interface/patient_file/summary/demographics_full.php

   1 <?php
   2  include_once("../../globals.php");
   3  include_once("$srcdir/acl.inc");
   4  include_once("$srcdir/options.inc.php");
   5
   6  // Session pid must be right or bad things can happen when demographics are saved!
   7  //
   8  include_once("$srcdir/pid.inc");
   9  $set_pid = $_GET["set_pid"] ? $_GET["set_pid"] : $_GET["pid"];
  10  if ($set_pid && $set_pid != $_SESSION["pid"]) {
  11   setpid($set_pid);
  12  }
  13
  14  include_once("$srcdir/patient.inc");
  15
  16  $result = getPatientData($pid, "*, DATE_FORMAT(DOB,'%Y-%m-%d') as DOB_YMD");
  17  $result2 = getEmployerData($pid);
  18
  19  // Check authorization.
  20  $thisauth = acl_check('patients', 'demo');
  21  if ($pid) {
  22   if ($thisauth != 'write')
  23    die("Updating demographics is not authorized.");
  24   if ($result['squad'] && ! acl_check('squads', $result['squad']))
  25    die("You are not authorized to access this squad.");
  26  } else {
  27   if ($thisauth != 'write' && $thisauth != 'addonly')
  28    die("Adding demographics is not authorized.");
  29  }
  30
  31 $CPR = 4; // cells per row
  32
  33 // Might want to use the list_options table and then trash this.
  34 $relats = array('','self','spouse','child','other');
  35
  36 // $statii = array('married','single','divorced','widowed','separated','domestic partner');
  37 // $langi = getLanguages();
  38 // $ethnoraciali = getEthnoRacials();
  39 // $provideri = getProviderInfo();
  40
  41 $insurancei = getInsuranceProviders();
  42
  43 $fres = sqlStatement("SELECT * FROM layout_options " .
  44   "WHERE form_id = 'DEM' AND uor > 0 " .
  45   "ORDER BY group_name, seq");
  46 ?>
  47 <html>
  48 <head>
  49 <?php html_header_show();?>
  50
  51 <link rel="stylesheet" href="<?php echo $css_header; ?>" type="text/css">
  52
  53 <style>
  54 body, td, input, select, textarea {
  55  font-family: Arial, Helvetica, sans-serif;
  56  font-size: 10pt;
  57 }
  58
  59 body {
  60  padding: 5pt 5pt 5pt 5pt;
  61 }
  62
  63 div.section {
  64  border: solid;
  65  border-width: 1px;
  66  border-color: #0000ff;
  67  margin: 0 0 0 10pt;
  68  padding: 5pt;
  69 }
  70
  71 </style>
  72
  73 <style type="text/css">@import url(../../../library/dynarch_calendar.css);</style>
  74
  75 <script type="text/javascript" src="../../../library/dialog.js"></script>
  76 <script type="text/javascript" src="../../../library/textformat.js"></script>
  77 <script type="text/javascript" src="../../../library/dynarch_calendar.js"></script>
  78 <script type="text/javascript" src="../../../library/dynarch_calendar_en.js"></script>
  79 <script type="text/javascript" src="../../../library/dynarch_calendar_setup.js"></script>
  80
  81 <SCRIPT LANGUAGE="JavaScript"><!--
  82
  83 var mypcc = '<?php echo $GLOBALS['phone_country_code'] ?>';
  84
  85 //code used from http://tech.irt.org/articles/js037/
  86 function replace(string,text,by) {
  87  // Replaces text with by in string
  88  var strLength = string.length, txtLength = text.length;
  89  if ((strLength == 0) || (txtLength == 0)) return string;
  90
  91  var i = string.indexOf(text);
  92  if ((!i) && (text != string.substring(0,txtLength))) return string;
  93  if (i == -1) return string;
  94
  95  var newstr = string.substring(0,i) + by;
  96
  97  if (i+txtLength < strLength)
  98   newstr += replace(string.substring(i+txtLength,strLength),text,by);
  99
 100  return newstr;
 101 }
 102
 103 function upperFirst(string,text) {
