <td valign=top>
 622    <span class=required><?php xl('Subscriber','e'); ?>: </span>
 623    <input type=entry size=10 name=i<?php echo $i?>subscriber_fname
 624     value="<?php echo $result3{"subscriber_fname"}?>"
 625     onchange="capitalizeMe(this);" />
 626    <input type=entry size=3 name=i<?php echo $i?>subscriber_mname
 627     value="<?php echo $result3{"subscriber_mname"}?>"
 628     onchange="capitalizeMe(this);" />
 629    <input type=entry size=10 name=i<?php echo $i?>subscriber_lname
 630     value="<?php echo $result3{"subscriber_lname"}?>"
 631     onchange="capitalizeMe(this);" />
 632    <br>
 633    <span class=required><?php xl('Relationship','e'); ?>: </span>
 634    <?php
 635     // Modified 6/2009 by BM to use list_options and function
 636     generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_relationship'),'list_id'=>'sub_relation','empty_title'=>' '), $result3['subscriber_relationship']);
 637    ?>
 638    <a href="javascript:popUp('../../interface/patient_file/summary/browse.php?browsenum=<?php echo $i?>')" class=text>(<?php xl('Browse','e'); ?>)</a><br />
 639
 640    <span class=bold><?php xl('D.O.B.','e'); ?>: </span>
 641    <input type='entry' size='11' name='i<?php echo $i?>subscriber_DOB'
 642     id='i<?php echo $i?>subscriber_DOB'
 643     value='<?php echo $result3['subscriber_DOB'] ?>'
 644     onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)'
 645     title='yyyy-mm-dd' />
 646
 647    <img src='../../interface/pic/show_calendar.gif' align='absbottom' width='24' height='22'
 648     id='img_i<?php echo $i; ?>dob_date' border='0' alt='[?]' style='cursor:pointer'
 649     title='<?php xl('Click here to choose a date','e'); ?>'>
 650
 651     <script LANGUAGE="JavaScript">
 652     Calendar.setup({inputField:"i<?php echo $i?>subscriber_DOB", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i; ?>dob_date"});
 653     </script>
 654
 655
 656    <span class=bold><?php xl('S.S.','e'); ?>: </span><input type=entry size=11 name=i<?php echo $i?>subscriber_ss value="<?php echo $result3{"subscriber_ss"}?>">&nbsp;
 657    <span class=bold><?php xl('Sex','e'); ?>: </span>
 658    <?php
 659     // Modified 6/2009 by BM to use list_options and function
 660     generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_sex'),'list_id'=>'sex'), $result3['subscriber_sex']);
 661    ?>
 662    <br>
 663    <span class=required><?php xl('Subscriber Address','e'); ?>: </span>
 664    <input type=entry size=25 name=i<?php echo $i?>subscriber_street
 665     value="<?php echo $result3{"subscriber_street"}?>"
 666     onchange="capitalizeMe(this);" /><br>
 667    <span class=required><?php xl('City','e'); ?>: </span>
 668    <input type=entry size=15 name=i<?php echo $i?>subscriber_city
 669     value="<?php echo $result3{"subscriber_city"}?>"
 670     onchange="capitalizeMe(this);" />
 671    <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('State','e') : xl('Locality','e') ?>: </span>
 672    <?php
 673     // Modified 7/2009 by BM to incorporate data types
 674     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'), $result3['subscriber_state']);
 675    ?>
 676    <br />
 677    <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('Zip Code','e') : xl('Postal Code','e') ?>: </span><input type=entry size=10 name=i<?php echo $i?>subscriber_postal_code value="<?php echo $result3{"subscriber_postal_code"}?>">
 678    <span class='required'<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 679    <?php xl('Country','e'); ?>: </span>
 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    <br />
 685    <span class=bold><?php xl('Subscriber Phone','e'); ?>:
 686    <input type='text' size='20' name='i<?php echo $i?>subscriber_phone' value='<?php echo $result3["subscriber_phone"] ?>' onkeyup='phonekeyup(this,mypcc)' />
 687    </span><br />
 688    <span class=bold><?php xl('CoPay','e'); ?>: <input type=text size="6" name=i<?php echo $i?>copay value="<?php echo $result3{"copay"}?>">
 689    </span><br />
 690    <span class='required'><?php xl('Accept Assignment','e'); ?>: </span>
 691    <select name=i<?php echo $i?>accept_assignment>
 692      <option value="TRUE" <?php if (strtoupper($result3{"accept_assignment"}) == "TRUE") echo "selected"?>><?php xl('YES','e'); ?></option>
 693      <option value="FALSE" <?php if (strtoupper($result3{"accept_assignment"}) == "FALSE") echo "selected"?>><?php xl('NO','e'); ?></option>
