interface/new/new_comprehensive.php

   1 <?php
   2 /**
   3  * New patient or search patient.
   4  *
   5  * @package   OpenEMR
   6  * @link      http://www.open-emr.org
   7  * @author    Rod Roark <rod@sunsetsystems.com>
   8  * @author    Brady Miller <brady.g.miller@gmail.com>
   9  * @copyright Copyright (c) 2009-2017 Rod Roark <rod@sunsetsystems.com>
  10  * @copyright Copyright (c) 2017 Brady Miller <brady.g.miller@gmail.com>
  11  * @license   https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  12  */
  13
  14 require_once("../globals.php");
  15 require_once("$srcdir/acl.inc");
  16 require_once("$srcdir/options.inc.php");
  17 require_once("$srcdir/patient.inc");
  18 require_once("$srcdir/erx_javascript.inc.php");
  19 require_once("$srcdir/validation/LBF_Validation.php");
  20 require_once("$srcdir/patientvalidation.inc.php");
  21
  22 // Check authorization.
  23 if (!acl_check('patients', 'demo', '', array('write','addonly'))) {
  24     die(xlt("Adding demographics is not authorized."));
  25 }
  26
  27 $CPR = 4; // cells per row
  28
  29 $searchcolor = empty($GLOBALS['layout_search_color']) ?
  30   '#ffff55' : $GLOBALS['layout_search_color'];
  31
  32 $WITH_SEARCH = ($GLOBALS['full_new_patient_form'] == '1' || $GLOBALS['full_new_patient_form'] == '2' );
  33 $SHORT_FORM  = ($GLOBALS['full_new_patient_form'] == '2' || $GLOBALS['full_new_patient_form'] == '3' || $GLOBALS['full_new_patient_form'] == '4');
  34
  35 $grparr = array();
  36 getLayoutProperties('DEM', $grparr);
  37
  38 function getLayoutRes()
  39 {
  40     global $SHORT_FORM;
  41     return sqlStatement("SELECT * FROM layout_options " .
  42     "WHERE form_id = 'DEM' AND uor > 0 AND field_id != '' " .
  43     ($SHORT_FORM ? "AND ( uor > 1 OR edit_options LIKE '%N%' ) " : "") .
  44     "ORDER BY group_id, seq");
  45 }
  46
  47 // Determine layout field search treatment from its data type:
  48 // 1 = text field
  49 // 2 = select list
  50 // 0 = not searchable
  51 //
  52 function getSearchClass($data_type)
  53 {
  54     switch ($data_type) {
  55         case 1: // single-selection list
  56         case 10: // local provider list
  57         case 11: // provider list
  58         case 12: // pharmacy list
  59         case 13: // squads
  60         case 14: // address book list
  61         case 26: // single-selection list with add
  62         case 35: // facilities
  63             return 2;
  64         case 2: // text field
  65         case 3: // textarea
  66         case 4: // date
  67             return 1;
  68     }
  69
  70     return 0;
  71 }
  72
  73 $fres = getLayoutRes();
  74 ?>
  75 <html>
  76 <head>
  77 <?php html_header_show(); ?>
  78
  79 <title><?php echo xlt("Search or Add Patient"); ?></title>
  80
  81 <link rel="stylesheet" href="<?php echo $GLOBALS['assets_static_relative'] ?>/bootstrap-3-3-4/dist/css/bootstrap.min.css">
  82 <?php if ($_SESSION['language_direction'] == 'rtl') { ?>
  83     <link rel="stylesheet" href="<?php echo $GLOBALS['assets_static_relative'] ?>/bootstrap-rtl-3-3-4/dist/css/bootstrap-rtl.min.css">
  84 <?php } ?>
  85 <link rel="stylesheet" href="<?php echo $css_header; ?>" type="text/css">
  86 <link rel="stylesheet" href="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-datetimepicker-2-5-4/build/jquery.datetimepicker.min.css">
  87 <link rel="stylesheet" type="text/css" href="../../library/js/fancybox/jquery.fancybox-1.2.6.css" media="screen" />
  88
  89 <style>
  90 body {
  91  padding: 5pt 5pt 5pt 5pt;
  92 }
  93
  94 div.section {
  95  border: solid;
  96  border-width: 1px;
  97  border-color: #0000ff;
  98  margin: 0 0 0 10pt;
  99  padding: 5pt;
 100 }
 101
 102 .form-control {
 103     width: auto;
 104     display: inline;
 105     height: auto;
 106 }
 107 </style>
 108
 109 <script type="text/javascript" src="../../library/dialog.js?v=<?php echo $v_js_includes; ?>"></script>
 110 <script type="text/javascript" src="../../library/textformat.js?v=<?php echo $v_js_includes; ?>"></script>
 111 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-min-1-7-2/index.js"></script>
 112 <script type="text/javascript" src="../../library/js/common.js?v=<?php echo $v_js_includes; ?>"></script>
 113 <script type="text/javascript" src="../../library/js/fancybox/jquery.fancybox-1.2.6.js"></script>
 114 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-datetimepicker-2-5-4/build/jquery.datetimepicker.full.min.js"></script>
 115
 116 <?php include_once("{$GLOBALS['srcdir']}/options.js.php"); ?>
 117
 118 <SCRIPT LANGUAGE="JavaScript"><!--
 119 //Visolve - sync the radio buttons - Start
 120 if((top.window.parent) && (parent.window)){
 121         var wname = top.window.parent.left_nav;
 122         fname = (parent.window.name)?parent.window.name:window.name;
 123         wname.syncRadios();
 124 }//Visolve - sync the radio buttons - End
 125
 126 var mypcc = '<?php echo $GLOBALS['phone_country_code'] ?>';
 127
 128 // This may be changed to true by the AJAX search script.
