interface/patient_file/summary/demographics_full.php

   1 <?php
   2 // This program is free software; you can redistribute it and/or
   3 // modify it under the terms of the GNU General Public License
   4 // as published by the Free Software Foundation; either version 2
   5 // of the License, or (at your option) any later version.
   6
   7 require_once("../../globals.php");
   8 require_once("$srcdir/acl.inc");
   9 require_once("$srcdir/options.inc.php");
  10 require_once("$srcdir/formatting.inc.php");
  11 require_once("$srcdir/erx_javascript.inc.php");
  12 require_once("$srcdir/validation/LBF_Validation.php");
  13 require_once ("$srcdir/patientvalidation.inc.php");
  14
  15  // Session pid must be right or bad things can happen when demographics are saved!
  16  //
  17  include_once("$srcdir/pid.inc");
  18  $set_pid = $_GET["set_pid"] ? $_GET["set_pid"] : $_GET["pid"];
  19  if ($set_pid && $set_pid != $_SESSION["pid"]) {
  20   setpid($set_pid);
  21  }
  22
  23  include_once("$srcdir/patient.inc");
  24
  25  $result = getPatientData($pid, "*, DATE_FORMAT(DOB,'%Y-%m-%d') as DOB_YMD");
  26  $result2 = getEmployerData($pid);
  27
  28  // Check authorization.
  29  if ($pid) {
  30   if (!acl_check('patients', 'demo', '', 'write'))
  31    die(xl('Updating demographics is not authorized.'));
  32   if ($result['squad'] && ! acl_check('squads', $result['squad']))
  33    die(xl('You are not authorized to access this squad.'));
  34  } else {
  35   if (!acl_check('patients', 'demo', '', array('write','addonly') ))
  36    die(xl('Adding demographics is not authorized.'));
  37  }
  38
  39 $CPR = 4; // cells per row
  40
  41 // $statii = array('married','single','divorced','widowed','separated','domestic partner');
  42 // $langi = getLanguages();
  43 // $ethnoraciali = getEthnoRacials();
  44 // $provideri = getProviderInfo();
  45 if ($GLOBALS['insurance_information'] != '0') {
  46     $insurancei = getInsuranceProvidersExtra();
  47 }else{
  48         $insurancei = getInsuranceProviders();
  49 }
  50
  51 $fres = sqlStatement("SELECT * FROM layout_options " .
  52   "WHERE form_id = 'DEM' AND uor > 0 " .
  53   "ORDER BY group_name, seq");
  54 ?>
  55 <html>
  56 <head>
  57 <?php html_header_show();?>
  58
  59 <link rel="stylesheet" href="<?php echo $css_header; ?>" type="text/css">
  60
  61 <style type="text/css">@import url(../../../library/dynarch_calendar.css);</style>
  62
  63 <script type="text/javascript" src="../../../library/dialog.js?v=<?php echo $v_js_includes; ?>"></script>
  64 <script type="text/javascript" src="../../../library/textformat.js"></script>
  65 <script type="text/javascript" src="../../../library/dynarch_calendar.js"></script>
  66 <?php include_once("{$GLOBALS['srcdir']}/dynarch_calendar_en.inc.php"); ?>
  67 <script type="text/javascript" src="../../../library/dynarch_calendar_setup.js"></script>
  68 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-min-1-9-1/index.js"></script>
  69 <script type="text/javascript" src="../../../library/js/common.js"></script>
  70 <script type="text/javascript" src="../../../library/js/fancybox/jquery.fancybox-1.2.6.js"></script>
  71
  72 <?php include_once("{$GLOBALS['srcdir']}/options.js.php"); ?>
  73
  74 <link rel="stylesheet" type="text/css" href="../../../library/js/fancybox/jquery.fancybox-1.2.6.css" media="screen" />
  75
  76 <script type="text/javascript">
  77
  78 // Support for beforeunload handler.
  79 var somethingChanged = false;
  80
  81 $(document).ready(function(){
  82     tabbify();
  83     enable_modals();
  84
  85     // special size for
  86         $(".medium_modal").fancybox( {
  87                 'overlayOpacity' : 0.0,
  88                 'showCloseButton' : true,
  89                 'frameHeight' : 460,
  90                 'frameWidth' : 650
  91         });
  92
  93   // Support for beforeunload handler.
