interface/patient_file/summary/demographics_full.php

   1 <?php
   2 /**
   3  * Edit demographics.
   4  *
   5  * @package   OpenEMR
   6  * @link      http://www.open-emr.org
   7  * @author    Brady Miller <brady.g.miller@gmail.com>
   8  * @copyright Copyright (c) 2017 Brady Miller <brady.g.miller@gmail.com>
   9  * @license   https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  10  */
  11
  12 require_once("../../globals.php");
  13 require_once("$srcdir/acl.inc");
  14 require_once("$srcdir/options.inc.php");
  15 require_once("$srcdir/erx_javascript.inc.php");
  16 require_once("$srcdir/validation/LBF_Validation.php");
  17 require_once("$srcdir/patientvalidation.inc.php");
  18 require_once("$srcdir/pid.inc");
  19 require_once("$srcdir/patient.inc");
  20
  21 use OpenEMR\Common\Csrf\CsrfUtils;
  22 use OpenEMR\Core\Header;
  23 use OpenEMR\Events\PatientDemographics\UpdateEvent;
  24
  25 // Session pid must be right or bad things can happen when demographics are saved!
  26 //
  27 $set_pid = $_GET["set_pid"] ? $_GET["set_pid"] : $_GET["pid"];
  28 if ($set_pid && $set_pid != $_SESSION["pid"]) {
  29     setpid($set_pid);
  30 }
  31
  32 $result = getPatientData($pid, "*, DATE_FORMAT(DOB,'%Y-%m-%d') as DOB_YMD");
  33 $result2 = getEmployerData($pid);
  34
  35  // Check authorization.
  36 if ($pid) {
  37     // Create and fire the patient demographics update event
  38     $updateEvent = new UpdateEvent($pid);
  39     $updateEvent = $GLOBALS["kernel"]->getEventDispatcher()->dispatch(UpdateEvent::EVENT_HANDLE, $updateEvent, 10);
  40
  41     if (!$updateEvent->authorized() ||
  42         !acl_check('patients', 'demo', '', 'write')) {
  43         die(xlt('Updating demographics is not authorized.'));
  44     }
  45
  46     if ($result['squad'] && ! acl_check('squads', $result['squad'])) {
  47         die(xlt('You are not authorized to access this squad.'));
  48     }
  49 } else {
  50     if (!acl_check('patients', 'demo', '', array('write','addonly'))) {
  51         die(xlt('Adding demographics is not authorized.'));
  52     }
  53 }
  54
  55 $CPR = 4; // cells per row
  56
  57 // $statii = array('married','single','divorced','widowed','separated','domestic partner');
  58 // $langi = getLanguages();
  59 // $ethnoraciali = getEthnoRacials();
  60 // $provideri = getProviderInfo();
  61 if ($GLOBALS['insurance_information'] != '0') {
  62     $insurancei = getInsuranceProvidersExtra();
  63 } else {
  64     $insurancei = getInsuranceProviders();
  65 }
  66
  67 $fres = sqlStatement("SELECT * FROM layout_options " .
  68   "WHERE form_id = 'DEM' AND uor > 0 " .
  69   "ORDER BY group_id, seq");
  70 ?>
  71 <html>
  72 <head>
  73
  74 <title><?php echo xlt('Edit Current Patient'); ?></title>
  75
  76 <?php Header::setupHeader(['datetime-picker','common','select2']); ?>
  77
  78 <style>
  79     .form-control {
  80         width: auto;
  81         display: inline;
  82         height: auto;
  83     }
  84 </style>
  85
  86 <?php include_once($GLOBALS['srcdir'] . "/options.js.php"); ?>
  87
  88 <script type="text/javascript">
  89
  90 // Support for beforeunload handler.
  91 var somethingChanged = false;
  92
  93 $(document).ready(function(){
  94     tabbify();
  95
  96     $(".medium_modal").on('click', function(e) {
  97         e.preventDefault();e.stopPropagation();
  98         let title = <?php echo xlj('Insurance Search/Select/Add'); ?>;
  99         dlgopen('', '', 700, 460, '', title, {
 100             buttons: [
 101                 {text: <?php echo xlj('Close'); ?>, close: true, style: 'default btn-sm'}
 102             ],
 103             allowResize: true,
 104             allowDrag: true,
 105             dialogId: '',
 106             type: 'iframe',
 107             url: $(this).attr('href')
 108         });
 109     });
 110
 111   $('.datepicker').datetimepicker({
 112     <?php $datetimepicker_timepicker = false; ?>
 113     <?php $datetimepicker_showseconds = false; ?>
 114     <?php $datetimepicker_formatInput = true; ?>
 115     <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 116     <?php // can add any additional javascript settings to datetimepicker here; need to prepend first setting with a comma ?>
 117   });
 118   $('.datetimepicker').datetimepicker({
 119     <?php $datetimepicker_timepicker = true; ?>
 120     <?php $datetimepicker_showseconds = false; ?>
 121     <?php $datetimepicker_formatInput = true; ?>
 122     <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 123     <?php // can add any additional javascript settings to datetimepicker here; need to prepend first setting with a comma ?>
 124   });
 125
 126   // Support for beforeunload handler.