 129 var force_submit = false;
 130
 131 //code used from http://tech.irt.org/articles/js037/
 132 function replace(string,text,by) {
 133  // Replaces text with by in string
 134  var strLength = string.length, txtLength = text.length;
 135  if ((strLength == 0) || (txtLength == 0)) return string;
 136
 137  var i = string.indexOf(text);
 138  if ((!i) && (text != string.substring(0,txtLength))) return string;
 139  if (i == -1) return string;
 140
 141  var newstr = string.substring(0,i) + by;
 142
 143  if (i+txtLength < strLength)
 144   newstr += replace(string.substring(i+txtLength,strLength),text,by);
 145
 146  return newstr;
 147 }
 148
 149 <?php for ($i=1; $i<=3; $i++) { ?>
 150 function auto_populate_employer_address<?php echo $i ?>(){
 151  var f = document.demographics_form;
 152  if (f.form_i<?php echo $i?>subscriber_relationship.options[f.form_i<?php echo $i?>subscriber_relationship.selectedIndex].value == "self") {
 153   f.i<?php echo $i?>subscriber_fname.value=f.form_fname.value;
 154   f.i<?php echo $i?>subscriber_mname.value=f.form_mname.value;
 155   f.i<?php echo $i?>subscriber_lname.value=f.form_lname.value;
 156   f.i<?php echo $i?>subscriber_street.value=f.form_street.value;
 157   f.i<?php echo $i?>subscriber_city.value=f.form_city.value;
 158   f.form_i<?php echo $i?>subscriber_state.value=f.form_state.value;
 159   f.i<?php echo $i?>subscriber_postal_code.value=f.form_postal_code.value;
 160   if (f.form_country_code)
 161     f.form_i<?php echo $i?>subscriber_country.value=f.form_country_code.value;
 162   f.i<?php echo $i?>subscriber_phone.value=f.form_phone_home.value;
 163   f.i<?php echo $i?>subscriber_DOB.value=f.form_DOB.value;
 164   f.i<?php echo $i?>subscriber_ss.value=f.form_ss.value;
 165   f.form_i<?php echo $i?>subscriber_sex.value = f.form_sex.value;
 166   f.i<?php echo $i?>subscriber_employer.value=f.form_em_name.value;
 167   f.i<?php echo $i?>subscriber_employer_street.value=f.form_em_street.value;
 168   f.i<?php echo $i?>subscriber_employer_city.value=f.form_em_city.value;
 169   f.form_i<?php echo $i?>subscriber_employer_state.value=f.form_em_state.value;
 170   f.i<?php echo $i?>subscriber_employer_postal_code.value=f.form_em_postal_code.value;
 171   if (f.form_em_country)
 172     f.form_i<?php echo $i?>subscriber_employer_country.value=f.form_em_country.value;
 173  }
 174 }
 175
 176 <?php } ?>
 177
 178 function upperFirst(string,text) {
 179  return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
 180 }
 181
 182 // The ins_search.php window calls this to set the selected insurance.
 183 function set_insurance(ins_id, ins_name) {
 184  var thesel = document.forms[0]['i' + insurance_index + 'provider'];
 185  var theopts = thesel.options; // the array of Option objects
 186  var i = 0;
 187  for (; i < theopts.length; ++i) {
 188   if (theopts[i].value == ins_id) {
 189    theopts[i].selected = true;
 190    return;
 191   }
 192  }
 193  // no matching option was found so create one, append it to the
 194  // end of the list, and select it.
 195  theopts[i] = new Option(ins_name, ins_id, false, true);
 196 }
 197
 198 // Indicates which insurance slot is being updated.
 199 var insurance_index = 0;
 200
 201 // The OnClick handler for searching/adding the insurance company.
 202 function ins_search(ins) {
 203  insurance_index = ins;
 204  return false;
 205 }
 206
 207 function checkNum () {
 208  var re= new RegExp();
 209  re = /^\d*\.?\d*$/;
 210  str=document.forms[0].monthly_income.value;
 211  if(re.exec(str))
 212  {
 213  }else{
 214   alert("<?php echo xls("Please enter a dollar amount using only numbers and a decimal point."); ?>");
 215  }
 216 }
 217
 218 // This capitalizes the first letter of each word in the passed input
 219 // element.  It also strips out extraneous spaces.
 220 function capitalizeMe(elem) {
 221  var a = elem.value.split(' ');
 222  var s = '';
 223  for(var i = 0; i < a.length; ++i) {
 224   if (a[i].length > 0) {
 225    if (s.length > 0) s += ' ';
 226    s += a[i].charAt(0).toUpperCase() + a[i].substring(1);
 227   }
 228  }
 229  elem.value = s;
 230 }
 231
 232 // Onkeyup handler for policy number.  Allows only A-Z and 0-9.