  94   $('.tab input, .tab select, .tab textarea').change(function() {
  95     somethingChanged = true;
  96   });
  97   window.addEventListener("beforeunload", function (e) {
  98     if (somethingChanged && !top.timed_out) {
  99       var msg = "<?php echo xls('You have unsaved changes.'); ?>";
 100       e.returnValue = msg;     // Gecko, Trident, Chrome 34+
 101       return msg;              // Gecko, WebKit, Chrome <34
 102     }
 103   });
 104 });
 105
 106 var mypcc = '<?php echo $GLOBALS['phone_country_code'] ?>';
 107
 108 //code used from http://tech.irt.org/articles/js037/
 109 function replace(string,text,by) {
 110  // Replaces text with by in string
 111  var strLength = string.length, txtLength = text.length;
 112  if ((strLength == 0) || (txtLength == 0)) return string;
 113
 114  var i = string.indexOf(text);
 115  if ((!i) && (text != string.substring(0,txtLength))) return string;
 116  if (i == -1) return string;
 117
 118  var newstr = string.substring(0,i) + by;
 119
 120  if (i+txtLength < strLength)
 121   newstr += replace(string.substring(i+txtLength,strLength),text,by);
 122
 123  return newstr;
 124 }
 125
 126 function upperFirst(string,text) {
 127  return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
 128 }
 129
 130 <?php for ($i=1;$i<=3;$i++) { ?>
 131 function auto_populate_employer_address<?php echo $i ?>(){
 132  var f = document.demographics_form;
 133  if (f.form_i<?php echo $i?>subscriber_relationship.options[f.form_i<?php echo $i?>subscriber_relationship.selectedIndex].value == "self")
 134  {
 135   f.i<?php echo $i?>subscriber_fname.value=f.form_fname.value;
 136   f.i<?php echo $i?>subscriber_mname.value=f.form_mname.value;
 137   f.i<?php echo $i?>subscriber_lname.value=f.form_lname.value;
 138   f.i<?php echo $i?>subscriber_street.value=f.form_street.value;
 139   f.i<?php echo $i?>subscriber_city.value=f.form_city.value;
 140   f.form_i<?php echo $i?>subscriber_state.value=f.form_state.value;
 141   f.i<?php echo $i?>subscriber_postal_code.value=f.form_postal_code.value;
 142   if (f.form_country_code)
 143     f.form_i<?php echo $i?>subscriber_country.value=f.form_country_code.value;
 144   f.i<?php echo $i?>subscriber_phone.value=f.form_phone_home.value;
 145   f.i<?php echo $i?>subscriber_DOB.value=f.form_DOB.value;
 146   if(typeof f.form_ss!="undefined")
 147     {
 148         f.i<?php echo $i?>subscriber_ss.value=f.form_ss.value;
 149     }
 150   f.form_i<?php echo $i?>subscriber_sex.value = f.form_sex.value;
 151   f.i<?php echo $i?>subscriber_employer.value=f.form_em_name.value;
 152   f.i<?php echo $i?>subscriber_employer_street.value=f.form_em_street.value;
 153   f.i<?php echo $i?>subscriber_employer_city.value=f.form_em_city.value;
 154   f.form_i<?php echo $i?>subscriber_employer_state.value=f.form_em_state.value;
 155   f.i<?php echo $i?>subscriber_employer_postal_code.value=f.form_em_postal_code.value;
 156   if (f.form_em_country)
 157     f.form_i<?php echo $i?>subscriber_employer_country.value=f.form_em_country.value;
 158  }
 159 }
 160
 161 <?php } ?>
 162
 163 function popUp(URL) {
 164  day = new Date();
 165  id = day.getTime();
 166  top.restoreSession();
 167  eval("page" + id + " = window.open(URL, '" + id + "', 'toolbar=0,scrollbars=1,location=0,statusbar=0,menubar=0,resizable=1,width=400,height=300,left = 440,top = 362');");
 168 }
 169
 170 function checkNum () {
 171  var re= new RegExp();
 172  re = /^\d*\.?\d*$/;
 173  str=document.demographics_form.monthly_income.value;
 174  if(re.exec(str))
 175  {
 176  }else{
 177   alert("<?php xl('Please enter a monetary amount using only numbers and a decimal point.','e'); ?>");
 178  }
 179 }
 180
 181 // Indicates which insurance slot is being updated.
 182 var insurance_index = 0;
 183
 184 // The OnClick handler for searching/adding the insurance company.
 185 function ins_search(ins) {
 186         insurance_index = ins;
 187         return false;
 188 }
 189
 190 // The ins_search.php window calls this to set the selected insurance.
 191 function set_insurance(ins_id, ins_name) {
 192  var thesel = document.forms[0]['i' + insurance_index + 'provider'];
 193  var theopts = thesel.options; // the array of Option objects
 194  var i = 0;
 195  for (; i < theopts.length; ++i) {
 196   if (theopts[i].value == ins_id) {
 197    theopts[i].selected = true;
 198    return;
 199   }
 200  }
 201  // no matching option was found so create one, append it to the
 202  // end of the list, and select it.
 203  theopts[i] = new Option(ins_name, ins_id, false, true);
 204 }
 205
 206 // This capitalizes the first letter of each word in the passed input
 207 // element.  It also strips out extraneous spaces.
 208 function capitalizeMe(elem) {
 209  var a = elem.value.split(' ');
 210  var s = '';
 211  for(var i = 0; i < a.length; ++i) {
 212   if (a[i].length > 0) {
 213    if (s.length > 0) s += ' ';
 214    s += a[i].charAt(0).toUpperCase() + a[i].substring(1);
 215   }
 216  }
 217  elem.value = s;
 218 }
 219
 220 function divclick(cb, divid) {
 221  var divstyle = document.getElementById(divid).style;
 222  if (cb.checked) {
 223   divstyle.display = 'block';
 224  } else {
 225   divstyle.display = 'none';
 226  }
 227  return true;
 228 }
 229
 230 // Compute the length of a string without leading and trailing spaces.