 127   $('.tab input, .tab select, .tab textarea').change(function() {
 128     somethingChanged = true;
 129   });
 130   window.addEventListener("beforeunload", function (e) {
 131     if (somethingChanged && !top.timed_out) {
 132       var msg = <?php echo xlj('You have unsaved changes.'); ?>;
 133       e.returnValue = msg;     // Gecko, Trident, Chrome 34+
 134       return msg;              // Gecko, WebKit, Chrome <34
 135     }
 136   });
 137
 138   if (window.checkSkipConditions) {
 139     checkSkipConditions();
 140   }
 141 });
 142
 143 var mypcc = <?php echo js_escape($GLOBALS['phone_country_code']); ?>;
 144
 145 //code used from http://tech.irt.org/articles/js037/
 146 function replace(string,text,by) {
 147  // Replaces text with by in string
 148  var strLength = string.length, txtLength = text.length;
 149  if ((strLength == 0) || (txtLength == 0)) return string;
 150
 151  var i = string.indexOf(text);
 152  if ((!i) && (text != string.substring(0,txtLength))) return string;
 153  if (i == -1) return string;
 154
 155  var newstr = string.substring(0,i) + by;
 156
 157  if (i+txtLength < strLength)
 158   newstr += replace(string.substring(i+txtLength,strLength),text,by);
 159
 160  return newstr;
 161 }
 162
 163 function upperFirst(string,text) {
 164  return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
 165 }
 166
 167 <?php for ($i=1; $i<=3; $i++) { ?>
 168 function auto_populate_employer_address<?php echo attr($i); ?>(){
 169  var f = document.demographics_form;
 170  if (f.form_i<?php echo attr($i); ?>subscriber_relationship.options[f.form_i<?php echo attr($i); ?>subscriber_relationship.selectedIndex].value == "self")
 171  {
 172   f.i<?php echo attr($i); ?>subscriber_fname.value=f.form_fname.value;
 173   f.i<?php echo attr($i); ?>subscriber_mname.value=f.form_mname.value;
 174   f.i<?php echo attr($i); ?>subscriber_lname.value=f.form_lname.value;
 175   f.i<?php echo attr($i); ?>subscriber_street.value=f.form_street.value;
 176   f.i<?php echo attr($i); ?>subscriber_city.value=f.form_city.value;
 177   f.form_i<?php echo attr($i); ?>subscriber_state.value=f.form_state.value;
 178   f.i<?php echo attr($i); ?>subscriber_postal_code.value=f.form_postal_code.value;
 179   if (f.form_country_code)
 180     f.form_i<?php echo attr($i); ?>subscriber_country.value=f.form_country_code.value;
 181   f.i<?php echo attr($i); ?>subscriber_phone.value=f.form_phone_home.value;
 182   f.i<?php echo attr($i); ?>subscriber_DOB.value=f.form_DOB.value;
 183   if(typeof f.form_ss!="undefined")
 184     {
 185         f.i<?php echo attr($i); ?>subscriber_ss.value=f.form_ss.value;
 186     }
 187   f.form_i<?php echo attr($i); ?>subscriber_sex.value = f.form_sex.value;
 188   f.i<?php echo attr($i); ?>subscriber_employer.value=f.form_em_name.value;
 189   f.i<?php echo attr($i); ?>subscriber_employer_street.value=f.form_em_street.value;
 190   f.i<?php echo attr($i); ?>subscriber_employer_city.value=f.form_em_city.value;
 191   f.form_i<?php echo attr($i); ?>subscriber_employer_state.value=f.form_em_state.value;
 192   f.i<?php echo attr($i); ?>subscriber_employer_postal_code.value=f.form_em_postal_code.value;
 193   if (f.form_em_country)
 194     f.form_i<?php echo attr($i); ?>subscriber_employer_country.value=f.form_em_country.value;
 195  }
 196 }
 197
 198 <?php } ?>
 199
 200 function popUp(URL) {
 201  day = new Date();
 202  id = day.getTime();
 203  top.restoreSession();
 204  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');");
 205 }
 206
 207 function checkNum () {
 208  var re= new RegExp();
 209  re = /^\d*\.?\d*$/;
 210  str=document.demographics_form.monthly_income.value;
 211  if(re.exec(str))
 212  {
 213  }else{
 214   alert(<?php echo xlj('Please enter a monetary amount using only numbers and a decimal point.'); ?>);
 215  }
 216 }
 217
 218 // Indicates which insurance slot is being updated.
 219 var insurance_index = 0;
 220
 221 // The OnClick handler for searching/adding the insurance company.
 222 function ins_search(ins) {
 223     insurance_index = ins;
 224     return false;
 225 }
 226 function InsSaveClose() {
 227     top.restoreSession();
 228     document.location.reload();
 229 }
 230 // The ins_search.php window calls this to set the selected insurance.
 231 function set_insurance(ins_id, ins_name) {
 232  var thesel = document.forms[0]['i' + insurance_index + 'provider'];
 233  var theopts = thesel.options; // the array of Option objects
 234  var i = 0;
 235  for (; i < theopts.length; ++i) {
 236   if (theopts[i].value == ins_id) {
 237    theopts[i].selected = true;
 238    return;
 239   }
 240  }
 241  // no matching option was found so create one, append it to the
 242  // end of the list, and select it.