 233 function policykeyup(e) {
 234  var v = e.value.toUpperCase();
 235  var filteredString="";
 236  for (var i = 0; i < v.length; ++i) {
 237   var c = v.charAt(i);
 238   if ((c >= '0' && c <= '9') ||
 239      (c >= 'A' && c <= 'Z') ||
 240      (c == '*') ||
 241      (c == '-') ||
 242      (c == '_') ||
 243      (c == '(') ||
 244      (c == ')') ||
 245      (c == '#'))
 246      {
 247          filteredString+=c;
 248      }
 249  }
 250  e.value = filteredString;
 251  return;
 252 }
 253
 254 function divclick(cb, divid) {
 255  var divstyle = document.getElementById(divid).style;
 256  if (cb.checked) {
 257   divstyle.display = 'block';
 258  } else {
 259   divstyle.display = 'none';
 260  }
 261  return true;
 262 }
 263
 264 // Compute the length of a string without leading and trailing spaces.
 265 function trimlen(s) {
 266  var i = 0;
 267  var j = s.length - 1;
 268  for (; i <= j && s.charAt(i) == ' '; ++i);
 269  for (; i <= j && s.charAt(j) == ' '; --j);
 270  if (i > j) return 0;
 271  return j + 1 - i;
 272 }
 273
 274 function validate(f) {
 275   var errMsgs = new Array();
 276     <?php generate_layout_validation('DEM'); ?>
 277     <?php if ($GLOBALS['erx_enable']) { ?>
 278   alertMsg='';
 279   for(i=0;i<f.length;i++){
 280     if(f[i].type=='text' && f[i].value)
 281     {
 282       if(f[i].name == 'form_fname' || f[i].name == 'form_mname' || f[i].name == 'form_lname')
 283       {
 284         alertMsg += checkLength(f[i].name,f[i].value,35);
 285         alertMsg += checkUsername(f[i].name,f[i].value);
 286       }
 287       else if(f[i].name == 'form_street' || f[i].name == 'form_city')
 288       {
 289         alertMsg += checkLength(f[i].name,f[i].value,35);
 290         alertMsg += checkAlphaNumericExtended(f[i].name,f[i].value);
 291       }
 292       else if(f[i].name == 'form_phone_home')
 293       {
 294        alertMsg += checkPhone(f[i].name,f[i].value);
 295       }
 296     }
 297   }
 298   if(alertMsg)
 299   {
 300     alert(alertMsg);
 301     return false;
 302   }
 303     <?php } ?>
 304   var msg = "";
 305   msg += "<?php echo xla('The following fields are required'); ?>:\n\n";
 306   for ( var i = 0; i < errMsgs.length; i++ ) {
 307          msg += errMsgs[i] + "\n";
 308   }
 309   msg += "\n<?php echo xla('Please fill them in before continuing.'); ?>";
 310
 311
 312 //Misc  Deceased Date Validation for Future Date
 313 var dateVal = document.getElementById("form_deceased_date").value;
 314 var currentDate;
 315 var d = new Date();
 316 month = '' + (d.getMonth() + 1),
 317 day = '' + d.getDate(),
 318 year = d.getFullYear();
 319 if (month.length < 2) month = '0' + month;
 320 if (day.length < 2) day = '0' + day;
 321 currentDate = year+'-'+month+'-'+day;
 322 if(errMsgs.length > 0 || dateVal > currentDate)
 323 {
 324 if(errMsgs.length > 0)
 325     alert(msg);
 326 if(dateVal > currentDate)
 327     alert ('<?php echo xls("Deceased Date should not be greater than Today"); ?>');
 328     return false;
 329 }
 330  return true;
 331 }
 332
 333 function toggleSearch(elem) {
 334  var f = document.forms[0];
 335 <?php if ($WITH_SEARCH) { ?>
 336  // Toggle background color.
 337  if (elem.style.backgroundColor == '')
 338   elem.style.backgroundColor = '<?php echo $searchcolor; ?>';
 339  else
 340   elem.style.backgroundColor = '';
 341 <?php } ?>
 342  if (force_submit) {
 343   force_submit = false;
 344   f.create.value = '<?php echo xla('Create New Patient'); ?>';
 345  }
 346  return true;
 347 }
 348
 349 // If a <select> list is dropped down, this is its name.
 350 var open_sel_name = '';
 351
 352 function selClick(elem) {
 353  if (open_sel_name == elem.name) {
 354   open_sel_name = '';
 355  }
 356  else {
 357   open_sel_name = elem.name;
 358   toggleSearch(elem);
 359  }
 360  return true;
 361 }
 362
 363 function selBlur(elem) {
 364  if (open_sel_name == elem.name) {
 365   open_sel_name = '';
 366  }
 367  return true;
 368 }
 369
 370 // This invokes the patient search dialog.
 371 function searchme() {
 372  var f = document.forms[0];
 373  var url = '../main/finder/patient_select.php?popup=1';
 374
 375 <?php
 376 $lres = getLayoutRes();
 377
 378 while ($lrow = sqlFetchArray($lres)) {
 379     $field_id  = $lrow['field_id'];
 380     if (strpos($field_id, 'em_') === 0) {
 381         continue;
 382     }
 383
 384     $data_type = $lrow['data_type'];
 385     $fldname = "form_$field_id";
 386     switch (getSearchClass($data_type)) {
 387         case 1:
 388             echo
 389             " if (f.$fldname.style.backgroundColor != '' && trimlen(f.$fldname.value) > 0) {\n" .