 231 function trimlen(s) {
 232  var i = 0;
 233  var j = s.length - 1;
 234  for (; i <= j && s.charAt(i) == ' '; ++i);
 235  for (; i <= j && s.charAt(j) == ' '; --j);
 236  if (i > j) return 0;
 237  return j + 1 - i;
 238 }
 239
 240 function validate(f) {
 241  var errCount = 0;
 242  var errMsgs = new Array();
 243 <?php generate_layout_validation('DEM'); ?>
 244
 245  var msg = "";
 246  msg += "<?php xl('The following fields are required', 'e' ); ?>:\n\n";
 247  for ( var i = 0; i < errMsgs.length; i++ ) {
 248         msg += errMsgs[i] + "\n";
 249  }
 250  msg += "\n<?php xl('Please fill them in before continuing.', 'e'); ?>";
 251
 252  if ( errMsgs.length > 0 ) {
 253         alert(msg);
 254  }
 255
 256  //Misc  Deceased Date Validation for Future Date
 257 var dateVal = document.getElementById("form_deceased_date").value;
 258 var currentDate;
 259 var d = new Date();
 260 month = '' + (d.getMonth() + 1),
 261 day = '' + d.getDate(),
 262 year = d.getFullYear();
 263 if (month.length < 2) month = '0' + month;
 264 if (day.length < 2) day = '0' + day;
 265 currentDate = year+'-'+month+'-'+day;
 266 if(dateVal > currentDate)
 267 {
 268         alert ('<?php echo xls("Deceased Date should not be greater than Today"); ?>');
 269         return false;
 270 }
 271
 272 //Patient Data validations
 273  <?php if($GLOBALS['erx_enable']){ ?>
 274  alertMsg='';
 275  for(i=0;i<f.length;i++){
 276   if(f[i].type=='text' && f[i].value)
 277   {
 278    if(f[i].name == 'form_fname' || f[i].name == 'form_mname' || f[i].name == 'form_lname')
 279    {
 280     alertMsg += checkLength(f[i].name,f[i].value,35);
 281     alertMsg += checkUsername(f[i].name,f[i].value);
 282    }
 283    else if(f[i].name == 'form_street' || f[i].name == 'form_city')
 284    {
 285     alertMsg += checkLength(f[i].name,f[i].value,35);
 286     alertMsg += checkAlphaNumericExtended(f[i].name,f[i].value);
 287    }
 288    else if(f[i].name == 'form_phone_home')
 289    {
 290     alertMsg += checkPhone(f[i].name,f[i].value);
 291    }
 292   }
 293  }
 294  if(alertMsg)
 295  {
 296    alert(alertMsg);
 297    return false;
 298  }
 299  <?php } ?>
 300  //return false;
 301
 302 // Some insurance validation.
 303  for (var i = 1; i <= 3; ++i) {
 304   subprov = 'i' + i + 'provider';
 305   if (!f[subprov] || f[subprov].selectedIndex <= 0) continue;
 306   var subpfx = 'i' + i + 'subscriber_';
 307   var subrelat = f['form_' + subpfx + 'relationship'];
 308   var samename =
 309    f[subpfx + 'fname'].value == f.form_fname.value &&
 310    f[subpfx + 'mname'].value == f.form_mname.value &&
 311    f[subpfx + 'lname'].value == f.form_lname.value;
 312   var ss_regexp=/[0-9][0-9][0-9]-?[0-9][0-9]-?[0-9][0-9][0-9][0-9]/;
 313   var samess=true;
 314   var ss_valid=false;
 315   if(typeof f.form_ss!="undefined")
 316       {
 317         samess = f[subpfx + 'ss'].value == f.form_ss.value;
 318         ss_valid=ss_regexp.test(f[subpfx + 'ss'].value) && ss_regexp.test(f.form_ss.value);
 319       }
 320   if (subrelat.options[subrelat.selectedIndex].value == "self") {
 321    if (!samename) {
 322     if (!confirm("<?php echo xls('Subscriber relationship is self but name is different! Is this really OK?'); ?>"))
 323      return false;
 324    }
 325    if (!samess && ss_valid) {
 326     if(!confirm("<?php echo xls('Subscriber relationship is self but SS number is different!')." ". xls("Is this really OK?"); ?>"))
 327     return false;
 328    }
 329   } // end self
 330   else {
 331    if (samename) {
 332     if (!confirm("<?php echo xls('Subscriber relationship is not self but name is the same! Is this really OK?'); ?>"))
 333      return false;
 334    }
 335    if (samess && ss_valid)  {
 336     if(!confirm("<?php echo xls('Subscriber relationship is not self but SS number is the same!') ." ". xls("Is this really OK?"); ?>"))
 337     return false;
 338    }
 339   } // end not self
 340  } // end for
 341
 342  return errMsgs.length < 1;
 343 }
 344
 345
 346
 347 // Onkeyup handler for policy number.  Allows only A-Z and 0-9.