 243  theopts[i] = new Option(ins_name, ins_id, false, true);
 244 }
 245
 246 // This capitalizes the first letter of each word in the passed input
 247 // element.  It also strips out extraneous spaces.
 248 function capitalizeMe(elem) {
 249  var a = elem.value.split(' ');
 250  var s = '';
 251  for(var i = 0; i < a.length; ++i) {
 252   if (a[i].length > 0) {
 253    if (s.length > 0) s += ' ';
 254    s += a[i].charAt(0).toUpperCase() + a[i].substring(1);
 255   }
 256  }
 257  elem.value = s;
 258 }
 259
 260 function divclick(cb, divid) {
 261  var divstyle = document.getElementById(divid).style;
 262  if (cb.checked) {
 263   divstyle.display = 'block';
 264  } else {
 265   divstyle.display = 'none';
 266  }
 267  return true;
 268 }
 269
 270 // Compute the length of a string without leading and trailing spaces.
 271 function trimlen(s) {
 272  var i = 0;
 273  var j = s.length - 1;
 274  for (; i <= j && s.charAt(i) == ' '; ++i);
 275  for (; i <= j && s.charAt(j) == ' '; --j);
 276  if (i > j) return 0;
 277  return j + 1 - i;
 278 }
 279
 280 function validate(f) {
 281  var errCount = 0;
 282  var errMsgs = new Array();
 283 <?php generate_layout_validation('DEM'); ?>
 284
 285  var msg = "";
 286  msg += <?php echo xlj('The following fields are required'); ?> + ":\n\n";
 287  for ( var i = 0; i < errMsgs.length; i++ ) {
 288     msg += errMsgs[i] + "\n";
 289  }
 290  msg += "\n" + <?php echo xlj('Please fill them in before continuing.'); ?>;
 291
 292  if ( errMsgs.length > 0 ) {
 293     alert(msg);
 294  }
 295
 296  //Misc  Deceased Date Validation for Future Date
 297 var dateVal = document.getElementById("form_deceased_date").value;
 298 var currentDate;
 299 var d = new Date();
 300 month = '' + (d.getMonth() + 1),
 301 day = '' + d.getDate(),
 302 year = d.getFullYear();
 303 if (month.length < 2) month = '0' + month;
 304 if (day.length < 2) day = '0' + day;
 305 currentDate = year+'-'+month+'-'+day;
 306 if(dateVal > currentDate)
 307 {
 308     alert (<?php echo xlj("Deceased Date should not be greater than Today"); ?>);
 309     return false;
 310 }
 311
 312 //Patient Data validations
 313     <?php if ($GLOBALS['erx_enable']) { ?>
 314  alertMsg='';
 315  for(i=0;i<f.length;i++){
 316   if(f[i].type=='text' && f[i].value)
 317   {
 318    if(f[i].name == 'form_fname' || f[i].name == 'form_mname' || f[i].name == 'form_lname')
 319    {
 320     alertMsg += checkLength(f[i].name,f[i].value,35);
 321     alertMsg += checkUsername(f[i].name,f[i].value);
 322    }
 323    else if(f[i].name == 'form_street' || f[i].name == 'form_city')
 324    {
 325     alertMsg += checkLength(f[i].name,f[i].value,35);
 326     alertMsg += checkAlphaNumericExtended(f[i].name,f[i].value);
 327    }
 328    else if(f[i].name == 'form_phone_home')
 329    {
 330     alertMsg += checkPhone(f[i].name,f[i].value);
 331    }
 332   }
 333  }
 334  if(alertMsg)
 335  {
 336    alert(alertMsg);
 337    return false;
 338  }
 339     <?php } ?>
 340  //return false;
 341
 342 // Some insurance validation.
 343  for (var i = 1; i <= 3; ++i) {
 344   subprov = 'i' + i + 'provider';
 345   if (!f[subprov] || f[subprov].selectedIndex <= 0) continue;
 346   var subpfx = 'i' + i + 'subscriber_';
 347   var subrelat = f['form_' + subpfx + 'relationship'];
 348   var samename =
 349    f[subpfx + 'fname'].value == f.form_fname.value &&
 350    f[subpfx + 'mname'].value == f.form_mname.value &&
 351    f[subpfx + 'lname'].value == f.form_lname.value;
 352   var ss_regexp=/[0-9][0-9][0-9]-?[0-9][0-9]-?[0-9][0-9][0-9][0-9]/;
 353   var samess=true;
 354   var ss_valid=false;
 355   if(typeof f.form_ss!="undefined")
 356       {
 357         samess = f[subpfx + 'ss'].value == f.form_ss.value;
 358         ss_valid=ss_regexp.test(f[subpfx + 'ss'].value) && ss_regexp.test(f.form_ss.value);
 359       }
 360   if (subrelat.options[subrelat.selectedIndex].value == "self") {
 361    if (!samename) {
 362     if (!confirm(<?php echo xlj('Subscriber relationship is self but name is different! Is this really OK?'); ?>))
 363      return false;
 364    }
 365    if (!samess && ss_valid) {
 366     if(!confirm(<?php echo js_escape(xl('Subscriber relationship is self but SS number is different!')." ".xl("Is this really OK?")); ?>))
 367     return false;
 368    }
 369   } // end self
 370   else {
 371    if (samename) {
 372     if (!confirm(<?php echo xlj('Subscriber relationship is not self but name is the same! Is this really OK?'); ?>))
 373      return false;
 374    }
 375    if (samess && ss_valid)  {
 376     if(!confirm(<?php echo js_escape(xl('Subscriber relationship is not self but SS number is the same!')." ".xl("Is this really OK?")); ?>))
 377     return false;
 378    }
 379   } // end not self
 380  } // end for
 381
 382  return errMsgs.length < 1;
 383 }
 384
 385
 386
 387 // Onkeyup handler for policy number.  Allows only A-Z and 0-9.
