interface/new/new_comprehensive.php

   1 <?php
   2 // Copyright (C) 2009-2010 Rod Roark <rod@sunsetsystems.com>
   3 //
   4 // This program is free software; you can redistribute it and/or
   5 // modify it under the terms of the GNU General Public License
   6 // as published by the Free Software Foundation; either version 2
   7 // of the License, or (at your option) any later version.
   8
   9 require_once("../globals.php");
  10 require_once("$srcdir/acl.inc");
  11 require_once("$srcdir/options.inc.php");
  12 require_once("$srcdir/patient.inc");
  13 require_once("$srcdir/erx_javascript.inc.php");
  14 require_once("$srcdir/validation/LBF_Validation.php");
  15 require_once ("$srcdir/patientvalidation.inc.php");
  16
  17 // Check authorization.
  18 if (!acl_check('patients','demo','',array('write','addonly') ))
  19   die("Adding demographics is not authorized.");
  20
  21 $CPR = 4; // cells per row
  22
  23 $searchcolor = empty($GLOBALS['layout_search_color']) ?
  24   '#ffff55' : $GLOBALS['layout_search_color'];
  25
  26 $WITH_SEARCH = ($GLOBALS['full_new_patient_form'] == '1' || $GLOBALS['full_new_patient_form'] == '2' || $GLOBALS['full_new_patient_form'] == '4');
  27 $SHORT_FORM  = ($GLOBALS['full_new_patient_form'] == '2' || $GLOBALS['full_new_patient_form'] == '3' );
  28
  29 function getLayoutRes() {
  30   global $SHORT_FORM;
  31   return sqlStatement("SELECT * FROM layout_options " .
  32     "WHERE form_id = 'DEM' AND uor > 0 AND field_id != '' " .
  33     ($SHORT_FORM ? "AND ( uor > 1 OR edit_options LIKE '%N%' ) " : "") .
  34     "ORDER BY group_name, seq");
  35 }
  36
  37 // Determine layout field search treatment from its data type:
  38 // 1 = text field
  39 // 2 = select list
  40 // 0 = not searchable
  41 //
  42 function getSearchClass($data_type) {
  43   switch($data_type) {
  44     case  1: // single-selection list
  45     case 10: // local provider list
  46     case 11: // provider list
  47     case 12: // pharmacy list
  48     case 13: // squads
  49     case 14: // address book list
  50     case 26: // single-selection list with add
  51     case 35: // facilities
  52       return 2;
  53     case  2: // text field
  54     case  3: // textarea
  55     case  4: // date
  56       return 1;
  57   }
  58   return 0;
  59 }
  60
  61 $fres = getLayoutRes();
  62 ?>
  63 <html>
  64 <head>
  65 <?php html_header_show(); ?>
  66
  67 <link rel="stylesheet" href="<?php echo $css_header; ?>" type="text/css">
  68
  69 <style>
  70 body, td, input, select, textarea {
  71  font-family: Arial, Helvetica, sans-serif;
  72  font-size: 10pt;
  73 }
  74
  75 body {
  76  padding: 5pt 5pt 5pt 5pt;
  77 }
  78
  79 div.section {
  80  border: solid;
  81  border-width: 1px;
  82  border-color: #0000ff;
  83  margin: 0 0 0 10pt;
  84  padding: 5pt;
  85 }
  86
  87 </style>
  88
  89 <style type="text/css">@import url(../../library/dynarch_calendar.css);</style>
  90
  91 <script type="text/javascript" src="../../library/dialog.js"></script>
  92 <script type="text/javascript" src="../../library/textformat.js"></script>
  93 <script type="text/javascript" src="../../library/dynarch_calendar.js"></script>
  94 <?php include_once("{$GLOBALS['srcdir']}/dynarch_calendar_en.inc.php"); ?>
  95 <script type="text/javascript" src="../../library/dynarch_calendar_setup.js"></script>
  96 <script type="text/javascript" src="../../library/js/jquery-1.9.1.min.js"></script>
  97 <script type="text/javascript" src="../../library/js/common.js"></script>
  98 <script type="text/javascript" src="../../library/js/fancybox/jquery.fancybox-1.2.6.js"></script>
  99 <?php include_once("{$GLOBALS['srcdir']}/options.js.php"); ?>
 100 <link rel="stylesheet" type="text/css" href="../../library/js/fancybox/jquery.fancybox-1.2.6.css" media="screen" />
 101
 102 <SCRIPT LANGUAGE="JavaScript"><!--
 103 //Visolve - sync the radio buttons - Start
 104 if((top.window.parent) && (parent.window)){
 105         var wname = top.window.parent.left_nav;
 106         fname = (parent.window.name)?parent.window.name:window.name;
 107         wname.syncRadios();
 108         wname.setRadio(fname, "new");
 109 }//Visolve - sync the radio buttons - End
 110
 111 var mypcc = '<?php echo $GLOBALS['phone_country_code'] ?>';
 112
 113 // This may be changed to true by the AJAX search script.