 104  return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
 105 }
 106
 107 <?php for ($i=1;$i<=3;$i++) { ?>
 108 function auto_populate_employer_address<?php echo $i ?>(){
 109  var f = document.demographics_form;
 110  if (f.i<?php echo $i?>subscriber_relationship.options[f.i<?php echo $i?>subscriber_relationship.selectedIndex].value == "self") {
 111   f.i<?php echo $i?>subscriber_fname.value=f.form_fname.value;
 112   f.i<?php echo $i?>subscriber_mname.value=f.form_mname.value;
 113   f.i<?php echo $i?>subscriber_lname.value=f.form_lname.value;
 114   f.i<?php echo $i?>subscriber_street.value=f.form_street.value;
 115   f.i<?php echo $i?>subscriber_city.value=f.form_city.value;
 116   f.i<?php echo $i?>subscriber_state.value=f.form_state.value;
 117   f.i<?php echo $i?>subscriber_postal_code.value=f.form_postal_code.value;
 118   if (f.form_country_code)
 119     f.i<?php echo $i?>subscriber_country.value=f.form_country_code.value;
 120   f.i<?php echo $i?>subscriber_phone.value=f.form_phone_home.value;
 121   f.i<?php echo $i?>subscriber_DOB.value=f.form_DOB.value;
 122   f.i<?php echo $i?>subscriber_ss.value=f.form_ss.value;
 123   //
 124   // TBD: This is a kludge. subscriber_sex should come from the same list as form_sex!
 125   f.i<?php echo $i?>subscriber_sex.selectedIndex = f.form_sex.selectedIndex - 1;
 126   //
 127   f.i<?php echo $i?>subscriber_employer.value=f.form_em_name.value;
 128   f.i<?php echo $i?>subscriber_employer_street.value=f.form_em_street.value;
 129   f.i<?php echo $i?>subscriber_employer_city.value=f.form_em_city.value;
 130   f.i<?php echo $i?>subscriber_employer_state.value=f.form_em_state.value;
 131   f.i<?php echo $i?>subscriber_employer_postal_code.value=f.form_em_postal_code.value;
 132   if (f.form_em_country)
 133     f.i<?php echo $i?>subscriber_employer_country.value=f.form_em_country.value;
 134  }
 135 }
 136
 137 <?php } ?>
 138
 139 function popUp(URL) {
 140  day = new Date();
 141  id = day.getTime();
 142  top.restoreSession();
 143  eval("page" + id + " = window.open(URL, '" + id + "', 'toolbar=0,scrollbars=1,location=0,statusbar=0,menubar=0,resizable=1,width=400,height=300,left = 440,top = 362');");
 144 }
 145
 146 function checkNum () {
 147  var re= new RegExp();
 148  re = /^\d*\.?\d*$/;
 149  str=document.demographics_form.monthly_income.value;
 150  if(re.exec(str))
 151  {
 152  }else{
 153   alert("Please enter a dollar amount using only numbers and a decimal point.");
 154  }
 155 }
 156
 157 // Indicates which insurance slot is being updated.
 158 var insurance_index = 0;
 159
 160 // The OnClick handler for searching/adding the insurance company.
 161 function ins_search(ins) {
 162  insurance_index = ins;
 163  dlgopen('../../practice/ins_search.php', '_blank', 550, 400);
 164  return false;
 165 }
 166
 167 // The ins_search.php window calls this to set the selected insurance.
 168 function set_insurance(ins_id, ins_name) {
 169  var thesel = document.forms[0]['i' + insurance_index + 'provider'];
 170  var theopts = thesel.options; // the array of Option objects
 171  var i = 0;
 172  for (; i < theopts.length; ++i) {
 173   if (theopts[i].value == ins_id) {
 174    theopts[i].selected = true;
 175    return;
 176   }
 177  }
 178  // no matching option was found so create one, append it to the
 179  // end of the list, and select it.
 180  theopts[i] = new Option(ins_name, ins_id, false, true);
 181 }
 182
 183 // This capitalizes the first letter of each word in the passed input
 184 // element.  It also strips out extraneous spaces.