 388 function policykeyup(e) {
 389  var v = e.value.toUpperCase();
 390  var filteredString="";
 391  for (var i = 0; i < v.length; ++i) {
 392   var c = v.charAt(i);
 393   if ((c >= '0' && c <= '9') ||
 394      (c >= 'A' && c <= 'Z') ||
 395      (c == '*') ||
 396      (c == '-') ||
 397      (c == '_') ||
 398      (c == '(') ||
 399      (c == ')') ||
 400      (c == '#'))
 401      {
 402          filteredString+=c;
 403      }
 404  }
 405  e.value = filteredString;
 406  return;
 407 }
 408
 409 // Added 06/2009 by BM to make compatible with list_options table and functions - using jquery
 410 $(function() {
 411
 412     <?php for ($i=1; $i<=3; $i++) { ?>
 413   $("#form_i<?php echo attr($i); ?>subscriber_relationship").change(function() { auto_populate_employer_address<?php echo attr($i); ?>(); });
 414     <?php } ?>
 415
 416 });
 417
 418 </script>
 419 </head>
 420
 421 <?php
 422 /*Get the constraint from the DB-> LBF forms accordinf the form_id*/
 423 $constraints = LBF_Validation::generate_validate_constraints("DEM");
 424 ?>
 425 <script> var constraints = <?php echo $constraints;?>; </script>
 426
 427 <body class="body_top">
 428
 429 <form action='demographics_save.php' name='demographics_form' id="DEM" method='post' onsubmit="submitme(<?php echo $GLOBALS['new_validate'] ? 1 : 0;?>,event,'DEM',constraints)">
 430 <input type="hidden" name="csrf_token_form" value="<?php echo attr(CsrfUtils::collectCsrfToken()); ?>" />
 431 <input type='hidden' name='mode' value='save' />
 432 <input type='hidden' name='db_id' value="<?php echo attr($result['id']); ?>" />
 433
 434     <div class="container-fluid">
 435         <div class="row">
 436             <div class="col-xs-12">
 437                 <div class="page-header">
 438                     <h2><?php echo xlt('Edit Current Patient');?></h2>
 439                 </div>
 440             </div>
 441             <div class="col-xs-12">
 442                 <div class="btn-group">
 443                     <button type="submit" class="btn btn-default btn-save" id="submit_btn" disabled="disabled" value="<?php echo xla('Save'); ?>">
 444                         <?php echo xlt('Save'); ?>
 445                     </button>
 446                     <a class="btn btn-link btn-cancel" href="demographics.php" onclick="top.restoreSession()">
 447                         <?php echo xlt('Cancel'); ?>
 448                     </a>
 449                 </div>
 450                 <hr>
 451             </div>
 452         </div>
 453     </div>
 454 <?php
 455
 456 function end_cell()
 457 {
 458     global $item_count, $cell_count;
 459     if ($item_count > 0) {
 460         echo "</td>";
 461         $item_count = 0;
 462     }
 463 }
 464
 465 function end_row()
 466 {
 467     global $cell_count, $CPR;
 468     end_cell();
 469     if ($cell_count > 0) {
 470         for (; $cell_count < $CPR; ++$cell_count) {
 471             echo "<td></td>";
 472         }
 473
 474         echo "</tr>\n";
 475         $cell_count = 0;
 476     }
 477 }
 478
 479 function end_group()
 480 {
 481     global $last_group;
 482     if (strlen($last_group) > 0) {
 483         end_row();
 484         echo " </table>\n";
 485         echo "</div>\n";
 486     }
 487 }
 488
 489 $last_group = '';
 490 $cell_count = 0;
 491 $item_count = 0;
 492 $display_style = 'block';
 493
 494 $group_seq=0; // this gives the DIV blocks unique IDs
 495
 496 $condition_str = '';
 497 ?>
 498 <br>
 499   <div class="section-header">
 500    <span class="text"><b> <?php echo xlt("Demographics")?></b></span>
 501 </div>
 502
 503 <div id="DEM" >
 504
 505     <ul class="tabNav">
 506         <?php display_layout_tabs('DEM', $result, $result2); ?>
 507     </ul>
 508
 509     <div class="tabContainer">
 510         <?php display_layout_tabs_data_editable('DEM', $result, $result2); ?>
 511     </div>
 512 </div>
 513 <br>
 514
 515 <div id="DEM" >
 516
 517
 518 <?php
 519 if (! $GLOBALS['simplified_demographics']) {
 520     $insurance_headings = array(xl("Primary Insurance Provider"), xl("Secondary Insurance Provider"), xl("Tertiary Insurance provider"));
 521     $insurance_info = array();
 522     $insurance_info[1] = getInsuranceData($pid, "primary");
 523     $insurance_info[2] = getInsuranceData($pid, "secondary");
 524     $insurance_info[3] = getInsuranceData($pid, "tertiary");
 525
 526     ?>
 527     <div class="section-header">
 528        <span class="text"><b><?php echo xlt("Insurance")?></b></span>
 529     </div>
 530     <div id="INSURANCE" >
 531        <ul class="tabNav">
 532         <?php
 533         foreach (array('primary','secondary','tertiary') as $instype) {
 534             ?><li <?php echo $instype == 'primary' ? 'class="current"' : '' ?>><a href="#"><?php $CapInstype=ucfirst($instype);
 535 echo xlt($CapInstype); ?></a></li><?php
 536         }
 537         ?>
 538         </ul>
 539