 114 var force_submit = false;
 115
 116 //code used from http://tech.irt.org/articles/js037/
 117 function replace(string,text,by) {
 118  // Replaces text with by in string
 119  var strLength = string.length, txtLength = text.length;
 120  if ((strLength == 0) || (txtLength == 0)) return string;
 121
 122  var i = string.indexOf(text);
 123  if ((!i) && (text != string.substring(0,txtLength))) return string;
 124  if (i == -1) return string;
 125
 126  var newstr = string.substring(0,i) + by;
 127
 128  if (i+txtLength < strLength)
 129   newstr += replace(string.substring(i+txtLength,strLength),text,by);
 130
 131  return newstr;
 132 }
 133
 134 <?php for ($i=1;$i<=3;$i++) { ?>
 135 function auto_populate_employer_address<?php echo $i ?>(){
 136  var f = document.demographics_form;
 137  if (f.form_i<?php echo $i?>subscriber_relationship.options[f.form_i<?php echo $i?>subscriber_relationship.selectedIndex].value == "self") {
 138   f.i<?php echo $i?>subscriber_fname.value=f.form_fname.value;
 139   f.i<?php echo $i?>subscriber_mname.value=f.form_mname.value;
 140   f.i<?php echo $i?>subscriber_lname.value=f.form_lname.value;
 141   f.i<?php echo $i?>subscriber_street.value=f.form_street.value;
 142   f.i<?php echo $i?>subscriber_city.value=f.form_city.value;
 143   f.form_i<?php echo $i?>subscriber_state.value=f.form_state.value;
 144   f.i<?php echo $i?>subscriber_postal_code.value=f.form_postal_code.value;
 145   if (f.form_country_code)
 146     f.form_i<?php echo $i?>subscriber_country.value=f.form_country_code.value;
 147   f.i<?php echo $i?>subscriber_phone.value=f.form_phone_home.value;
 148   f.i<?php echo $i?>subscriber_DOB.value=f.form_DOB.value;
 149   f.i<?php echo $i?>subscriber_ss.value=f.form_ss.value;
 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 $i?>subscriber_employer_country.value=f.form_em_country.value;
 158  }
 159 }
 160
 161 <?php } ?>
 162
 163 function upperFirst(string,text) {
 164  return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
 165 }
 166
 167 // The ins_search.php window calls this to set the selected insurance.
 168 function set_insurance(ins_id, ins_name) {
 169  var thesel = document.forms[0]['i' + insurance_index + 'provider'];
 170  var theopts = thesel.options; // the array of Option objects
 171  var i = 0;
 172  for (; i < theopts.length; ++i) {
 173   if (theopts[i].value == ins_id) {
 174    theopts[i].selected = true;
 175    return;
 176   }
 177  }
 178  // no matching option was found so create one, append it to the
 179  // end of the list, and select it.
 180  theopts[i] = new Option(ins_name, ins_id, false, true);
 181 }
 182
 183 // Indicates which insurance slot is being updated.
 184 var insurance_index = 0;
 185
 186 // The OnClick handler for searching/adding the insurance company.
 187 function ins_search(ins) {
 188  insurance_index = ins;
 189  return false;
 190 }
 191
 192 function checkNum () {
 193  var re= new RegExp();
 194  re = /^\d*\.?\d*$/;
 195  str=document.forms[0].monthly_income.value;
 196  if(re.exec(str))
 197  {
 198  }else{
 199   alert("Please enter a dollar amount using only numbers and a decimal point.");
 200  }
 201 }
 202
 203 // This capitalizes the first letter of each word in the passed input
 204 // element.  It also strips out extraneous spaces.
 205 function capitalizeMe(elem) {
 206  var a = elem.value.split(' ');
 207  var s = '';
 208  for(var i = 0; i < a.length; ++i) {
 209   if (a[i].length > 0) {
 210    if (s.length > 0) s += ' ';
 211    s += a[i].charAt(0).toUpperCase() + a[i].substring(1);
 212   }
 213  }
 214  elem.value = s;
 215 }
 216
 217 // Onkeyup handler for policy number.  Allows only A-Z and 0-9.
 218 function policykeyup(e) {
 219  var v = e.value.toUpperCase();
 220  var filteredString="";
 221  for (var i = 0; i < v.length; ++i) {
 222   var c = v.charAt(i);
 223   if ((c >= '0' && c <= '9') ||
 224      (c >= 'A' && c <= 'Z') ||
 225      (c == '*') ||
 226      (c == '-') ||
 227      (c == '_') ||
 228      (c == '(') ||
 229      (c == ')') ||
 230      (c == '#'))
 231      {
 232          filteredString+=c;
 233      }
 234  }
 235  e.value = filteredString;
 236  return;
 237 }
 238
 239 function divclick(cb, divid) {
 240  var divstyle = document.getElementById(divid).style;
 241  if (cb.checked) {
 242   divstyle.display = 'block';
 243  } else {
 244   divstyle.display = 'none';
 245  }
 246  return true;
 247 }
 248
 249 // Compute the length of a string without leading and trailing spaces.