 390             "  url += '&$field_id=' + encodeURIComponent(f.$fldname.value);\n" .
 391             " }\n";
 392             break;
 393         case 2:
 394             echo
 395             " if (f.$fldname.style.backgroundColor != '' && f.$fldname.selectedIndex > 0) {\n" .
 396             "  url += '&$field_id=' + encodeURIComponent(f.$fldname.options[f.$fldname.selectedIndex].value);\n" .
 397             " }\n";
 398             break;
 399     }
 400 }
 401 ?>
 402
 403  dlgopen(url, '_blank', 700, 500);
 404 }
 405
 406 //-->
 407
 408 </script>
 409 </head>
 410
 411 <body class="body_top">
 412
 413 <?php
 414 /*Get the constraint from the DB-> LBF forms accordinf the form_id*/
 415 $constraints = LBF_Validation::generate_validate_constraints("DEM");
 416 ?>
 417 <script> var constraints = <?php echo $constraints;?>; </script>
 418
 419 <form action='new_comprehensive_save.php' name='demographics_form' id="DEM"  method='post' onsubmit='return submitme(<?php echo $GLOBALS['new_validate'] ? 1 : 0;?>,event,"DEM",constraints)'>
 420
 421     <div class="container-fluid">
 422         <div class="row">
 423             <div class="col-xs-12">
 424                 <div class="page-header">
 425                     <h2><?php echo xlt('Search or Add Patient');?></h2>
 426                 </div>
 427             </div>
 428             <div class="col-xs-12">
 429                 <div class="btn-group">
 430                     <?php if ($WITH_SEARCH) { ?>
 431                         <button type="button" class="btn btn-default btn-search" id="search" value="<?php echo xla('Search'); ?>">
 432                             <?php echo xlt('Search'); ?>
 433                         </button>
 434                     <?php } ?>
 435                     <button type="button" class="btn btn-default btn-save" name='create' id="create" value="<?php echo xla('Create New Patient'); ?>">
 436                         <?php echo xlt('Create New Patient'); ?>
 437                     </button>
 438                 </div>
 439                 <hr>
 440             </div>
 441         </div>
 442     </div>
 443
 444 <table width='100%' cellpadding='0' cellspacing='8'>
 445  <tr>
 446   <td align='left' valign='top'>
 447 <?php if ($SHORT_FORM) {
 448     echo "  <center>\n";
 449 } ?>
 450 <?php
 451
 452 function end_cell()
 453 {
 454     global $item_count, $cell_count;
 455     if ($item_count > 0) {
 456         echo "</td>";
 457         $item_count = 0;
 458     }
 459 }
 460
 461 function end_row()
 462 {
 463     global $cell_count, $CPR;
 464     end_cell();
 465     if ($cell_count > 0) {
 466         for (; $cell_count < $CPR;
 467         ++$cell_count) {
 468             echo "<td></td>";
 469         }
 470
 471         echo "</tr>\n";
 472         $cell_count = 0;
 473     }
 474 }
 475
 476 function end_group()
 477 {
 478     global $last_group, $SHORT_FORM;
 479     if (strlen($last_group) > 0) {
 480         end_row();
 481         echo " </table>\n";
 482         if (!$SHORT_FORM) {
 483             echo "</div>\n";
 484         }
 485     }
 486 }
 487
 488 $last_group    = '';
 489 $cell_count    = 0;
 490 $item_count    = 0;
 491 $display_style = 'block';
 492 $group_seq     = 0; // this gives the DIV blocks unique IDs
 493
 494 $condition_str = '';
 495
 496 while ($frow = sqlFetchArray($fres)) {
 497     $this_group = $frow['group_id'];
 498     $titlecols  = $frow['titlecols'];
 499     $datacols   = $frow['datacols'];
 500     $data_type  = $frow['data_type'];
 501     $field_id   = $frow['field_id'];
 502     $list_id    = $frow['list_id'];
 503     $currvalue  = '';
 504
 505     // Accumulate action conditions into a JSON expression for the browser side.
 506     accumActionConditions($field_id, $condition_str, $frow['conditions']);
 507
 508     if (strpos($field_id, 'em_') === 0) {
 509         $tmp = substr($field_id, 3);
 510         if (isset($result2[$tmp])) {
 511             $currvalue = $result2[$tmp];
 512         }
 513     } else {
 514         if (isset($result[$field_id])) {
 515             $currvalue = $result[$field_id];
 516         }
 517     }
 518
 519   // Handle a data category (group) change.
 520     if (strcmp($this_group, $last_group) != 0) {
 521         if (!$SHORT_FORM) {
 522             end_group();
 523             $group_seq++;    // ID for DIV tags
 524             $group_name = $grparr[$this_group]['grp_title'];
 525
 526             if (strlen($last_group) > 0) {
 527                 echo "<br />";
 528             }
 529
 530             echo "<span class='bold'><input type='checkbox' name='form_cb_$group_seq' id='form_cb_$group_seq' value='1' " .