 540     <div class="tabContainer">
 541
 542     <?php
 543     for ($i=1; $i<=3; $i++) {
 544         $result3 = $insurance_info[$i];
 545         ?>
 546
 547      <div class="tab <?php echo $i == 1 ? 'current': '' ?>" style='height:auto;width:auto'>     <!---display icky, fix to auto-->
 548
 549       <div class="row">
 550         <div class="col-md-6">
 551          <table border="0">
 552
 553            <tr>
 554             <td valign='top'>
 555             <label class='required'><?php echo text($insurance_headings[$i -1])."&nbsp;"?></label>
 556             </td>
 557             <td class='required'>:</td>
 558             <td>
 559              <a href="../../practice/ins_search.php" class="medium_modal css_button" onclick="ins_search(<?php echo attr_js($i); ?>)">
 560              <span><?php echo xlt('Search/Add') ?></span>
 561                   </a>
 562              <select name="i<?php echo attr($i); ?>provider" class="form-control sel2" style="width: 300;">
 563              <option value=""><?php echo xlt('Unassigned'); ?></option>
 564                 <?php
 565                 foreach ($insurancei as $iid => $iname) {
 566                     echo "<option value='" . attr($iid) . "'";
 567                     if (strtolower($iid) == strtolower($result3["provider"])) {
 568                         echo " selected";
 569                     }
 570
 571                     echo ">" . text($iname) . "</option>\n";
 572                 }
 573                 ?>
 574                </select>
 575
 576               </td>
 577              </tr>
 578
 579             <tr>
 580              <td>
 581               <label class='required'><?php echo xlt('Plan Name'); ?> </label>
 582              </td>
 583              <td class='required'>:</td>
 584              <td>
 585               <input type='entry' class='form-control' size='20' name='i<?php echo attr($i); ?>plan_name' value="<?php echo attr($result3["plan_name"]); ?>"
 586                onchange="capitalizeMe(this);" />&nbsp;&nbsp;
 587              </td>
 588             </tr>
 589
 590             <tr>
 591              <td>
 592               <label class='required'><?php echo xlt('Effective Date'); ?></label>
 593              </td>
 594              <td class='required'>:</td>
 595              <td>
 596               <input type='entry' size='16' class='datepicker form-control' id='i<?php echo attr($i); ?>effective_date' name='i<?php echo attr($i); ?>effective_date'
 597                value='<?php echo attr(oeFormatShortDate($result3['date'])); ?>'
 598                 />
 599              </td>
 600             </tr>
 601
 602             <tr>
 603              <td><label class=required><?php echo xlt('Policy Number'); ?></label></td>
 604              <td class='required'>:</td>
 605              <td><input type='entry' class='form-control' size='16' name='i<?php echo attr($i); ?>policy_number' value="<?php echo attr($result3["policy_number"]); ?>"
 606               onkeyup='policykeyup(this)'></td>
 607             </tr>
 608
 609             <tr>
 610              <td><label class=required><?php echo xlt('Group Number'); ?></label></td>
 611              <td class='required'>:</td>
 612              <td><input type=entry class='form-control' size=16 name=i<?php echo attr($i); ?>group_number value="<?php echo attr($result3["group_number"]); ?>" onkeyup='policykeyup(this)'></td>
 613             </tr>
 614
 615             <tr<?php if ($GLOBALS['omit_employers']) {
 616                 echo " style='display:none'";
 617                } ?>>
 618              <td class='required'><?php echo xlt('Subscriber Employer (SE)'); ?><br><label style='font-weight:normal'>
 619               (<?php echo xlt('if unemployed enter Student'); ?>,<br><?php echo xlt('PT Student, or leave blank'); ?>) </label></td>
 620               <td class='required'>:</td>
 621              <td><input type=entry class='form-control' size=25 name=i<?php echo attr($i); ?>subscriber_employer
 622               value="<?php echo attr($result3["subscriber_employer"]); ?>"
 623                onchange="capitalizeMe(this);" /></td>
 624             </tr>
 625
 626             <tr<?php if ($GLOBALS['omit_employers']) {
 627                 echo " style='display:none'";
 628                } ?>>
 629              <td><label class=required><?php echo xlt('SE Address'); ?></label></td>
 630              <td class='required'>:</td>
 631              <td><input type=entry class='form-control' size=25 name=i<?php echo attr($i); ?>subscriber_employer_street
 632               value="<?php echo attr($result3["subscriber_employer_street"]); ?>"
 633                onchange="capitalizeMe(this);" /></td>
 634             </tr>
 635
 636             <tr<?php if ($GLOBALS['omit_employers']) {
 637                 echo " style='display:none'";
 638                } ?>>
 639              <td colspan="3">
 640               <table>