 250 function trimlen(s) {
 251  var i = 0;
 252  var j = s.length - 1;
 253  for (; i <= j && s.charAt(i) == ' '; ++i);
 254  for (; i <= j && s.charAt(j) == ' '; --j);
 255  if (i > j) return 0;
 256  return j + 1 - i;
 257 }
 258
 259 function validate(f) {
 260   var errMsgs = new Array();
 261   <?php generate_layout_validation('DEM'); ?>
 262   <?php if($GLOBALS['erx_enable']){ ?>
 263   alertMsg='';
 264   for(i=0;i<f.length;i++){
 265     if(f[i].type=='text' && f[i].value)
 266     {
 267       if(f[i].name == 'form_fname' || f[i].name == 'form_mname' || f[i].name == 'form_lname')
 268       {
 269         alertMsg += checkLength(f[i].name,f[i].value,35);
 270         alertMsg += checkUsername(f[i].name,f[i].value);
 271       }
 272       else if(f[i].name == 'form_street' || f[i].name == 'form_city')
 273       {
 274         alertMsg += checkLength(f[i].name,f[i].value,35);
 275         alertMsg += checkAlphaNumericExtended(f[i].name,f[i].value);
 276       }
 277       else if(f[i].name == 'form_phone_home')
 278       {
 279        alertMsg += checkPhone(f[i].name,f[i].value);
 280       }
 281     }
 282   }
 283   if(alertMsg)
 284   {
 285     alert(alertMsg);
 286     return false;
 287   }
 288   <?php } ?>
 289   var msg = "";
 290   msg += "<?php echo htmlspecialchars(xl('The following fields are required'),ENT_QUOTES); ?>:\n\n";
 291   for ( var i = 0; i < errMsgs.length; i++ ) {
 292          msg += errMsgs[i] + "\n";
 293   }
 294   msg += "\n<?php echo htmlspecialchars(xl('Please fill them in before continuing.'),ENT_QUOTES); ?>";
 295
 296
 297 //Misc  Deceased Date Validation for Future Date
 298 var dateVal = document.getElementById("form_deceased_date").value;
 299 var currentDate;
 300 var d = new Date();
 301 month = '' + (d.getMonth() + 1),
 302 day = '' + d.getDate(),
 303 year = d.getFullYear();
 304 if (month.length < 2) month = '0' + month;
 305 if (day.length < 2) day = '0' + day;
 306 currentDate = year+'-'+month+'-'+day;
 307 if(errMsgs.length > 0 || dateVal > currentDate)
 308 {
 309 if(errMsgs.length > 0)
 310         alert(msg);
 311 if(dateVal > currentDate)
 312         alert ('<?php echo xls("Deceased Date should not be greater than Today"); ?>');
 313         return false;
 314 }
 315  return true;
 316 }
 317
 318 function toggleSearch(elem) {
 319  var f = document.forms[0];
 320 <?php if ($WITH_SEARCH) { ?>
 321  // Toggle background color.
 322  if (elem.style.backgroundColor == '')
 323   elem.style.backgroundColor = '<?php echo $searchcolor; ?>';
 324  else
 325   elem.style.backgroundColor = '';
 326 <?php } ?>
 327  if (force_submit) {
 328   force_submit = false;
 329   f.create.value = '<?php xl('Create New Patient','e'); ?>';
 330  }
 331  return true;
 332 }
 333
 334 // If a <select> list is dropped down, this is its name.
 335 var open_sel_name = '';
 336
 337 function selClick(elem) {
 338  if (open_sel_name == elem.name) {
 339   open_sel_name = '';
 340  }
 341  else {
 342   open_sel_name = elem.name;
 343   toggleSearch(elem);
 344  }
 345  return true;
 346 }
 347
 348 function selBlur(elem) {
 349  if (open_sel_name == elem.name) {
 350   open_sel_name = '';
 351  }
 352  return true;
 353 }
 354
 355 // This invokes the patient search dialog.
 356 function searchme() {
 357  var f = document.forms[0];
 358  var url = '../main/finder/patient_select.php?popup=1';
 359
 360 <?php
 361 $lres = getLayoutRes();
 362
 363 while ($lrow = sqlFetchArray($lres)) {
 364   $field_id  = $lrow['field_id'];
 365   if (strpos($field_id, 'em_') === 0) continue;
 366   $data_type = $lrow['data_type'];
 367   $fldname = "form_$field_id";
 368   switch(getSearchClass($data_type)) {
 369     case  1:
 370       echo
 371       " if (f.$fldname.style.backgroundColor != '' && trimlen(f.$fldname.value) > 0) {\n" .