 185 function capitalizeMe(elem) {
 186  var a = elem.value.split(' ');
 187  var s = '';
 188  for(var i = 0; i < a.length; ++i) {
 189   if (a[i].length > 0) {
 190    if (s.length > 0) s += ' ';
 191    s += a[i].charAt(0).toUpperCase() + a[i].substring(1);
 192   }
 193  }
 194  elem.value = s;
 195 }
 196
 197 function divclick(cb, divid) {
 198  var divstyle = document.getElementById(divid).style;
 199  if (cb.checked) {
 200   divstyle.display = 'block';
 201  } else {
 202   divstyle.display = 'none';
 203  }
 204  return true;
 205 }
 206
 207 // Compute the length of a string without leading and trailing spaces.
 208 function trimlen(s) {
 209  var i = 0;
 210  var j = s.length - 1;
 211  for (; i <= j && s.charAt(i) == ' '; ++i);
 212  for (; i <= j && s.charAt(j) == ' '; --j);
 213  if (i > j) return 0;
 214  return j + 1 - i;
 215 }
 216
 217 function validate(f) {
 218 <?php
 219 // Generate JavaScript validation logic for the required fields.
 220 while ($frow = sqlFetchArray($fres)) {
 221   if ($frow['uor'] < 2) continue;
 222   $data_type = $frow['data_type'];
 223   $field_id  = $frow['field_id'];
 224   $fldtitle  = $frow['title'];
 225   if (!$fldtitle) $fldtitle  = $frow['description'];
 226   $fldname   = "form_$field_id";
 227   switch($data_type) {
 228     case  1:
 229     case 11:
 230     case 12:
 231     case 13:
 232     case 14:
 233       echo
 234       " if (f.$fldname.selectedIndex <= 0) {\n" .
 235       "  alert('Please choose a value for $fldtitle');\n" .
 236       "  if (f.$fldname.focus) f.$fldname.focus();\n" .
 237       "  return false;\n" .
 238       " }\n";
 239       break;
 240     case 2:
 241     case 3:
 242     case 4:
 243       echo
 244       " if (trimlen(f.$fldname.value) == 0) {\n" .
 245       "  alert('Please enter a value for $fldtitle');\n" .
 246       "  if (f.$fldname.focus) f.$fldname.focus();\n" .
 247       "  return false;\n" .
 248       " }\n";
 249       break;
 250   }
 251 }
 252 ?>
 253  return true;
 254 }
 255
 256 function submitme() {
 257  var f = document.forms[0];
 258  if (validate(f)) {
 259   top.restoreSession();
 260   f.submit();
 261  }
 262 }
 263
 264 //-->
 265
 266 </script>
 267 </head>
 268
 269 <body class="body_top">
 270
 271 <form action='demographics_save.php' name='demographics_form' method='post' onsubmit='return validate(this)'>
 272 <input type='hidden' name='mode' value='save' />
 273 <input type='hidden' name='db_id' value="<?php echo $result['id']?>" />
 274
 275 <?php if ($GLOBALS['concurrent_layout']) { ?>
 276 <a href="demographics.php" onclick="top.restoreSession()">
 277 <?php } else { ?>
 278 <a href="patient_summary.php" target="Main" onclick="top.restoreSession()">
 279 <?php } ?>
 280 <font class=title><?php xl('Demographics','e'); ?></font>
 281 <font class=back><?php echo $tback;?></font></a>
 282
 283 <?php
 284
 285 function end_cell() {
 286   global $item_count, $cell_count;
 287   if ($item_count > 0) {
 288     echo "</td>";
 289     $item_count = 0;
 290   }
 291 }
 292
 293 function end_row() {
 294   global $cell_count, $CPR;
 295   end_cell();
 296   if ($cell_count > 0) {
 297     for (; $cell_count < $CPR; ++$cell_count) echo "<td></td>";
 298     echo "</tr>\n";
 299     $cell_count = 0;
 300   }
 301 }
 302
 303 function end_group() {
 304   global $last_group;
 305   if (strlen($last_group) > 0) {
 306     end_row();
 307     echo " </table>\n";
 308     echo "</div>\n";
 309   }
 310 }
 311
 312 $last_group = '';
 313 $cell_count = 0;
 314 $item_count = 0;
 315 $display_style = 'block';
 316
 317 mysql_data_seek($fres, 0); // TBD: Move this to sql.inc.