 348 function policykeyup(e) {
 349  var v = e.value.toUpperCase();
 350  var filteredString="";
 351  for (var i = 0; i < v.length; ++i) {
 352   var c = v.charAt(i);
 353   if ((c >= '0' && c <= '9') ||
 354      (c >= 'A' && c <= 'Z') ||
 355      (c == '*') ||
 356      (c == '-') ||
 357      (c == '_') ||
 358      (c == '(') ||
 359      (c == ')') ||
 360      (c == '#'))
 361      {
 362          filteredString+=c;
 363      }
 364  }
 365  e.value = filteredString;
 366  return;
 367 }
 368
 369 // Added 06/2009 by BM to make compatible with list_options table and functions - using jquery
 370 $(document).ready(function() {
 371
 372  <?php for ($i=1;$i<=3;$i++) { ?>
 373   $("#form_i<?php echo $i?>subscriber_relationship").change(function() { auto_populate_employer_address<?php echo $i?>(); });
 374  <?php } ?>
 375
 376 });
 377
 378 </script>
 379 </head>
 380
 381 <?php
 382 /*Get the constraint from the DB-> LBF forms accordinf the form_id*/
 383 $constraints = LBF_Validation::generate_validate_constraints("DEM");
 384 ?>
 385 <script> var constraints = <?php echo $constraints;?>; </script>
 386
 387 <body class="body_top">
 388
 389 <form action='demographics_save.php' name='demographics_form' id="DEM" method='post' onsubmit="submitme(<?php echo $GLOBALS['new_validate'] ? 1 : 0;?>,event,'DEM',constraints)">
 390 <input type='hidden' name='mode' value='save' />
 391 <input type='hidden' name='db_id' value="<?php echo $result['id']?>" />
 392 <table cellpadding='0' cellspacing='0' border='0'>
 393         <tr>
 394                 <td>
 395                         <a href="demographics.php" onclick="top.restoreSession()">
 396                         <font class=title><?php xl('Current Patient','e'); ?></font>
 397                         </a>
 398                         &nbsp;&nbsp;
 399                 </td>
 400         <td>
 401             <input id="submit_btn" class="css_btn" type="submit" disabled="disabled" value="<?php xl('Save','e'); ?>">
 402         </td>
 403                 <td>
 404                         <a class="css_button" href="demographics.php" onclick="top.restoreSession()">
 405                         <span><?php xl('Cancel','e'); ?></span>
 406                         </a>
 407                 </td>
 408         </tr>
 409 </table>
 410 <?php
 411
 412 function end_cell() {
 413   global $item_count, $cell_count;
 414   if ($item_count > 0) {
 415     echo "</td>";
 416     $item_count = 0;
 417   }
 418 }
 419
 420 function end_row() {
 421   global $cell_count, $CPR;
 422   end_cell();
 423   if ($cell_count > 0) {
 424     for (; $cell_count < $CPR; ++$cell_count) echo "<td></td>";
 425     echo "</tr>\n";
 426     $cell_count = 0;
 427   }
 428 }
 429
 430 function end_group() {
 431   global $last_group;
 432   if (strlen($last_group) > 0) {
 433     end_row();
 434     echo " </table>\n";
 435     echo "</div>\n";
 436   }
 437 }
 438
 439 $last_group = '';
 440 $cell_count = 0;
 441 $item_count = 0;
 442 $display_style = 'block';
 443
 444 $group_seq=0; // this gives the DIV blocks unique IDs
 445
 446 ?>
 447 <br>
 448   <div class="section-header">
 449    <span class="text"><b> <?php xl("Demographics", "e" )?></b></span>
 450 </div>
 451
 452 <div id="DEM" >
 453
 454         <ul class="tabNav">
 455            <?php display_layout_tabs('DEM', $result, $result2); ?>
 456         </ul>
 457
 458         <div class="tabContainer">
 459                 <?php display_layout_tabs_data_editable('DEM', $result, $result2); ?>
 460         </div>
 461 </div>
 462 <br>
 463
 464 <div id="DEM" >
 465
 466
 467 <?php
 468  if (! $GLOBALS['simplified_demographics']) {
 469
 470           $insurance_headings = array(xl("Primary Insurance Provider"), xl("Secondary Insurance Provider"), xl("Tertiary Insurance provider"));
 471           $insurance_info = array();
 472           $insurance_info[1] = getInsuranceData($pid,"primary");
 473           $insurance_info[2] = getInsuranceData($pid,"secondary");
 474           $insurance_info[3] = getInsuranceData($pid,"tertiary");
 475
 476         ?>
 477      <div class="section-header">
 478          <span class="text"><b><?php xl("Insurance", "e" )?></b></span>
 479      </div>
 480         <div id="INSURANCE" >
 481                 <ul class="tabNav">
 482                 <?php
 483                 foreach (array('primary','secondary','tertiary') as $instype) {
 484                         ?><li <?php echo $instype == 'primary' ? 'class="current"' : '' ?>><a href="#"><?php $CapInstype=ucfirst($instype); xl($CapInstype,'e'); ?></a></li><?php
 485                 }
 486                 ?>
 487                 </ul>
 488
 489         <div class="tabContainer">
 490
 491         <?php
 492           for($i=1;$i<=3;$i++) {
 493            $result3 = $insurance_info[$i];
 494         ?>
 495
 496                 <div class="tab <?php echo $i == 1 ? 'current': '' ?>" style='height:auto;width:auto'>          <!---display icky, fix to auto-->
 497
 498                 <table border="0">
 499
 500                  <tr>
 501                   <td valign=top width="430">
 502                    <table border="0">
 503
 504                          <tr>
 505                           <td valign='top'>
 506                            <span class='required'><?php echo $insurance_headings[$i -1]."&nbsp;"?></span>
 507                           </td>
 508                           <td class='required'>:</td>
 509                           <td>
 510                            <a href="../../practice/ins_search.php" class="iframe medium_modal css_button" onclick="ins_search(<?php echo $i?>)">
 511                                 <span><?php echo xl('Search/Add') ?></span>
 512                                 </a>
 513                                 <select name="i<?php echo $i?>provider">