 372       "  url += '&$field_id=' + encodeURIComponent(f.$fldname.value);\n" .
 373       " }\n";
 374       break;
 375     case 2:
 376       echo
 377       " if (f.$fldname.style.backgroundColor != '' && f.$fldname.selectedIndex > 0) {\n" .
 378       "  url += '&$field_id=' + encodeURIComponent(f.$fldname.options[f.$fldname.selectedIndex].value);\n" .
 379       " }\n";
 380       break;
 381   }
 382 }
 383 ?>
 384
 385  dlgopen(url, '_blank', 700, 500);
 386 }
 387
 388 //-->
 389
 390 </script>
 391 </head>
 392
 393 <body class="body_top">
 394
 395 <?php
 396 /*Get the constraint from the DB-> LBF forms accordinf the form_id*/
 397 $constraints = LBF_Validation::generate_validate_constraints("DEM");
 398 ?>
 399 <script> var constraints = <?php echo $constraints;?>; </script>
 400
 401 <form action='new_comprehensive_save.php' name='demographics_form' id="DEM"  method='post' onsubmit='return submitme(<?php echo $GLOBALS['new_validate'] ? 1 : 0;?>,event,"DEM",constraints)'>
 402
 403 <span class='title'><?php xl('Search or Add Patient','e'); ?></span>
 404
 405 <table width='100%' cellpadding='0' cellspacing='8'>
 406  <tr>
 407   <td align='left' valign='top'>
 408 <?php if ($SHORT_FORM) echo "  <center>\n"; ?>
 409 <?php
 410
 411 function end_cell() {
 412   global $item_count, $cell_count;
 413   if ($item_count > 0) {
 414     echo "</td>";
 415     $item_count = 0;
 416   }
 417 }
 418
 419 function end_row() {
 420   global $cell_count, $CPR;
 421   end_cell();
 422   if ($cell_count > 0) {
 423     for (; $cell_count < $CPR; ++$cell_count) echo "<td></td>";
 424     echo "</tr>\n";
 425     $cell_count = 0;
 426   }
 427 }
 428
 429 function end_group() {
 430   global $last_group, $SHORT_FORM;
 431   if (strlen($last_group) > 0) {
 432     end_row();
 433     echo " </table>\n";
 434     if (!$SHORT_FORM) echo "</div>\n";
 435   }
 436 }
 437
 438 $last_group    = '';
 439 $cell_count    = 0;
 440 $item_count    = 0;
 441 $display_style = 'block';
 442 $group_seq     = 0; // this gives the DIV blocks unique IDs
 443
 444 while ($frow = sqlFetchArray($fres)) {
 445   $this_group = $frow['group_name'];
 446   $titlecols  = $frow['titlecols'];
 447   $datacols   = $frow['datacols'];
 448   $data_type  = $frow['data_type'];
 449   $field_id   = $frow['field_id'];
 450   $list_id    = $frow['list_id'];
 451   $currvalue  = '';
 452   $condition_str = get_conditions_str($condition_str,$group_fields);
 453
 454   if (strpos($field_id, 'em_') === 0) {
 455     $tmp = substr($field_id, 3);
 456     if (isset($result2[$tmp])) $currvalue = $result2[$tmp];
 457   }
 458   else {
 459     if (isset($result[$field_id])) $currvalue = $result[$field_id];
 460   }
 461
 462   // Handle a data category (group) change.
 463   if (strcmp($this_group, $last_group) != 0) {
 464     if (!$SHORT_FORM) {
 465       end_group();
 466       $group_seq++;    // ID for DIV tags
 467       $group_name = substr($this_group, 1);
 468       if (strlen($last_group) > 0) echo "<br />";
 469       echo "<span class='bold'><input type='checkbox' name='form_cb_$group_seq' id='form_cb_$group_seq' value='1' " .
 470         "onclick='return divclick(this,\"div_$group_seq\");'";
 471       if ($display_style == 'block') echo " checked";
 472
 473       // Modified 6-09 by BM - Translate if applicable
 474       echo " /><b>" . xl_layout_label($group_name) . "</b></span>\n";
 475
 476       echo "<div id='div_$group_seq' class='section' style='display:$display_style;'>\n";
 477       echo " <table border='0' cellpadding='0'>\n";
 478       $display_style = 'none';
 479     }
 480     else if (strlen($last_group) == 0) {
 481       echo " <table border='0' cellpadding='0'>\n";
 482     }
 483     $last_group = $this_group;
 484   }
 485
 486   // Handle starting of a new row.