 318
 319 while ($frow = sqlFetchArray($fres)) {
 320   $this_group = $frow['group_name'];
 321   $titlecols  = $frow['titlecols'];
 322   $datacols   = $frow['datacols'];
 323   $data_type  = $frow['data_type'];
 324   $field_id   = $frow['field_id'];
 325   $list_id    = $frow['list_id'];
 326   $currvalue  = '';
 327   if (strpos($field_id, 'em_') === 0) {
 328     $tmp = substr($field_id, 3);
 329     if (isset($result2[$tmp])) $currvalue = $result2[$tmp];
 330   }
 331   else {
 332     if (isset($result[$field_id])) $currvalue = $result[$field_id];
 333   }
 334
 335   // Handle a data category (group) change.
 336   if (strcmp($this_group, $last_group) != 0) {
 337     end_group();
 338     $group_seq  = substr($this_group, 0, 1);
 339     $group_name = substr($this_group, 1);
 340     $last_group = $this_group;
 341     echo "<br /><span class='bold'><input type='checkbox' name='form_cb_$group_seq' value='1' " .
 342       "onclick='return divclick(this,\"div_$group_seq\");'";
 343     if ($display_style == 'block') echo " checked";
 344     echo " /><b>$group_name</b></span>\n";
 345     echo "<div id='div_$group_seq' class='section' style='display:$display_style;'>\n";
 346     echo " <table border='0' cellpadding='0'>\n";
 347     $display_style = 'none';
 348   }
 349
 350   // Handle starting of a new row.
 351   if (($titlecols > 0 && $cell_count >= $CPR) || $cell_count == 0) {
 352     end_row();
 353     echo "  <tr>";
 354   }
 355
 356   if ($item_count == 0 && $titlecols == 0) $titlecols = 1;
 357
 358   // Handle starting of a new label cell.
 359   if ($titlecols > 0) {
 360     end_cell();
 361     echo "<td colspan='$titlecols'";
 362     echo ($frow['uor'] == 2) ? " class='required'" : " class='bold'";
 363     if ($cell_count == 2) echo " style='padding-left:10pt'";
 364     echo ">";
 365     $cell_count += $titlecols;
 366   }
 367   ++$item_count;
 368
 369   echo "<b>";
 370   if ($frow['title']) echo $frow['title'] . ":"; else echo "&nbsp;";
 371   echo "</b>";
 372
 373   // Handle starting of a new data cell.
 374   if ($datacols > 0) {
 375     end_cell();
 376     echo "<td colspan='$datacols' class='text'";
 377     if ($cell_count > 0) echo " style='padding-left:5pt'";
 378     echo ">";
 379     $cell_count += $datacols;
 380   }
 381
 382   ++$item_count;
 383   generate_form_field($frow, $currvalue);
 384 }
 385
 386 end_group();
 387
 388  if (! $GLOBALS['simplified_demographics']) {
 389   $insurance_headings = array("Primary Insurance Provider:", "Secondary Insurance Provider", "Tertiary Insurance provider");
 390   $insurance_info = array();
 391   $insurance_info[1] = getInsuranceData($pid,"primary");
 392   $insurance_info[2] = getInsuranceData($pid,"secondary");
 393   $insurance_info[3] = getInsuranceData($pid,"tertiary");
 394
 395   echo "<br /><span class='bold'><input type='checkbox' name='form_cb_ins' value='1' " .