 694    </select>
 695   </td>
 696  </tr>
 697
 698 </table>
 699 <hr />
 700 <?php
 701   }
 702   echo "</div>\n";
 703  } // end of "if not simplified_demographics"
 704 ?>
 705
 706 <?php if (!$SHORT_FORM) echo "  <center>\n"; ?>
 707 <br />
 708 <?php if ($WITH_SEARCH) { ?>
 709 <input type="button" id="search" value=<?php xl('Search','e','\'','\''); ?>
 710  style='background-color:<?php echo $searchcolor; ?>' />
 711 &nbsp;&nbsp;
 712 <?php } ?>
 713 <input type="button" name='create' id="create" value=<?php xl('Create New Patient','e','\'','\''); ?> />
 714
 715 </center>
 716
 717   </td>
 718   <td align='right' valign='top' width='1%' nowrap>
 719    <!-- Image upload stuff was here but got moved. -->
 720   </td>
 721  </tr>
 722 </table>
 723
 724 </form>
 725
 726 <!-- include support for the list-add selectbox feature -->
 727 <?php include($GLOBALS['fileroot']."/library/options_listadd.inc"); ?>
 728
 729 </body>
 730
 731 <script language="JavaScript">
 732
 733 // fix inconsistently formatted phone numbers from the database
 734 var f = document.forms[0];
 735 if (f.form_phone_contact) phonekeyup(f.form_phone_contact,mypcc);
 736 if (f.form_phone_home   ) phonekeyup(f.form_phone_home   ,mypcc);
 737 if (f.form_phone_biz    ) phonekeyup(f.form_phone_biz    ,mypcc);
 738 if (f.form_phone_cell   ) phonekeyup(f.form_phone_cell   ,mypcc);
 739
 740 <?php echo $date_init; ?>
 741
 742 // -=- jQuery makes life easier -=-
 743
 744 // var matches = 0; // number of patients that match the demographic information being entered
 745 // var override = false; // flag that overrides the duplication warning
 746
 747 $(document).ready(function() {
 748
 749     // added to integrate insurance stuff
 750     <?php for ($i=1;$i<=3;$i++) { ?>
 751     $("#form_i<?php echo $i?>subscriber_relationship").change(function() { auto_populate_employer_address<?php echo $i?>(); });
 752     <?php } ?>
 753
 754     $('#search').click(function() { searchme(); });
 755     $('#create').click(function() { submitme(); });
 756
 757     var submitme = function() {
 758       top.restoreSession();
 759       var f = document.forms[0];
 760
 761       if (validate(f)) {
 762         if (force_submit) {
 763           // In this case dups were shown already and Save should just save.
 764           f.submit();
 765           return;
 766         }
 767 <?php
 768 // D in edit_options indicates the field is used in duplication checking.
 769 // This constructs a list of the names of those fields.
 770 $mflist = "";
 771 $mfres = sqlStatement("SELECT * FROM layout_options " .
 772   "WHERE form_id = 'DEM' AND uor > 0 AND field_id != '' AND " .
 773   "edit_options LIKE '%D%' " .
 774   "ORDER BY group_name, seq");
 775 while ($mfrow = sqlFetchArray($mfres)) {
 776   $field_id  = $mfrow['field_id'];
 777   if (strpos($field_id, 'em_') === 0) continue;
 778   if (!empty($mflist)) $mflist .= ",";
 779   $mflist .= "'" . htmlentities($field_id) . "'";
 780 }
 781 ?>
 782         // Build and invoke the URL to create the dup-checker dialog.
 783         var url = 'new_search_popup.php';
 784         var flds = new Array(<?php echo $mflist; ?>);
 785         var separator = '?';
 786         for (var i = 0; i < flds.length; ++i) {
 787           var fval = $('#form_' + flds[i]).val();
 788           if (fval && fval != '') {
 789             url += separator;
 790             separator = '&';
 791             url += 'mf_' + flds[i] + '=' + encodeURIComponent(fval);
 792           }
 793         }
 794         dlgopen(url, '_blank', 700, 500);
 795
 796       } // end if validate
 797     } // end function
 798
 799 // Set onclick/onfocus handlers for toggling background color.
 800 <?php
 801 $lres = getLayoutRes();
 802 while ($lrow = sqlFetchArray($lres)) {
 803   $field_id  = $lrow['field_id'];
 804   if (strpos($field_id, 'em_') === 0) continue;
 805   switch(getSearchClass($lrow['data_type'])) {
 806     case 1:
 807       echo "    \$('#form_$field_id').click(function() { toggleSearch(this); });\n";
 808       break;
 809     case 2:
 810       echo "    \$('#form_$field_id').click(function() { selClick(this); });\n";
 811       echo "    \$('#form_$field_id').blur(function() { selBlur(this); });\n";
 812       break;
 813   }
 814 }
 815 ?>
 816
 817 }); // end document.ready
 818
 819 </script>
 820
 821 </html>
 822