 514                                 <option value=""><?php xl('Unassigned','e'); ?></option>
 515                                 <?php
 516                                  foreach ($insurancei as $iid => $iname) {
 517                                   echo "<option value='" . $iid . "'";
 518                                   if (strtolower($iid) == strtolower($result3{"provider"}))
 519                                    echo " selected";
 520                                   echo ">" . $iname . "</option>\n";
 521                                  }
 522                                 ?>
 523                            </select>
 524
 525                           </td>
 526                          </tr>
 527
 528                         <tr>
 529                          <td>
 530                           <span class='required'><?php xl('Plan Name','e'); ?> </span>
 531                          </td>
 532                          <td class='required'>:</td>
 533                          <td>
 534                           <input type='entry' size='20' name='i<?php echo $i?>plan_name' value="<?php echo $result3{"plan_name"} ?>"
 535                            onchange="capitalizeMe(this);" />&nbsp;&nbsp;
 536                          </td>
 537                         </tr>
 538
 539                         <tr>
 540                          <td>
 541                           <span class='required'><?php xl('Effective Date','e'); ?></span>
 542                          </td>
 543                          <td class='required'>:</td>
 544                          <td>
 545                           <input type='entry' size='16' id='i<?php echo $i ?>effective_date' name='i<?php echo $i ?>effective_date'
 546                            value='<?php echo $result3['date'] ?>'
 547                            onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)'
 548                            title='yyyy-mm-dd' />
 549                           <img src='../../pic/show_calendar.gif' align='absbottom' width='24' height='22' id='img_i<?php echo $i ?>effective_date' border='0' alt='[?]' style='cursor:pointer' title='<?php xl('Click here to choose a date','e'); ?>'>
 550                          </td>
 551                         </tr>
 552
 553                         <tr>
 554                          <td><span class=required><?php xl('Policy Number','e'); ?></span></td>
 555                          <td class='required'>:</td>
 556                          <td><input type='entry' size='16' name='i<?php echo $i?>policy_number' value="<?php echo $result3{"policy_number"}?>"
 557                           onkeyup='policykeyup(this)'></td>
 558                         </tr>
 559
 560                         <tr>
 561                          <td><span class=required><?php xl('Group Number','e'); ?></span></td>
 562                          <td class='required'>:</td>
 563                          <td><input type=entry size=16 name=i<?php echo $i?>group_number value="<?php echo $result3{"group_number"}?>" onkeyup='policykeyup(this)'></td>
 564                         </tr>
 565
 566                         <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 567                          <td class='required'><?php xl('Subscriber Employer (SE)','e'); ?><br><span style='font-weight:normal'>
 568                           (<?php xl('if unemployed enter Student','e'); ?>,<br><?php xl('PT Student, or leave blank','e'); ?>) </span></td>
 569                           <td class='required'>:</td>
 570                          <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer
 571                           value="<?php echo $result3{"subscriber_employer"}?>"
 572                            onchange="capitalizeMe(this);" /></td>
 573                         </tr>
 574
 575                         <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 576                          <td><span class=required><?php xl('SE Address','e'); ?></span></td>
 577                          <td class='required'>:</td>
 578                          <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer_street
 579                           value="<?php echo $result3{"subscriber_employer_street"}?>"
 580                            onchange="capitalizeMe(this);" /></td>
 581                         </tr>
 582
 583                         <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 584                          <td colspan="3">
 585                           <table>
 586                            <tr>
 587                                 <td><span class=required><?php xl('SE City','e'); ?>: </span></td>
 588                                 <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_city
 589                                  value="<?php echo $result3{"subscriber_employer_city"}?>"
 590                                   onchange="capitalizeMe(this);" /></td>
 591                                 <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE State','e') : xl('SE Locality','e') ?>: </span></td>
 592                         <td>
 593                                  <?php
 594                                   // Modified 7/2009 by BM to incorporate data types
 595                           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'), $result3['subscriber_employer_state']);
 596                                  ?>
 597                                 </td>
 598                            </tr>
 599                            <tr>
 600                                 <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE Zip Code','e') : xl('SE Postal Code','e') ?>: </span></td>
 601                                 <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_postal_code value="<?php echo $result3{"subscriber_employer_postal_code"}?>"></td>