 396     "onclick='return divclick(this,\"div_ins\");'";
 397   if ($display_style == 'block') echo " checked";
 398   echo " /><b>Insurance</b></span>\n";
 399   echo "<div id='div_ins' class='section' style='display:$display_style;'>\n";
 400
 401   for($i=1;$i<=3;$i++) {
 402    $result3 = $insurance_info[$i];
 403 ?>
 404 <table border="0">
 405  <tr>
 406   <td valign='top' colspan='2'>
 407    <span class='required'><?php echo $insurance_headings[$i -1]?></span>
 408    <select name="i<?php echo $i?>provider">
 409     <option value=""><?php xl('Unassigned','e'); ?></option>
 410 <?php
 411  foreach ($insurancei as $iid => $iname) {
 412   echo "<option value='" . $iid . "'";
 413   if (strtolower($iid) == strtolower($result3{"provider"}))
 414    echo " selected";
 415   echo ">" . $iname . "</option>\n";
 416  }
 417 ?>
 418    </select>&nbsp;<a href='' onclick='return ins_search(<?php echo $i?>)'>
 419    <?php xl('Search/Add Insurer','e'); ?></a>
 420   </td>
 421  </tr>
 422
 423  <tr>
 424   <td valign=top>
 425    <table border="0">
 426
 427     <tr>
 428      <td>
 429       <span class='required'><?php xl('Plan Name','e'); ?>: </span>
 430      </td>
 431      <td>
 432       <input type='entry' size='20' name='i<?php echo $i?>plan_name' value="<?php echo $result3{"plan_name"} ?>"
 433        onchange="capitalizeMe(this);" />&nbsp;&nbsp;
 434      </td>
 435     </tr>
 436
 437     <tr>
 438      <td>
 439       <span class='required'><?php xl('Effective Date','e'); ?>: </span>
 440      </td>
 441      <td>
 442       <input type='entry' size='11' name='i<?php echo $i ?>effective_date'
 443        value='<?php echo $result3['date'] ?>'
 444        onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)'
 445        title='yyyy-mm-dd' />
 446      </td>
 447     </tr>
 448
 449     <tr>
 450      <td><span class=required><?php xl('Policy Number','e'); ?>: </span></td>
 451      <td><input type=entry size=16 name=i<?php echo $i?>policy_number value="<?php echo $result3{"policy_number"}?>"></td>
 452     </tr>
 453
 454     <tr>
 455      <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 $result3{"group_number"}?>"></td>
 456     </tr>
 457
 458     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 459      <td class='required'><?php xl('Subscriber Employer (SE)','e'); ?><br><span style='font-weight:normal'>
 460       (<?php xl('if unemployed enter Student','e'); ?>,<br><?php xl('PT Student, or leave blank','e'); ?>): </span></td>
 461      <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer
 462       value="<?php echo $result3{"subscriber_employer"}?>"
 463        onchange="capitalizeMe(this);" /></td>
 464     </tr>
 465
 466     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 467      <td><span class=required><?php xl('SE Address','e'); ?>: </span></td>
 468      <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer_street
 469       value="<?php echo $result3{"subscriber_employer_street"}?>"
 470        onchange="capitalizeMe(this);" /></td>
 471     </tr>
 472
 473     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 474      <td colspan="2">
 475       <table>
 476        <tr>
 477         <td><span class=required><?php xl('SE City','e'); ?>: </span></td>
 478         <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_city
 479          value="<?php echo $result3{"subscriber_employer_city"}?>"
 480           onchange="capitalizeMe(this);" /></td>
 481         <td><span class=required><?php xl('SE','e'); ?> <?php echo ($GLOBALS['phone_country_code'] == '1') ? 'State' : 'Locality' ?>: </span></td>
 482         <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_state
 483          value="<?php echo $result3{"subscriber_employer_state"}?>"></td>