 487   if (($titlecols > 0 && $cell_count >= $CPR) || $cell_count == 0) {
 488     end_row();
 489     echo "  <tr>";
 490   }
 491
 492   if ($item_count == 0 && $titlecols == 0) $titlecols = 1;
 493   $field_id_label='label_'.$frow['field_id'];
 494   // Handle starting of a new label cell.
 495   if ($titlecols > 0) {
 496     end_cell();
 497     echo "<td colspan='$titlecols' id='$field_id_label'";
 498     echo ($frow['uor'] == 2) ? " class='required'" : " class='bold'";
 499     if ($cell_count == 2) echo " style='padding-left:10pt'";
 500     echo ">";
 501     $cell_count += $titlecols;
 502   }
 503   ++$item_count;
 504
 505   echo "<b>";
 506
 507   // Modified 6-09 by BM - Translate if applicable
 508   if ($frow['title']) echo (xl_layout_label($frow['title']).":"); else echo "&nbsp;";
 509
 510   echo "</b>";
 511
 512   // Handle starting of a new data cell.
 513   if ($datacols > 0) {
 514       $id_field_text = "text_".$frow['field_id'];
 515     end_cell();
 516     echo "<td colspan='$datacols' class='text data'";
 517     if ($cell_count > 0) echo " style='padding-left:5pt'". " id='".$id_field_text."'";
 518     echo ">";
 519     $cell_count += $datacols;
 520   }
 521
 522   ++$item_count;
 523   generate_form_field($frow, $currvalue);
 524 }
 525
 526 end_group();
 527 ?>
 528
 529 <?php
 530 if (! $GLOBALS['simplified_demographics']) {
 531   $insurancei = getInsuranceProviders();
 532   $pid = 0;
 533   $insurance_headings = array(xl("Primary Insurance Provider"), xl("Secondary Insurance Provider"), xl("Tertiary Insurance provider"));
 534   $insurance_info = array();
 535   $insurance_info[1] = getInsuranceData($pid,"primary");
 536   $insurance_info[2] = getInsuranceData($pid,"secondary");
 537   $insurance_info[3] = getInsuranceData($pid,"tertiary");
 538
 539   echo "<br /><span class='bold'><input type='checkbox' name='form_cb_ins' value='1' " .
 540     "onclick='return divclick(this,\"div_ins\");'";
 541   if ($display_style == 'block') echo " checked";
 542   echo " /><b>" . xl('Insurance') . "</b></span>\n";
 543   echo "<div id='div_ins' class='section' style='display:$display_style;'>\n";
 544
 545   for($i=1;$i<=3;$i++) {
 546    $result3 = $insurance_info[$i];
 547 ?>
 548 <table border="0">
 549  <tr>
 550   <td valign='top' colspan='2'>
 551    <span class='required'><?php echo $insurance_headings[$i -1].":"?></span>
 552    <select name="i<?php echo $i?>provider">
 553     <option value=""><?php xl('Unassigned','e'); ?></option>
 554 <?php
 555  foreach ($insurancei as $iid => $iname) {
 556   echo "<option value='" . $iid . "'";
 557   if (strtolower($iid) == strtolower($result3{"provider"}))
 558    echo " selected";
 559   echo ">" . $iname . "</option>\n";
 560  }
 561 ?>
 562    </select>&nbsp;<a class='iframe medium_modal' href='../practice/ins_search.php' onclick='ins_search(<?php echo $i?>)'>
 563   <span> <?php xl('Search/Add Insurer','e'); ?></span></a>
 564   </td>
 565  </tr>
 566  <tr>
 567   <td valign=top>
 568    <table border="0">
 569
 570     <tr>
 571      <td>
 572       <span class='required'><?php xl('Plan Name','e'); ?>: </span>
 573      </td>
 574      <td>
 575       <input type='entry' size='20' name='i<?php echo $i?>plan_name' value="<?php echo $result3{"plan_name"} ?>"
 576        onchange="capitalizeMe(this);" />&nbsp;&nbsp;
 577      </td>
 578     </tr>
 579
 580     <tr>
 581      <td>
 582       <span class='required'><?php xl('Effective Date','e'); ?>: </span>
 583      </td>
 584      <td>
 585       <input type='entry' size='11' name='i<?php echo $i ?>effective_date'
 586        id='i<?php echo $i ?>effective_date'
 587        value='<?php echo $result3['date'] ?>'
 588        onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)'
 589        title='yyyy-mm-dd' />
 590
 591       <img src='../../interface/pic/show_calendar.gif' align='absbottom' width='24' height='22'
 592       id='img_i<?php echo $i ?>effective_date' border='0' alt='[?]' style='cursor:pointer'
 593       title='<?php xl('Click here to choose a date','e'); ?>'>
 594
 595       <script LANGUAGE="JavaScript">
 596       Calendar.setup({inputField:"i<?php echo $i ?>effective_date", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i; ?>effective_date"});
 597       </script>
 598
 599
 600      </td>
 601     </tr>
 602
 603     <tr>
 604      <td><span class=required><?php xl('Policy Number','e'); ?>: </span></td>
 605      <td><input type='entry' size='16' name='i<?php echo $i?>policy_number' value="<?php echo $result3{"policy_number"}?>"