 641                <tr>
 642                 <td><label class=required><?php echo xlt('SE City'); ?>: </label></td>
 643                 <td><input type=entry class='form-control' size=15 name=i<?php echo attr($i); ?>subscriber_employer_city
 644                value="<?php echo attr($result3["subscriber_employer_city"]); ?>"
 645                 onchange="capitalizeMe(this);" /></td>
 646                 <td><label class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('SE State') : xlt('SE Locality') ?>: </label></td>
 647             <td>
 648                 <?php
 649                  // Modified 7/2009 by BM to incorporate data types
 650                 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'), $result3['subscriber_employer_state']);
 651                 ?>
 652                 </td>
 653                </tr>
 654                <tr>
 655                 <td><label class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('SE Zip Code') : xlt('SE Postal Code') ?>: </label></td>
 656                 <td><input type=entry class='form-control' size=15 name=i<?php echo attr($i); ?>subscriber_employer_postal_code value="<?php echo attr($result3["subscriber_employer_postal_code"]); ?>"></td>
 657                 <td><label class=required><?php echo xlt('SE Country'); ?>: </label></td>
 658             <td>
 659                     <?php
 660                   // Modified 7/2009 by BM to incorporate data types
 661                     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'), $result3['subscriber_employer_country']);
 662                     ?>
 663             </td>
 664                </tr>
 665               </table>
 666              </td>
 667             </tr>
 668
 669            </table>
 670           </div>
 671
 672           <div class="col-md-6">
 673         <table border="0">
 674             <tr>
 675                 <td><label class=required><?php echo xlt('Relationship'); ?></label></td>
 676                 <td class=required>:</td>
 677                 <td colspan=3><?php
 678                  // Modified 6/2009 by BM to use list_options and function
 679                  generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_relationship'),'list_id'=>'sub_relation','empty_title'=>' '), $result3['subscriber_relationship']);
 680                 ?>
 681
 682                 <a href="javascript:popUp('browse.php?browsenum=<?php echo attr_url($i); ?>')" class=text>(<?php echo xlt('Browse'); ?>)</a></td>
 683                 <td></td><td></td><td></td><td></td>
 684             </tr>
 685                       <tr>
 686                 <td width=120><label class=required><?php echo xlt('Subscriber'); ?> </label></td>
 687                 <td class=required>:</td>
 688                 <td colspan=3><input type=entry class='form-control'size=10 name=i<?php echo attr($i); ?>subscriber_fname   value="<?php echo attr($result3["subscriber_fname"]); ?>" onchange="capitalizeMe(this);" />
 689                 <input type=entry class='form-control' size=3 name=i<?php echo attr($i); ?>subscriber_mname value="<?php echo attr($result3["subscriber_mname"]); ?>" onchange="capitalizeMe(this);" />
 690                 <input type=entry class='form-control' size=10 name=i<?php echo attr($i); ?>subscriber_lname value="<?php echo attr($result3["subscriber_lname"]); ?>" onchange="capitalizeMe(this);" /></td>
 691                 <td></td><td></td><td></td><td></td>
 692             </tr>
 693             <tr>
 694                 <td><label class=bold><?php echo xlt('D.O.B.'); ?> </label></td>
 695                 <td class=required>:</td>
 696                 <td><input type='entry' size='11' class='datepicker form-control' id='i<?php echo attr($i); ?>subscriber_DOB' name='i<?php echo attr($i); ?>subscriber_DOB' value='<?php echo attr(oeFormatShortDate($result3['subscriber_DOB'])); ?>' />
 697         </td>
 698                 <td><label class=bold><?php echo xlt('Sex'); ?>: </label></td>
 699                 <td><?php
 700                  // Modified 6/2009 by BM to use list_options and function
 701                  generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_sex'),'list_id'=>'sex'), $result3['subscriber_sex']);
 702                 ?>
 703                 </td>
 704                 <td></td><td></td> <td></td><td></td>
 705             </tr>
 706             <tr>
 707                 <td class=leftborder><label class=bold><?php echo xlt('S.S.'); ?> </label></td>
 708                 <td class=required>:</td>
 709                 <td><input type=entry class='form-control' size=11 name=i<?php echo attr($i); ?>subscriber_ss value="<?php echo attr(trim($result3["subscriber_ss"])); ?>"></td>
 710             </tr>
 711
 712             <tr>
 713                 <td><label class=required><?php echo xlt('Subscriber Address'); ?> </label></td>
 714                 <td class=required>:</td>