 531             "onclick='return divclick(this,\"div_$group_seq\");'";
 532             if ($display_style == 'block') {
 533                 echo " checked";
 534             }
 535
 536             // Modified 6-09 by BM - Translate if applicable
 537             echo " /><b>" . xl_layout_label($group_name) . "</b></span>\n";
 538
 539             echo "<div id='div_$group_seq' class='section' style='display:$display_style;'>\n";
 540             echo " <table border='0' cellpadding='0'>\n";
 541             $display_style = 'none';
 542         } else if (strlen($last_group) == 0) {
 543             echo " <table border='0' cellpadding='0'>\n";
 544         }
 545
 546         $last_group = $this_group;
 547     }
 548
 549   // Handle starting of a new row.
 550     if (($titlecols > 0 && $cell_count >= $CPR) || $cell_count == 0) {
 551         end_row();
 552         echo "  <tr>";
 553     }
 554
 555     if ($item_count == 0 && $titlecols == 0) {
 556         $titlecols = 1;
 557     }
 558
 559     $field_id_label='label_'.$frow['field_id'];
 560   // Handle starting of a new label cell.
 561     if ($titlecols > 0) {
 562         end_cell();
 563         echo "<td colspan='$titlecols' id='$field_id_label'";
 564         echo ($frow['uor'] == 2) ? " class='required'" : " class='bold'";
 565         if ($cell_count == 2) {
 566             echo " style='padding-left:10pt'";
 567         }
 568
 569         echo ">";
 570         $cell_count += $titlecols;
 571     }
 572
 573     ++$item_count;
 574
 575     echo "<b>";
 576
 577   // Modified 6-09 by BM - Translate if applicable
 578     if ($frow['title']) {
 579         echo (xl_layout_label($frow['title']).":");
 580     } else {
 581         echo "&nbsp;";
 582     }
 583
 584     echo "</b>";
 585
 586   // Handle starting of a new data cell.
 587     if ($datacols > 0) {
 588         $id_field_text = "text_".$frow['field_id'];
 589         end_cell();
 590         echo "<td colspan='$datacols' class='text data'";
 591         if ($cell_count > 0) {
 592             echo " style='padding-left:5pt'". " id='".$id_field_text."'";
 593         }
 594
 595         echo ">";
 596         $cell_count += $datacols;
 597     }
 598
 599     ++$item_count;
 600     generate_form_field($frow, $currvalue);
 601 }
 602
 603 end_group();
 604 ?>
 605
 606 <?php
 607 if (! $GLOBALS['simplified_demographics']) {
 608     $insurancei = getInsuranceProviders();
 609     $pid = 0;
 610     $insurance_headings = array(xl("Primary Insurance Provider"), xl("Secondary Insurance Provider"), xl("Tertiary Insurance provider"));
 611     $insurance_info = array();
 612     $insurance_info[1] = getInsuranceData($pid, "primary");
 613     $insurance_info[2] = getInsuranceData($pid, "secondary");
 614     $insurance_info[3] = getInsuranceData($pid, "tertiary");
 615
 616     echo "<br /><span class='bold'><input type='checkbox' name='form_cb_ins' value='1' " .
 617     "onclick='return divclick(this,\"div_ins\");'";
 618     if ($display_style == 'block') {
 619         echo " checked";
 620     }
 621
 622     echo " /><b>" . xlt('Insurance') . "</b></span>\n";
 623     echo "<div id='div_ins' class='section' style='display:$display_style;'>\n";
 624
 625     for ($i=1; $i<=3; $i++) {
 626         $result3 = $insurance_info[$i];
 627     ?>
 628   <table border="0">
 629    <tr>
 630     <td valign='top' colspan='2'>
 631      <span class='required'><?php echo text($insurance_headings[$i -1]).":"?></span>
 632      <select name="i<?php echo $i?>provider" class="form-control">
 633     <option value=""><?php echo xlt('Unassigned'); ?></option>
 634 <?php
 635 foreach ($insurancei as $iid => $iname) {
 636     echo "<option value='" . attr($iid) . "'";
 637     if (strtolower($iid) == strtolower($result3{"provider"})) {
 638         echo " selected";
 639     }
 640
 641     echo ">" . text($iname) . "</option>\n";
 642 }
 643 ?>
 644      </select>&nbsp;<a class='iframe medium_modal' href='../practice/ins_search.php' onclick='ins_search(<?php echo $i?>)'>
 645   <span> <?php echo xlt('Search/Add Insurer'); ?></span></a>
 646   </td>
 647  </tr>
 648  <tr>
 649   <td valign=top>
 650    <table border="0">
 651
 652     <tr>
 653      <td>
 654       <span class='required'><?php echo xlt('Plan Name'); ?>: </span>
 655      </td>
 656      <td>
 657       <input type='entry' class='form-control' size='20' name='i<?php echo $i?>plan_name' value="<?php echo attr($result3{"plan_name"}); ?>"
 658        onchange="capitalizeMe(this);" />&nbsp;&nbsp;
 659      </td>
 660     </tr>
 661
 662     <tr>
 663      <td>
 664       <span class='required'><?php echo xlt('Effective Date'); ?>: </span>
 665      </td>
 666      <td>
 667       <input type='entry' size='11' class='datepicker form-control' name='i<?php echo $i ?>effective_date'
 668        id='i<?php echo $i ?>effective_date'
 669        value='<?php echo attr($result3['date']); ?>'
 670        title='yyyy-mm-dd' />
 671      </td>
 672     </tr>
 673
 674     <tr>
 675      <td><span class=required><?php echo xlt('Policy Number'); ?>: </span></td>
 676      <td><input type='entry' class='form-control' size='16' name='i<?php echo $i?>policy_number' value="<?php echo attr($result3{"policy_number"}); ?>"