 606       onkeyup='policykeyup(this)'></td>
 607     </tr>
 608
 609     <tr>
 610      <td><span class=required><?php xl('Group Number','e'); ?>: </span></td><td><input type=entry size=16 name=i<?php echo $i?>group_number value="<?php echo $result3{"group_number"}?>" onkeyup='policykeyup(this)'></td>
 611     </tr>
 612
 613     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 614      <td class='required'><?php xl('Subscriber Employer (SE)','e'); ?><br><span style='font-weight:normal'>
 615       (<?php xl('if unemployed enter Student','e'); ?>,<br><?php xl('PT Student, or leave blank','e'); ?>): </span></td>
 616      <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer
 617       value="<?php echo $result3{"subscriber_employer"}?>"
 618        onchange="capitalizeMe(this);" /></td>
 619     </tr>
 620
 621     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 622      <td><span class=required><?php xl('SE Address','e'); ?>: </span></td>
 623      <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer_street
 624       value="<?php echo $result3{"subscriber_employer_street"}?>"
 625        onchange="capitalizeMe(this);" /></td>
 626     </tr>
 627
 628     <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 629      <td colspan="2">
 630       <table>
 631        <tr>
 632         <td><span class=required><?php xl('SE City','e'); ?>: </span></td>
 633         <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_city
 634          value="<?php echo $result3{"subscriber_employer_city"}?>"
 635           onchange="capitalizeMe(this);" /></td>
 636         <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE State','e') : xl('SE Locality','e') ?>: </span></td>
 637         <td>
 638          <?php
 639           // Modified 7/2009 by BM to incorporate data types
 640           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'), $result3['subscriber_employer_state']);
 641          ?>
 642         </td>
 643        </tr>
 644        <tr>
 645         <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE Zip Code','e') : xl('SE Postal Code','e') ?>: </span></td>
 646         <td><input type=entry size=10 name=i<?php echo $i?>subscriber_employer_postal_code value="<?php echo $result3{"subscriber_employer_postal_code"}?>"></td>
 647         <td><span class=required><?php xl('SE Country','e'); ?>: </span></td>
 648         <td>
 649          <?php
 650           // Modified 7/2009 by BM to incorporate data types
 651           generate_form_field(array('data_type'=>$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']);
 652          ?>
 653         </td>
 654        </tr>
 655       </table>
 656      </td>
 657     </tr>
 658
 659    </table>
 660   </td>
 661
 662   <td valign=top>
 663    <span class=required><?php xl('Subscriber','e'); ?>: </span>
 664    <input type=entry size=10 name=i<?php echo $i?>subscriber_fname
 665     value="<?php echo $result3{"subscriber_fname"}?>"
 666     onchange="capitalizeMe(this);" />
 667    <input type=entry size=3 name=i<?php echo $i?>subscriber_mname
 668     value="<?php echo $result3{"subscriber_mname"}?>"
 669     onchange="capitalizeMe(this);" />
 670    <input type=entry size=10 name=i<?php echo $i?>subscriber_lname
 671     value="<?php echo $result3{"subscriber_lname"}?>"
 672     onchange="capitalizeMe(this);" />
 673    <br>
 674    <span class=required><?php xl('Relationship','e'); ?>: </span>
 675    <?php
 676     // Modified 6/2009 by BM to use list_options and function
 677     generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_relationship'),'list_id'=>'sub_relation','empty_title'=>' '), $result3['subscriber_relationship']);
 678    ?>
 679    <a href="javascript:popUp('../../interface/patient_file/summary/browse.php?browsenum=<?php echo $i?>')" class=text>(<?php xl('Browse','e'); ?>)</a><br />
 680
 681    <span class=bold><?php xl('D.O.B.','e'); ?>: </span>
 682    <input type='entry' size='11' name='i<?php echo $i?>subscriber_DOB'
 683     id='i<?php echo $i?>subscriber_DOB'
 684     value='<?php echo $result3['subscriber_DOB'] ?>'
 685     onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)'
 686     title='yyyy-mm-dd' />
 687
 688    <img src='../../interface/pic/show_calendar.gif' align='absbottom' width='24' height='22'
 689     id='img_i<?php echo $i; ?>dob_date' border='0' alt='[?]' style='cursor:pointer'
 690     title='<?php xl('Click here to choose a date','e'); ?>'>
 691
 692     <script LANGUAGE="JavaScript">