 602                                 <td><span class=required><?php xl('SE Country','e'); ?>: </span></td>
 603                         <td>
 604                                  <?php
 605                                   // Modified 7/2009 by BM to incorporate data types
 606                           generate_form_field(array('data_type'=>$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'), $result3['subscriber_employer_country']);
 607                                  ?>
 608                         </td>
 609                            </tr>
 610                           </table>
 611                          </td>
 612                         </tr>
 613
 614                    </table>
 615                   </td>
 616
 617                   <td valign=top>
 618                 <table border="0">
 619                         <tr>
 620                                 <td><span class=required><?php xl('Relationship','e'); ?></span></td>
 621                                 <td class=required>:</td>
 622                                 <td colspan=3><?php
 623                                         // Modified 6/2009 by BM to use list_options and function
 624                                         generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_relationship'),'list_id'=>'sub_relation','empty_title'=>' '), $result3['subscriber_relationship']);
 625                                         ?>
 626
 627                                 <a href="javascript:popUp('browse.php?browsenum=<?php echo $i?>')" class=text>(<?php xl('Browse','e'); ?>)</a></td>
 628                                 <td></td><td></td><td></td><td></td>
 629                         </tr>
 630                         <tr>
 631                                 <td width=120><span class=required><?php xl('Subscriber','e'); ?> </span></td>
 632                                 <td class=required>:</td>
 633                                 <td colspan=3><input type=entry size=10 name=i<?php echo $i?>subscriber_fname   value="<?php echo $result3{"subscriber_fname"}?>" onchange="capitalizeMe(this);" />
 634                                 <input type=entry size=3 name=i<?php echo $i?>subscriber_mname value="<?php echo $result3{"subscriber_mname"}?>" onchange="capitalizeMe(this);" />
 635                                 <input type=entry size=10 name=i<?php echo $i?>subscriber_lname value="<?php echo $result3{"subscriber_lname"}?>" onchange="capitalizeMe(this);" /></td>
 636                                 <td></td><td></td><td></td><td></td>
 637                         </tr>
 638                         <tr>
 639                                 <td><span class=bold><?php xl('D.O.B.','e'); ?> </span></td>
 640                                 <td class=required>:</td>
 641                                 <td><input type='entry' size='11' id='i<?php echo $i?>subscriber_DOB' name='i<?php echo $i?>subscriber_DOB' value='<?php echo $result3['subscriber_DOB'] ?>' onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)' title='yyyy-mm-dd' /><img src='../../pic/show_calendar.gif' align='absbottom' width='24' height='22' id='img_i<?php echo $i; ?>dob_date' border='0' alt='[?]' style='cursor:pointer' title='<?php xl('Click here to choose a date','e'); ?>'></td>
 642
 643                                 <td><span class=bold><?php xl('Sex','e'); ?>: </span></td>
 644                                 <td><?php
 645                                         // Modified 6/2009 by BM to use list_options and function
 646                                         generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_sex'),'list_id'=>'sex'), $result3['subscriber_sex']);
 647                                         ?>
 648                                 </td>
 649                                 <td></td><td></td> <td></td><td></td>
 650                         </tr>
 651                         <tr>
 652                                 <td class=leftborder><span class=bold><?php xl('S.S.','e'); ?> </span></td>
 653                                 <td class=required>:</td>
 654                                 <td><input type=entry size=11 name=i<?php echo $i?>subscriber_ss value="<?php echo trim($result3{"subscriber_ss"})?>"></td>
 655                         </tr>
 656
 657                         <tr>
 658                                 <td><span class=required><?php xl('Subscriber Address','e'); ?> </span></td>
 659                                 <td class=required>:</td>
 660                                 <td><input type=entry size=20 name=i<?php echo $i?>subscriber_street value="<?php echo $result3{"subscriber_street"}?>" onchange="capitalizeMe(this);" /></td>
 661
 662                                 <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('State','e') : xl('Locality','e') ?>: </span></td>
 663                                 <td>
 664                                         <?php
 665                                         // Modified 7/2009 by BM to incorporate data types
 666                                         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']);
 667                                 ?>
 668                                 </td>
 669                         </tr>
 670                         <tr>
 671                                 <td class=leftborder><span class=required><?php xl('City','e'); ?></span></td>
 672                                 <td class=required>:</td>
 673                                 <td><input type=entry size=11 name=i<?php echo $i?>subscriber_city value="<?php echo $result3{"subscriber_city"}?>" onchange="capitalizeMe(this);" /></td><td class=leftborder><span class='required'<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>><?php xl('Country','e'); ?>: </span></td><td>