 677       onkeyup='policykeyup(this)'></td>
 678     </tr>
 679
 680     <tr>
 681      <td><span class=required><?php echo xlt('Group Number'); ?>: </span></td>
 682     <td><input type=entry class='form-control' size=16 name=i<?php echo $i?>group_number value="<?php echo attr($result3{"group_number"}); ?>" onkeyup='policykeyup(this)'></td>
 683     </tr>
 684
 685     <tr<?php echo ($GLOBALS['omit_employers']) ? " style='display:none'" : ""; ?>>
 686      <td class='required'><?php echo xlt('Subscriber Employer (SE)'); ?><br><span style='font-weight:normal'>
 687       (<?php echo xlt('if unemployed enter Student'); ?>,<br><?php echo xlt('PT Student, or leave blank'); ?>): </span></td>
 688      <td><input type=entry class='form-control' size=25 name=i<?php echo $i?>subscriber_employer
 689       value="<?php echo attr($result3{"subscriber_employer"}); ?>"
 690        onchange="capitalizeMe(this);" /></td>
 691     </tr>
 692
 693     <tr<?php echo ($GLOBALS['omit_employers']) ? " style='display:none'" : ""; ?>>
 694      <td><span class=required><?php echo xlt('SE Address'); ?>: </span></td>
 695      <td><input type=entry class='form-control' size=25 name=i<?php echo $i?>subscriber_employer_street
 696       value="<?php echo attr($result3{"subscriber_employer_street"}); ?>"
 697        onchange="capitalizeMe(this);" /></td>
 698     </tr>
 699
 700     <tr<?php echo ($GLOBALS['omit_employers']) ? " style='display:none'" : ""; ?>>
 701      <td colspan="2">
 702       <table>
 703        <tr>
 704         <td><span class=required><?php echo xlt('SE City'); ?>: </span></td>
 705         <td><input type=entry class='form-control' size=15 name=i<?php echo $i?>subscriber_employer_city
 706          value="<?php echo attr($result3{"subscriber_employer_city"}); ?>"
 707           onchange="capitalizeMe(this);" /></td>
 708         <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('SE State') : xlt('SE Locality') ?>: </span></td>
 709     <td>
 710             <?php
 711             // Modified 7/2009 by BM to incorporate data types
 712             generate_form_field(array('data_type'=>$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'), $result3['subscriber_employer_state']);
 713                 ?>
 714           </td>
 715          </tr>
 716          <tr>
 717             <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('SE Zip Code') : xlt('SE Postal Code') ?>: </span></td>
 718             <td><input type=entry class='form-control' size=10 name=i<?php echo $i?>subscriber_employer_postal_code value="<?php echo attr($result3{"subscriber_employer_postal_code"}); ?>"></td>
 719             <td><span class=required><?php xl('SE Country', 'e'); ?>: </span></td>
 720       <td>
 721                 <?php
 722               // Modified 7/2009 by BM to incorporate data types
 723                 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']);
 724                 ?>
 725       </td>
 726          </tr>
 727         </table>
 728        </td>
 729       </tr>
 730
 731      </table>
 732     </td>
 733
 734     <td valign=top>
 735        <span class=required><?php echo xlt('Subscriber'); ?>: </span>
 736        <input type=entry class='form-control' size=10 name=i<?php echo $i?>subscriber_fname
 737         value="<?php echo attr($result3{"subscriber_fname"}); ?>"
 738       onchange="capitalizeMe(this);" />
 739        <input type=entry class='form-control' size=3 name=i<?php echo $i?>subscriber_mname
 740         value="<?php echo attr($result3{"subscriber_mname"}); ?>"
 741       onchange="capitalizeMe(this);" />
 742        <input type=entry class='form-control' size=10 name=i<?php echo $i?>subscriber_lname
 743         value="<?php echo attr($result3{"subscriber_lname"}); ?>"
 744       onchange="capitalizeMe(this);" />
 745      <br>
 746        <span class=required><?php echo xlt('Relationship'); ?>: </span>
 747         <?php
 748       // Modified 6/2009 by BM to use list_options and function
 749         generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_relationship'),'list_id'=>'sub_relation','empty_title'=>' '), $result3['subscriber_relationship']);
 750         ?>
 751        <a href="javascript:popUp('../../interface/patient_file/summary/browse.php?browsenum=<?php echo $i?>')" class=text>(<?php echo xla('Browse'); ?>)</a><br />
 752
 753        <span class=bold><?php echo xlt('D.O.B.'); ?>: </span>
 754        <input type='entry' size='11' class='datepicker form-control' name='i<?php echo $i?>subscriber_DOB'
 755       id='i<?php echo $i?>subscriber_DOB'
 756       value='<?php echo attr($result3['subscriber_DOB']); ?>'
 757     title='yyyy-mm-dd' />
 758
 759        <span class=bold><?php echo xlt('S.S.'); ?>: </span>
 760        <input type=entry class='form-control' size=11 name=i<?php echo $i?>subscriber_ss value="<?php echo attr($result3{"subscriber_ss"}); ?>">&nbsp;
 761        <span class=bold><?php echo xlt('Sex'); ?>: </span>
 762         <?php
 763       // Modified 6/2009 by BM to use list_options and function
 764         generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_sex'),'list_id'=>'sex'), $result3['subscriber_sex']);
 765         ?>
 766      <br>
 767        <span class=required><?php echo xlt('Subscriber Address'); ?>: </span>