 693     Calendar.setup({inputField:"i<?php echo $i?>subscriber_DOB", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i; ?>dob_date"});
 694     </script>
 695
 696
 697    <span class=bold><?php xl('S.S.','e'); ?>: </span><input type=entry size=11 name=i<?php echo $i?>subscriber_ss value="<?php echo $result3{"subscriber_ss"}?>">&nbsp;
 698    <span class=bold><?php xl('Sex','e'); ?>: </span>
 699    <?php
 700     // Modified 6/2009 by BM to use list_options and function
 701     generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_sex'),'list_id'=>'sex'), $result3['subscriber_sex']);
 702    ?>
 703    <br>
 704    <span class=required><?php xl('Subscriber Address','e'); ?>: </span>
 705    <input type=entry size=25 name=i<?php echo $i?>subscriber_street
 706     value="<?php echo $result3{"subscriber_street"}?>"
 707     onchange="capitalizeMe(this);" /><br>
 708    <span class=required><?php xl('City','e'); ?>: </span>
 709    <input type=entry size=15 name=i<?php echo $i?>subscriber_city
 710     value="<?php echo $result3{"subscriber_city"}?>"
 711     onchange="capitalizeMe(this);" />
 712    <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('State','e') : xl('Locality','e') ?>: </span>
 713    <?php
 714     // Modified 7/2009 by BM to incorporate data types
 715     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'), $result3['subscriber_state']);
 716    ?>
 717    <br />
 718    <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('Zip Code','e') : xl('Postal Code','e') ?>: </span><input type=entry size=10 name=i<?php echo $i?>subscriber_postal_code value="<?php echo $result3{"subscriber_postal_code"}?>">
 719    <span class='required'<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 720    <?php xl('Country','e'); ?>: </span>
 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_country'),'list_id'=>$GLOBALS['country_list'],'fld_length'=>'10','max_length'=>'63','edit_options'=>'C'), $result3['subscriber_country']);
 724    ?>
 725    <br />
 726    <span class=bold><?php xl('Subscriber Phone','e'); ?>:
 727    <input type='text' size='20' name='i<?php echo $i?>subscriber_phone' value='<?php echo $result3["subscriber_phone"] ?>' onkeyup='phonekeyup(this,mypcc)' />
 728    </span><br />
 729    <span class=bold><?php xl('CoPay','e'); ?>: <input type=text size="6" name=i<?php echo $i?>copay value="<?php echo $result3{"copay"}?>">
 730    </span><br />
 731    <span class='required'><?php xl('Accept Assignment','e'); ?>: </span>
 732    <select name=i<?php echo $i?>accept_assignment>
 733      <option value="TRUE" <?php if (strtoupper($result3{"accept_assignment"}) == "TRUE") echo "selected"?>><?php xl('YES','e'); ?></option>
 734      <option value="FALSE" <?php if (strtoupper($result3{"accept_assignment"}) == "FALSE") echo "selected"?>><?php xl('NO','e'); ?></option>
 735    </select>
 736   </td>
 737  </tr>
 738
 739 </table>
 740 <hr />
 741 <?php
 742   }
 743   echo "</div>\n";
 744  } // end of "if not simplified_demographics"
 745 ?>
 746
 747 <?php if (!$SHORT_FORM) echo "  <center>\n"; ?>
 748 <br />
 749 <?php if ($WITH_SEARCH) { ?>
 750 <input type="button" id="search" value=<?php xl('Search','e','\'','\''); ?>
 751  style='background-color:<?php echo $searchcolor; ?>' />
 752 &nbsp;&nbsp;
 753 <?php } ?>
 754 <input type="button" name='create' id="create" value=<?php xl('Create New Patient','e','\'','\''); ?> />
 755
 756 </center>
 757
 758   </td>
 759   <td align='right' valign='top' width='1%' nowrap>
 760    <!-- Image upload stuff was here but got moved. -->
 761   </td>
 762  </tr>
 763 </table>
 764
 765 </form>
 766
 767 <!-- include support for the list-add selectbox feature -->
 768 <?php include($GLOBALS['fileroot']."/library/options_listadd.inc"); ?>
 769
 770 </body>
 771
 772 <script language="JavaScript">
 773
 774 // hard code validation for old validation, in the new validation possible to add match rules
 775 <?php if($GLOBALS['new_validate'] == 0) { ?>
 776
 777 // fix inconsistently formatted phone numbers from the database
 778 var f = document.forms[0];
 779 if (f.form_phone_contact) phonekeyup(f.form_phone_contact,mypcc);
 780 if (f.form_phone_home   ) phonekeyup(f.form_phone_home   ,mypcc);
 781 if (f.form_phone_biz    ) phonekeyup(f.form_phone_biz    ,mypcc);
 782 if (f.form_phone_cell   ) phonekeyup(f.form_phone_cell   ,mypcc);
 783
 784 <?php }?>
 785
 786 <?php echo $date_init; ?>
 787
 788 // -=- jQuery makes life easier -=-
 789
 790 // var matches = 0; // number of patients that match the demographic information being entered