 715                 <td><input type=entry class='form-control' size=20 name=i<?php echo attr($i); ?>subscriber_street value="<?php echo attr($result3["subscriber_street"]); ?>" onchange="capitalizeMe(this);" /></td>
 716
 717                 <td><label class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('State') : xlt('Locality') ?>: </label></td>
 718                 <td>
 719                     <?php
 720                     // Modified 7/2009 by BM to incorporate data types
 721                     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'), $result3['subscriber_state']);
 722                     ?>
 723                 </td>
 724             </tr>
 725             <tr>
 726                 <td class=leftborder><label class=required><?php echo xlt('City'); ?></label></td>
 727                 <td class=required>:</td>
 728                 <td><input type=entry class='form-control' size=11 name=i<?php echo attr($i); ?>subscriber_city value="<?php echo attr($result3["subscriber_city"]); ?>" onchange="capitalizeMe(this);" /></td><td class=leftborder><label class='required'<?php if ($GLOBALS['omit_employers']) {
 729                     echo " style='display:none'";
 730                                                                          } ?>><?php echo xlt('Country'); ?>: </label></td><td>
 731                     <?php
 732                     // Modified 7/2009 by BM to incorporate data types
 733                     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'), $result3['subscriber_country']);
 734                     ?>
 735                 </td>
 736 </tr>
 737             <tr>
 738                 <td><label class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('Zip Code') : xlt('Postal Code') ?> </label></td>
 739                 <td class=required>:</td><td><input type=entry class='form-control' size=10 name=i<?php echo attr($i); ?>subscriber_postal_code value="<?php echo attr($result3["subscriber_postal_code"]); ?>"></td>
 740
 741                 <td colspan=2>
 742                 </td><td></td>
 743             </tr>
 744             <tr>
 745                 <td><label class=bold><?php echo xlt('Subscriber Phone'); ?></label></td>
 746                 <td class=required>:</td>
 747                 <td><input type='text' class='form-control' size='20' name='i<?php echo attr($i); ?>subscriber_phone' value='<?php echo attr($result3["subscriber_phone"]); ?>' onkeyup='phonekeyup(this,mypcc)' /></td>
 748                 <td colspan=2><label class=bold><?php echo xlt('CoPay'); ?>: <input type=text class='form-control' size="6" name=i<?php echo attr($i); ?>copay value="<?php echo attr($result3["copay"]); ?>"></label></td>
 749                 <td colspan=2>
 750                 </td><td></td><td></td>
 751             </tr>
 752             <tr>
 753                 <td colspan=0><label class='required'><?php echo xlt('Accept Assignment'); ?></label></td>
 754                 <td class=required>:</td>
 755                 <td colspan=2>
 756                     <select class='form-control' name=i<?php echo attr($i); ?>accept_assignment>
 757                      <option value="TRUE" <?php if (strtoupper($result3["accept_assignment"]) == "TRUE") {
 758                             echo "selected";
 759                                           }?>><?php echo xlt('YES'); ?></option>
 760                      <option value="FALSE" <?php if (strtoupper($result3["accept_assignment"]) == "FALSE") {
 761                             echo "selected";
 762                                            }?>><?php echo xlt('NO'); ?></option>
 763                     </select>
 764                 </td>
 765                 <td></td><td></td>
 766                 <td colspan=2>
 767                 </td><td></td>
 768             </tr>
 769       <tr>
 770         <td><label class='bold'><?php echo xlt('Secondary Medicare Type'); ?></label></td>
 771         <td class='bold'>:</td>
 772         <td colspan='6'>
 773           <select class='form-control sel2' name=i<?php echo attr($i); ?>policy_type>
 774         <?php
 775         foreach ($policy_types as $key => $value) {
 776             echo "            <option value ='" . attr($key) . "'";
 777             if ($key == $result3['policy_type']) {
 778                 echo " selected";
 779             }
 780
 781             echo ">" . text($value) . "</option>\n";
 782         }
 783         ?>
 784         </select>
 785       </td>
 786     </tr>
 787       </table>
 788
 789         </div>
 790       </div>
 791
 792       </div>
 793
 794         <?php
 795     } //end insurer for loop ?>
 796
 797    </div>
 798 </div>
 799
 800 <?php } // end of "if not simplified_demographics" ?>
 801 </div></div>
 802
 803 </form>
 804
 805 <br>
 806
 807 <script language="JavaScript">
 808
 809 // Array of skip conditions for the checkSkipConditions() function.