 768        <input type=entry class='form-control' size=25 name=i<?php echo $i?>subscriber_street
 769       value="<?php echo attr($result3{"subscriber_street"}); ?>"
 770     onchange="capitalizeMe(this);" /><br>
 771        <span class=required><?php echo xlt('City'); ?>: </span>
 772        <input type=entry class='form-control' size=15 name=i<?php echo $i?>subscriber_city
 773       value="<?php echo attr($result3{"subscriber_city"}); ?>"
 774     onchange="capitalizeMe(this);" />
 775        <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('State') : xlt('Locality') ?>: </span>
 776         <?php
 777       // Modified 7/2009 by BM to incorporate data types
 778         generate_form_field(array('data_type'=>$GLOBALS['state_data_type'],'field_id'=>('i'.$i.'subscriber_state'),'list_id'=>$GLOBALS['state_list'],'fld_length'=>'15','max_length'=>'63','edit_options'=>'C'), $result3['subscriber_state']);
 779         ?>
 780      <br />
 781        <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('Zip Code') : xlt('Postal Code') ?>: </span>
 782        <input type=entry class='form-control' size=10 name=i<?php echo $i?>subscriber_postal_code value="<?php echo attr($result3{"subscriber_postal_code"}); ?>">
 783        <span class='required'<?php echo ($GLOBALS['omit_employers']) ? " style='display:none'" : ""; ?>>
 784         <?php echo xlt('Country'); ?>: </span>
 785         <?php
 786       // Modified 7/2009 by BM to incorporate data types
 787         generate_form_field(array('data_type'=>$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']);
 788         ?>
 789      <br />
 790        <span class=bold><?php echo xlt('Subscriber Phone'); ?>:
 791        <input type='text' class='form-control' size='20' name='i<?php echo $i?>subscriber_phone' value='<?php echo attr($result3["subscriber_phone"]); ?>' onkeyup='phonekeyup(this,mypcc)' />
 792      </span><br />
 793        <span class=bold><?php echo xlt('CoPay'); ?>: <input type=text class='form-control' size="6" name=i<?php echo $i?>copay value="<?php echo attr($result3{"copay"}); ?>">
 794      </span><br />
 795        <span class='required'><?php echo xlt('Accept Assignment'); ?>: </span>
 796        <select class='form-control' name=i<?php echo $i?>accept_assignment>
 797          <option value="TRUE" <?php echo (strtoupper($result3{"accept_assignment"}) == "TRUE") ? "selected" : ""; ?>><?php echo xlt('YES'); ?></option>
 798          <option value="FALSE" <?php echo (strtoupper($result3{"accept_assignment"}) == "FALSE") ? "selected" : ""; ?>><?php echo xlt('NO'); ?></option>
 799        </select>
 800     </td>
 801    </tr>
 802
 803   </table>
 804   <hr />
 805     <?php
 806     }
 807
 808     echo "</div>\n";
 809 } // end of "if not simplified_demographics"
 810 ?>
 811
 812 <?php if ($SHORT_FORM) {
 813     echo "  </center>\n";
 814 } ?>
 815
 816   </td>
 817   <td align='right' valign='top' width='1%' nowrap>
 818    <!-- Image upload stuff was here but got moved. -->
 819   </td>
 820  </tr>
 821 </table>
 822
 823 </form>
 824
 825 <!-- include support for the list-add selectbox feature -->
 826 <?php include($GLOBALS['fileroot']."/library/options_listadd.inc"); ?>
 827
 828 </body>
 829
 830 <script language="JavaScript">
 831
 832 // hard code validation for old validation, in the new validation possible to add match rules
 833 <?php if ($GLOBALS['new_validate'] == 0) { ?>
 834
 835 // fix inconsistently formatted phone numbers from the database
 836 var f = document.forms[0];
 837 if (f.form_phone_contact) phonekeyup(f.form_phone_contact,mypcc);
 838 if (f.form_phone_home   ) phonekeyup(f.form_phone_home   ,mypcc);
 839 if (f.form_phone_biz    ) phonekeyup(f.form_phone_biz    ,mypcc);
 840 if (f.form_phone_cell   ) phonekeyup(f.form_phone_cell   ,mypcc);
 841
 842 <?php }?>
 843
 844 <?php echo $date_init; ?>
 845
 846 // -=- jQuery makes life easier -=-
 847
 848 // var matches = 0; // number of patients that match the demographic information being entered
 849 // var override = false; // flag that overrides the duplication warning
 850
 851 $(document).ready(function() {
 852 enable_modals();
 853  $(".medium_modal").fancybox( {
 854                 'overlayOpacity' : 0.0,
 855                 'showCloseButton' : true,
 856                 'frameHeight' : 460,
 857                 'frameWidth' : 650
 858         });
 859     // added to integrate insurance stuff
 860     <?php for ($i=1; $i<=3; $i++) { ?>
 861     $("#form_i<?php echo $i?>subscriber_relationship").change(function() { auto_populate_employer_address<?php echo $i?>(); });
 862     <?php } ?>
 863
 864     $('#search').click(function() { searchme(); });
 865     $('#create').click(function() { check()});
 866
 867     var check = function(e) {
 868         <?php if ($GLOBALS['new_validate']) {?>
 869             var valid = submitme(<?php echo $GLOBALS['new_validate'] ? 1 : 0;?>,e,"DEM",constraints);
 870         <?php } else {?>
 871             top.restoreSession();
 872             var f = document.forms[0];
 873             var valid = validate(f);
 874         <?php }?>
 875         if (valid) {
 876             if (force_submit) {
 877                 // In this case dups were shown already and Save should just save.