 674                                         <?php
 675                                         // Modified 7/2009 by BM to incorporate data types
 676                                         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'), $result3['subscriber_country']);
 677                                         ?>
 678                                 </td>
 679 </tr>
 680                         <tr>
 681                                 <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('Zip Code','e') : xl('Postal Code','e') ?> </span></td><td class=required>:</td><td><input type=entry size=10 name=i<?php echo $i?>subscriber_postal_code value="<?php echo $result3{"subscriber_postal_code"}?>"></td>
 682
 683                                 <td colspan=2>
 684                                 </td><td></td>
 685                         </tr>
 686                         <tr>
 687                                 <td><span class=bold><?php xl('Subscriber Phone','e'); ?></span></td>
 688                                 <td class=required>:</td>
 689                                 <td><input type='text' size='20' name='i<?php echo $i?>subscriber_phone' value='<?php echo $result3["subscriber_phone"] ?>' onkeyup='phonekeyup(this,mypcc)' /></td>
 690                                 <td colspan=2><span class=bold><?php xl('CoPay','e'); ?>: <input type=text size="6" name=i<?php echo $i?>copay value="<?php echo $result3{"copay"}?>"></span></td>
 691                                 <td colspan=2>
 692                                 </td><td></td><td></td>
 693                         </tr>
 694                         <tr>
 695                                 <td colspan=0><span class='required'><?php xl('Accept Assignment','e'); ?></span></td>
 696                                 <td class=required>:</td>
 697                                 <td colspan=2>
 698                                         <select name=i<?php echo $i?>accept_assignment>
 699                                                 <option value="TRUE" <?php if (strtoupper($result3{"accept_assignment"}) == "TRUE") echo "selected"?>><?php xl('YES','e'); ?></option>
 700                                                 <option value="FALSE" <?php if (strtoupper($result3{"accept_assignment"}) == "FALSE") echo "selected"?>><?php xl('NO','e'); ?></option>
 701                                         </select>
 702                                 </td>
 703                                 <td></td><td></td>
 704                                 <td colspan=2>
 705                                 </td><td></td>
 706                         </tr>
 707       <tr>
 708         <td><span class='bold'><?php xl('Secondary Medicare Type','e'); ?></span></td>
 709         <td class='bold'>:</td>
 710         <td colspan='6'>
 711           <select name=i<?php echo $i?>policy_type>
 712 <?php
 713   foreach ($policy_types AS $key => $value) {
 714     echo "            <option value ='$key'";
 715     if ($key == $result3['policy_type']) echo " selected";
 716     echo ">" . htmlspecialchars($value) . "</option>\n";
 717   }
 718 ?>
 719           </select>
 720         </td>
 721       </tr>
 722                 </table>
 723
 724                   </td>
 725                  </tr>
 726                 </table>
 727
 728                 </div>
 729
 730         <?php } //end insurer for loop ?>
 731
 732         </div>
 733 </div>
 734
 735 <?php } // end of "if not simplified_demographics" ?>
 736 </div></div>
 737
 738 </form>
 739
 740 <br>
 741
 742 <script language="JavaScript">
 743 // hard code validation for old validation, in the new validation possible to add match rules
 744 <?php if($GLOBALS['new_validate'] == 0) { ?>
 745  // fix inconsistently formatted phone numbers from the database
 746  var f = document.forms[0];
 747  if (f.form_phone_contact) phonekeyup(f.form_phone_contact,mypcc);
 748  if (f.form_phone_home   ) phonekeyup(f.form_phone_home   ,mypcc);
 749  if (f.form_phone_biz    ) phonekeyup(f.form_phone_biz    ,mypcc);
 750  if (f.form_phone_cell   ) phonekeyup(f.form_phone_cell   ,mypcc);
 751
 752 <?php if (! $GLOBALS['simplified_demographics']) { ?>
 753  phonekeyup(f.i1subscriber_phone,mypcc);
 754  phonekeyup(f.i2subscriber_phone,mypcc);
 755  phonekeyup(f.i3subscriber_phone,mypcc);
 756 <?php } ?>
 757
 758 <?php }?>
 759
 760 <?php if ($set_pid) { ?>
 761  parent.left_nav.setPatient(<?php echo "'" . addslashes($result['fname']) . " " . addslashes($result['lname']) . "'," . addslashes($pid) . ",'" . addslashes($result['pubpid']) . "','', ' " . xls('DOB') . ": " . addslashes(oeFormatShortDate($result['DOB_YMD'])) . " " . xls('Age') . ": " . addslashes(getPatientAgeDisplay($result['DOB_YMD'])) . "'"; ?>);
 762 <?php } ?>
 763
 764 <?php echo $date_init; ?>
 765 <?php if (! $GLOBALS['simplified_demographics']) { for ($i=1; $i<=3; $i++): ?>
 766  Calendar.setup({inputField:"i<?php echo $i?>effective_date", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i?>effective_date"});
 767  Calendar.setup({inputField:"i<?php echo $i?>subscriber_DOB", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i?>dob_date"});
 768 <?php endfor; } ?>
 769 </script>
 770
 771 <!-- include support for the list-add selectbox feature -->
 772 <?php include $GLOBALS['fileroot']."/library/options_listadd.inc"; ?>
 773
 774 <?php /*Include the validation script and rules for this form*/
 775 $form_id="DEM";
 776 //LBF forms use the new validation depending on the global value
 777 $use_validate_js=$GLOBALS['new_validate'];
 778
 779 ?>
 780 <?php  include_once("$srcdir/validation/validation_script.js.php");?>
 781
 782
 783 </body>
 784 <script language='JavaScript'>
 785         var duplicateFieldsArray=[];
 786
 787
 788     // Array of skip conditions for the checkSkipConditions() function.