 810 var skipArray = [
 811 <?php echo $condition_str; ?>
 812 ];
 813
 814 // hard code validation for old validation, in the new validation possible to add match rules
 815 <?php if ($GLOBALS['new_validate'] == 0) { ?>
 816  // fix inconsistently formatted phone numbers from the database
 817  var f = document.forms[0];
 818  if (f.form_phone_contact) phonekeyup(f.form_phone_contact,mypcc);
 819  if (f.form_phone_home   ) phonekeyup(f.form_phone_home   ,mypcc);
 820  if (f.form_phone_biz    ) phonekeyup(f.form_phone_biz    ,mypcc);
 821  if (f.form_phone_cell   ) phonekeyup(f.form_phone_cell   ,mypcc);
 822
 823     <?php if (! $GLOBALS['simplified_demographics']) { ?>
 824  phonekeyup(f.i1subscriber_phone,mypcc);
 825  phonekeyup(f.i2subscriber_phone,mypcc);
 826  phonekeyup(f.i3subscriber_phone,mypcc);
 827     <?php } ?>
 828
 829 <?php }?>
 830
 831 <?php if ($set_pid) { ?>
 832  parent.left_nav.setPatient(<?php echo js_escape($result['fname'] . " " . $result['lname']) . "," . js_escape($pid) . "," . js_escape($result['pubpid']) . ",''," . js_escape(" " . xl('DOB') . ": " . oeFormatShortDate($result['DOB_YMD']) . " " . xl('Age') . ": " . getPatientAgeDisplay($result['DOB_YMD'])); ?>);
 833 <?php } ?>
 834
 835 <?php echo $date_init; ?>
 836 </script>
 837
 838 <!-- include support for the list-add selectbox feature -->
 839 <?php include $GLOBALS['fileroot']."/library/options_listadd.inc"; ?>
 840
 841 <?php /*Include the validation script and rules for this form*/
 842 $form_id="DEM";
 843 //LBF forms use the new validation depending on the global value
 844 $use_validate_js=$GLOBALS['new_validate'];
 845
 846 ?>
 847 <?php  include_once("$srcdir/validation/validation_script.js.php");?>
 848
 849
 850 </body>
 851 <script language='JavaScript'>
 852     var duplicateFieldsArray=[];
 853
 854 //This code deals with demographics before save action -
 855     <?php if (($GLOBALS['gbl_edit_patient_form'] == '1') && (checkIfPatientValidationHookIsActive())) :?>
 856                 //Use the Zend patient validation hook.
 857                 //TODO - get the edit part of patient validation hook to work smoothly and then
 858                 //       remove the closeBeforeOpening=1 in the url below.
 859
 860         var f = $("form");
 861
 862         // Use hook to open the controller and get the new patient validation .
 863         // when no params are sent this window will be closed from the zend controller.
 864         var url ='<?php echo  $GLOBALS['web_root']."/interface/modules/zend_modules/public/patientvalidation";?>';
 865         $("#submit_btn").attr("name","btnSubmit");
 866         $("#submit_btn").attr("id","btnSubmit");
 867         $("#btnSubmit").click(function( event ) {
 868
 869       top.restoreSession();
 870
 871             if(!submitme(<?php echo $GLOBALS['new_validate'] ? 1 : 0;?>,event,'DEM',constraints)){
 872                 event.preventDefault();
 873                 return;
 874             }
 875             somethingChanged = false;
 876             <?php
 877             // D in edit_options indicates the field is used in duplication checking.
 878             // This constructs a list of the names of those fields.
 879             $mflist = "";
 880             $mfres = sqlStatement("SELECT field_id FROM layout_options " .
 881                 "WHERE form_id = 'DEM' AND uor > 0 AND field_id != '' AND " .
 882                 "(edit_options LIKE '%D%' OR edit_options LIKE '%E%')  " .
 883                 "ORDER BY group_id, seq");
 884             while ($mfrow = sqlFetchArray($mfres)) {
 885                 $field_id  = $mfrow['field_id'];
 886                 if (strpos($field_id, 'em_') === 0) {
 887                     continue;
 888                 }
 889
 890                 if (!empty($mflist)) {
 891                     $mflist .= ",";
 892                 }
 893
 894                     $mflist .= js_escape($field_id);
 895             } ?>
 896
 897             var flds = new Array(<?php echo $mflist; ?>);
 898             var separator = '?';
 899             var valueIsChanged=false;
 900             for (var i = 0; i < flds.length; ++i) {
 901                 var fval = $('#form_' + flds[i]).val();
 902                 if(duplicateFieldsArray['#form_' + flds[i]]!=fval) {
 903                     valueIsChanged = true;
 904
 905                 }
 906
 907                 if (fval && fval != '') {
 908                     url += separator;
 909                     separator = '&';
 910                     url += 'mf_' + flds[i] + '=' + encodeURIComponent(fval);
 911                 }
 912             }
 913
 914
 915             //Only if check for duplicates values are changed open the popup hook screen
 916             if(valueIsChanged) {
 917                 event.preventDefault();
 918                 //("value has changed for duplicate check inputs");
 919             url += '&page=edit&closeBeforeOpening=1&mf_id=' + encodeURIComponent($("[name='db_id']").val());
 920             dlgopen(url, '_blank', 700, 500);
 921             }
 922             else {//other wise submit me is a success just submit the form
 923                 $('#DEM').submit();
 924             }
 925         });
 926
 927     <?php endif;?>
 928
 929     $(document).ready(function(){
 930         //When document is ready collect all the values Marked with D (check duplicate) stored in the db into array duplicateFieldsArray.
 931         var flds = new Array(<?php echo $mflist; ?>);
 932         for (var i = 0; i < flds.length; ++i) {
 933             var fval = $('#form_' + flds[i]).val();
 934             duplicateFieldsArray['#form_' + flds[i]] = fval;
 935         }
 936         $(".sel2").select2({
 937             <?php require($GLOBALS['srcdir'] . '/js/xl/select2.js.php'); ?>
 938         });
 939     })
 940 </script>
 941
 942
 943 </html>