 878                 top.restoreSession();
 879                 f.submit();
 880                 return;
 881             }
 882
 883         <?php
 884         // D in edit_options indicates the field is used in duplication checking.
 885         // This constructs a list of the names of those fields.
 886         $mflist = "";
 887         $mfres = sqlStatement("SELECT * FROM layout_options " .
 888             "WHERE form_id = 'DEM' AND uor > 0 AND field_id != '' AND " .
 889             "(edit_options LIKE '%D%' OR  edit_options LIKE '%W%' )" .
 890             "ORDER BY group_id, seq");
 891         while ($mfrow = sqlFetchArray($mfres)) {
 892             $field_id  = $mfrow['field_id'];
 893             if (strpos($field_id, 'em_') === 0) {
 894                 continue;
 895             }
 896
 897             if (!empty($mflist)) {
 898                 $mflist .= ",";
 899             }
 900
 901             $mflist .= "'" . htmlentities($field_id) . "'";
 902         }
 903 ?>
 904         <?php if (($GLOBALS['full_new_patient_form'] == '4') && (checkIfPatientValidationHookIsActive())) :?>
 905             // Use zend module patient validation hook to open the controller and send the dup-checker fields.
 906             var url ='<?php echo  $GLOBALS['web_root']."/interface/modules/zend_modules/public/patientvalidation";?>';
 907         <?php else :?>
 908             // Build and invoke the URL to create the dup-checker dialog.
 909             var url = 'new_search_popup.php';
 910         <?php endif;?>
 911
 912         var flds = new Array(<?php echo $mflist; ?>);
 913         var separator = '?';
 914         for (var i = 0; i < flds.length; ++i) {
 915             var fval = $('#form_' + flds[i]).val();
 916             if (fval && fval != '') {
 917                 url += separator;
 918                 separator = '&';
 919                 url += 'mf_' + flds[i] + '=' + encodeURIComponent(fval);
 920             }
 921         }
 922         url+="&close"
 923         dlgopen(url, '_blank', 700, 500);
 924         } // end function
 925     } // end function
 926
 927
 928 // Set onclick/onfocus handlers for toggling background color.
 929 <?php
 930 $lres = getLayoutRes();
 931 while ($lrow = sqlFetchArray($lres)) {
 932     $field_id  = $lrow['field_id'];
 933     if (strpos($field_id, 'em_') === 0) {
 934         continue;
 935     }
 936
 937     switch (getSearchClass($lrow['data_type'])) {
 938         case 1:
 939             echo "    \$('#form_$field_id').click(function() { toggleSearch(this); });\n";
 940             break;
 941         case 2:
 942             echo "    \$('#form_$field_id').click(function() { selClick(this); });\n";
 943             echo "    \$('#form_$field_id').blur(function() { selBlur(this); });\n";
 944             break;
 945     }
 946 }
 947 ?>
 948
 949   $('.datepicker').datetimepicker({
 950     <?php $datetimepicker_timepicker = false; ?>
 951     <?php $datetimepicker_showseconds = false; ?>
 952     <?php $datetimepicker_formatInput = false; ?>
 953     <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 954     <?php // can add any additional javascript settings to datetimepicker here; need to prepend first setting with a comma ?>
 955   });
 956   $('.datetimepicker').datetimepicker({
 957     <?php $datetimepicker_timepicker = true; ?>
 958     <?php $datetimepicker_showseconds = false; ?>
 959     <?php $datetimepicker_formatInput = false; ?>
 960     <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 961     <?php // can add any additional javascript settings to datetimepicker here; need to prepend first setting with a comma ?>
 962   });
 963
 964 }); // end document.ready
 965
 966 </script>
 967 <?php /*Include the validation script and rules for this form*/
 968 $form_id="DEM";
 969 ?>
 970
 971 <?php
 972 //LBF forms use the new validation depending on the global value
 973 $use_validate_js=$GLOBALS['new_validate'];
 974 include_once("$srcdir/validation/validation_script.js.php");?>
 975 <script language='JavaScript'>
 976     // Array of skip conditions for the checkSkipConditions() function.
 977     var skipArray = [
 978         <?php echo $condition_str; ?>
 979     ];
 980     checkSkipConditions();
 981     $("input").change(function() {
 982         checkSkipConditions();
 983     });
 984     $("select").change(function() {
 985         checkSkipConditions();
 986     });
 987 </script>
 988
 989 </html>