 791 // var override = false; // flag that overrides the duplication warning
 792
 793 $(document).ready(function() {
 794 enable_modals();
 795  $(".medium_modal").fancybox( {
 796                 'overlayOpacity' : 0.0,
 797                 'showCloseButton' : true,
 798                 'frameHeight' : 460,
 799                 'frameWidth' : 650
 800         });
 801     // added to integrate insurance stuff
 802     <?php for ($i=1;$i<=3;$i++) { ?>
 803     $("#form_i<?php echo $i?>subscriber_relationship").change(function() { auto_populate_employer_address<?php echo $i?>(); });
 804     <?php } ?>
 805
 806     $('#search').click(function() { searchme(); });
 807     $('#create').click(function() { check()});
 808
 809     var check = function(e) {
 810       <?php if($GLOBALS['new_validate']){?>
 811             var valid = submitme(<?php echo $GLOBALS['new_validate'] ? 1 : 0;?>,e,"DEM",constraints);
 812       <?php }else{?>
 813             top.restoreSession();
 814             var f = document.forms[0];
 815             var valid = validate(f);
 816       <?php }?>
 817         if (valid) {
 818             if (force_submit) {
 819                 // In this case dups were shown already and Save should just save.
 820                 f.submit();
 821                 return;
 822             }
 823
 824       <?php
 825         // D in edit_options indicates the field is used in duplication checking.
 826         // This constructs a list of the names of those fields.
 827         $mflist = "";
 828         $mfres = sqlStatement("SELECT * FROM layout_options " .
 829             "WHERE form_id = 'DEM' AND uor > 0 AND field_id != '' AND " .
 830             "edit_options LIKE '%D%' " .
 831             "ORDER BY group_name, seq");
 832         while ($mfrow = sqlFetchArray($mfres)) {
 833             $field_id  = $mfrow['field_id'];
 834             if (strpos($field_id, 'em_') === 0) continue;
 835             if (!empty($mflist)) $mflist .= ",";
 836             $mflist .= "'" . htmlentities($field_id) . "'";
 837         }
 838 ?>
 839         <?php if ( ($GLOBALS['full_new_patient_form'] == '4') && (checkIfPatientValidationHookIsActive()) ):?>
 840             // Use zend module patient validation hook to open the controller and send the dup-checker fields.
 841             var url ='<?php echo  $GLOBALS['web_root']."/interface/modules/zend_modules/public/patientvalidation?close";?>';
 842         <?php else:?>
 843             // Build and invoke the URL to create the dup-checker dialog.
 844             var url = 'new_search_popup.php';
 845         <?php endif;?>
 846
 847         var flds = new Array(<?php echo $mflist; ?>);
 848         var separator = '?';
 849         for (var i = 0; i < flds.length; ++i) {
 850             var fval = $('#form_' + flds[i]).val();
 851             if (fval && fval != '') {
 852                 url += separator;
 853                 separator = '&';
 854                 url += 'mf_' + flds[i] + '=' + encodeURIComponent(fval);
 855             }
 856         }
 857
 858         dlgopen(url, '_blank', 700, 500);
 859         } // end function
 860     } // end function
 861
 862
 863 // Set onclick/onfocus handlers for toggling background color.
 864 <?php
 865 $lres = getLayoutRes();
 866 while ($lrow = sqlFetchArray($lres)) {
 867   $field_id  = $lrow['field_id'];
 868   if (strpos($field_id, 'em_') === 0) continue;
 869   switch(getSearchClass($lrow['data_type'])) {
 870     case 1:
 871       echo "    \$('#form_$field_id').click(function() { toggleSearch(this); });\n";
 872       break;
 873     case 2:
 874       echo "    \$('#form_$field_id').click(function() { selClick(this); });\n";
 875       echo "    \$('#form_$field_id').blur(function() { selBlur(this); });\n";
 876       break;
 877   }
 878 }
 879 ?>
 880
 881 }); // end document.ready
 882
 883 </script>
 884 <?php /*Include the validation script and rules for this form*/
 885 $form_id="DEM";
 886 ?>
 887
 888 <?php include_once("$srcdir/validation/validation_script.js.php");?>
 889 <script language='JavaScript'>
 890     // Array of skip conditions for the checkSkipConditions() function.
 891     var skipArray = [
 892         <?php echo $condition_str; ?>
 893     ];
 894     checkSkipConditions();
 895     $("input").change(function() {
 896         checkSkipConditions();
 897     });
 898     $("select").change(function() {
 899         checkSkipConditions();
 900     });
 901 </script>
 902
 903 </html>
 904