 484        </tr>
 485        <tr>
 486         <td><span class=required><?php xl('SE','e'); ?> <?php echo ($GLOBALS['phone_country_code'] == '1') ? 'Zip' : 'Postal' ?> <?php xl('Code','e'); ?>: </span></td>
 487         <td><input type=entry size=10 name=i<?php echo $i?>subscriber_employer_postal_code value="<?php echo $result3{"subscriber_employer_postal_code"}?>"></td>
 488         <td><span class=required><?php xl('SE Country','e'); ?>: </span></td>
 489         <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer_country
 490          value="<?php echo $result3{"subscriber_employer_country"}?>"
 491          onchange="capitalizeMe(this);" /></td>
 492        </tr>
 493       </table>
 494      </td>
 495     </tr>
 496
 497    </table>
 498   </td>
 499
 500   <td valign=top>
 501    <span class=required><?php xl('Subscriber','e'); ?>: </span>
 502    <input type=entry size=10 name=i<?php echo $i?>subscriber_fname
 503     value="<?php echo $result3{"subscriber_fname"}?>"
 504     onchange="capitalizeMe(this);" />
 505    <input type=entry size=3 name=i<?php echo $i?>subscriber_mname
 506     value="<?php echo $result3{"subscriber_mname"}?>"
 507     onchange="capitalizeMe(this);" />
 508    <input type=entry size=10 name=i<?php echo $i?>subscriber_lname
 509     value="<?php echo $result3{"subscriber_lname"}?>"
 510     onchange="capitalizeMe(this);" />
 511    <br>
 512    <span class=required><?php xl('Relationship','e'); ?>: </span>
 513    <select name=i<?php echo $i?>subscriber_relationship onchange="javascript:auto_populate_employer_address<?php echo $i?>();">
 514 <?php
 515  foreach ($relats as $s) {
 516   if ($s == "unassigned") {
 517    echo "<option value=''";
 518   } else {
 519    echo "<option value='".$s."'";
 520   }
 521   if ($s == strtolower($result3['subscriber_relationship']))
 522    echo " selected";
 523   echo ">".ucfirst($s)."</option>\n";
 524 }
 525 ?>
 526    </select>
 527    <a href="javascript:popUp('browse.php?browsenum=<?php echo $i?>')" class=text>(<?php xl('Browse','e'); ?>)</a><br />
 528    <span class=bold><?php xl('D.O.B.','e'); ?>: </span>
 529    <input type='entry' size='11' name='i<?php echo $i?>subscriber_DOB'
 530     value='<?php echo $result3['subscriber_DOB'] ?>'
 531     onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)'
 532     title='yyyy-mm-dd' />
 533
 534    <img src='../../pic/show_calendar.gif' align='absbottom' width='24' height='22'
 535     id='img_i<?php echo $i; ?>dob_date' border='0' alt='[?]' style='cursor:pointer'
 536     title='<?php xl('Click here to choose a date','e'); ?>'>
 537
 538    <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;
 539    <span class=bold><?php xl('Sex','e'); ?>: </span>
 540    <select name=i<?php echo $i?>subscriber_sex>
 541     <option value="Female" <?php if (strtolower($result3{"subscriber_sex"}) == "female") echo "selected"?>><?php xl('Female','e'); ?></option>
 542     <option value="Male" <?php if (strtolower($result3{"subscriber_sex"}) == "male") echo "selected"?>><?php xl('Male','e'); ?></option>
 543    </select>
 544    <br>
 545    <span class=required><?php xl('Subscriber Address','e'); ?>: </span>
 546    <input type=entry size=25 name=i<?php echo $i?>subscriber_street
 547     value="<?php echo $result3{"subscriber_street"}?>"
 548     onchange="capitalizeMe(this);" /><br>
 549    <span class=required><?php xl('City','e'); ?>: </span>
 550    <input type=entry size=15 name=i<?php echo $i?>subscriber_city
 551     value="<?php echo $result3{"subscriber_city"}?>"
 552     onchange="capitalizeMe(this);" />