 789     var skipArray = [
 790         <?php echo $condition_str; ?>
 791     ];
 792     checkSkipConditions();
 793     $("input").change(function() {
 794         checkSkipConditions();
 795     });
 796     $("select").change(function() {
 797         checkSkipConditions();
 798     });
 799
 800 //This code deals with demographics before save action -
 801         <?php if ( ($GLOBALS['gbl_edit_patient_form'] == '1') && (checkIfPatientValidationHookIsActive()) ):?>
 802
 803                 //Use the Zend patient validation hook.
 804                 //TODO - get the edit part of patient validation hook to work smoothly and then
 805                 //       remove the closeBeforeOpening=1 in the url below.
 806
 807                 var f = $("form");
 808
 809                 // Use hook to open the controller and get the new patient validation .
 810                 // when no params are sent this window will be closed from the zend controller.
 811                 var url ='<?php echo  $GLOBALS['web_root']."/interface/modules/zend_modules/public/patientvalidation";?>';
 812                 $("#submit_btn").attr("type","button");
 813                 $("#submit_btn").attr("name","btnSubmit");
 814                 $("#submit_btn").attr("id","btnSubmit");
 815                 $("#btnSubmit").click(function( event ) {
 816                         if(!submitme(<?php echo $GLOBALS['new_validate'] ? 1 : 0;?>,event,'DEM',constraints)){
 817                                 event.preventDefault();
 818                                 return;
 819                         }
 820                         somethingChanged = false;
 821                         <?php
 822                         // D in edit_options indicates the field is used in duplication checking.
 823                         // This constructs a list of the names of those fields.
 824                         $mflist = "";
 825                         $mfres = sqlStatement("SELECT field_id FROM layout_options " .
 826                                 "WHERE form_id = 'DEM' AND uor > 0 AND field_id != '' AND " .
 827                                 "edit_options LIKE '%D%' " .
 828                                 "ORDER BY group_name, seq");
 829                         while ($mfrow = sqlFetchArray($mfres)) {
 830                                 $field_id  = $mfrow['field_id'];
 831                                 if (strpos($field_id, 'em_') === 0) continue;
 832                                 if (!empty($mflist)) $mflist .= ",";
 833                                         $mflist .= "'" . text($field_id) . "'";
 834                         } ?>
 835
 836                         var flds = new Array(<?php echo $mflist; ?>);
 837                         var separator = '?';
 838                         var valueIsChanged=false;
 839                         for (var i = 0; i < flds.length; ++i) {
 840                                 var fval = $('#form_' + flds[i]).val();
 841                                 if(duplicateFieldsArray['#form_' + flds[i]]!=fval) {
 842                                         valueIsChanged = true;
 843
 844                                 }
 845
 846                                 if (fval && fval != '') {
 847                                         url += separator;
 848                                         separator = '&';
 849                                         url += 'mf_' + flds[i] + '=' + encodeURIComponent(fval);
 850                                 }
 851                         }
 852
 853
 854                         //Only if check for duplicates values are changed open the popup hook screen
 855                         if(valueIsChanged) {
 856                                 //("value has changed for duplicate check inputs");
 857                         url += '&page=edit&closeBeforeOpening=1&mf_id='+$("[name='db_id']").val();
 858                         dlgopen(url, '_blank', 700, 500);
 859                         }
 860                         else {//other wise submit me is a success just submit the form
 861                                 $('#DEM').submit();
 862                         }
 863                 });
 864
 865         <?php endif;?>
 866
 867         $(document).ready(function(){
 868                 //When document is ready collect all the values Marked with D (check duplicate) stored in the db into array duplicateFieldsArray.
 869                 var flds = new Array(<?php echo $mflist; ?>);
 870                 for (var i = 0; i < flds.length; ++i) {
 871                         var fval = $('#form_' + flds[i]).val();
 872                         duplicateFieldsArray['#form_' + flds[i]] = fval;
 873                 }
 874         })
 875 </script>
 876
 877
 878 </html>