 553    <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? 'State' : 'Locality' ?>: </span><input type=entry size=15 name=i<?php echo $i?>subscriber_state value="<?php echo $result3{"subscriber_state"}?>"><br>
 554    <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? 'Zip' : 'Postal' ?> <?php xl('Code','e'); ?>: </span><input type=entry size=10 name=i<?php echo $i?>subscriber_postal_code value="<?php echo $result3{"subscriber_postal_code"}?>">
 555    <span class='required'<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 556    <?php xl('Country','e'); ?>:
 557    <input type=entry size=10 name=i<?php echo $i?>subscriber_country
 558     value="<?php echo $result3{"subscriber_country"}?>"
 559     onchange="capitalizeMe(this);" /><br></span>
 560    <span class=bold><?php xl('Subscriber Phone','e'); ?>:
 561    <input type='text' size='20' name='i<?php echo $i?>subscriber_phone' value='<?php echo $result3["subscriber_phone"] ?>' onkeyup='phonekeyup(this,mypcc)' />
 562    </span><br />
 563    <span class=bold><?php xl('CoPay','e'); ?>: <input type=text size="6" name=i<?php echo $i?>copay value="<?php echo $result3{"copay"}?>">
 564    </span><br />
 565    <span class='required'><?php xl('Accept Assignment','e'); ?>: </span>
 566    <select name=i<?php echo $i?>accept_assignment>
 567      <option value="TRUE" <?php if (strtoupper($result3{"accept_assignment"}) == "TRUE") echo "selected"?>><?php xl('YES','e'); ?></option>
 568      <option value="FALSE" <?php if (strtoupper($result3{"accept_assignment"}) == "FALSE") echo "selected"?>><?php xl('NO','e'); ?></option>
 569    </select>
 570   </td>
 571  </tr>
 572 </table>
 573
 574 <?php
 575     if ($i < 3) echo "<hr />\n";
 576   } //end insurer for loop
 577   echo "</div>\n";
 578  } // end of "if not simplified_demographics"
 579 ?>
 580
 581 <center><br />
 582 <a href="javascript:submitme();"
 583  class='link_submit'>[<?php xl('Save Patient Demographics','e'); ?>]</a>
 584 </center>
 585
 586 </form>
 587
 588 <br>
 589
 590 <script language="JavaScript">
 591
 592  // fix inconsistently formatted phone numbers from the database
 593  var f = document.forms[0];
 594  if (f.form_phone_contact) phonekeyup(f.form_phone_contact,mypcc);
 595  if (f.form_phone_home   ) phonekeyup(f.form_phone_home   ,mypcc);
 596  if (f.form_phone_biz    ) phonekeyup(f.form_phone_biz    ,mypcc);
 597  if (f.form_phone_cell   ) phonekeyup(f.form_phone_cell   ,mypcc);
 598
 599 <?php if (! $GLOBALS['simplified_demographics']) { ?>
 600  phonekeyup(f.i1subscriber_phone,mypcc);
 601  phonekeyup(f.i2subscriber_phone,mypcc);
 602  phonekeyup(f.i3subscriber_phone,mypcc);
 603 <?php } ?>
 604
 605 <?php if ($GLOBALS['concurrent_layout'] && $set_pid) { ?>
 606  parent.left_nav.setPatient(<?php echo "'" . addslashes($result['fname']) . " " . addslashes($result['lname']) . "',$pid,'" . addslashes($result['pubpid']) . "','', ' DOB: ".$result['DOB_YMD']." Age: ".getPatientAge($result['DOB_YMD'])."'"; ?>);
 607  parent.left_nav.setRadio(window.name, 'dem');
 608 <?php } ?>
 609
 610 <?php echo $date_init; ?>
 611 <?php if (! $GLOBALS['simplified_demographics']) { for ($i=1; $i<=3; $i++): ?>
 612  Calendar.setup({inputField:"i<?php echo $i?>subscriber_DOB", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i?>dob_date"});
 613 <?php endfor; } ?>
 614 </script>
 615
 616 </body>
 617 <?php
 618 // <!-- stuff for the popup calendar -->
 619 // <style type="text/css">@import url(../../../library/dynarch_calendar.css);</style>
 620 // <script type="text/javascript" src="../../../library/dynarch_calendar.js"></script>
 621 // <script type="text/javascript" src="../../../library/dynarch_calendar_en.js"></script>
 622 // <script type="text/javascript" src="../../../library/dynarch_calendar_setup.js"></script>
 623 ?>
 624 </html>