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("$srcdir/formatting.inc.php");
  11
  12  // Session pid must be right or bad things can happen when demographics are saved!
  13  //
  14  include_once("$srcdir/pid.inc");
  15  $set_pid = $_GET["set_pid"] ? $_GET["set_pid"] : $_GET["pid"];
  16  if ($set_pid && $set_pid != $_SESSION["pid"]) {
  17   setpid($set_pid);
  18  }
  19
  20  include_once("$srcdir/patient.inc");
  21
  22  $result = getPatientData($pid, "*, DATE_FORMAT(DOB,'%Y-%m-%d') as DOB_YMD");
  23  $result2 = getEmployerData($pid);
  24
  25  // Check authorization.
  26  $thisauth = acl_check('patients', 'demo');
  27  if ($pid) {
  28   if ($thisauth != 'write')
  29    die(xl('Updating demographics is not authorized.'));
  30   if ($result['squad'] && ! acl_check('squads', $result['squad']))
  31    die(xl('You are not authorized to access this squad.'));
  32  } else {
  33   if ($thisauth != 'write' && $thisauth != 'addonly')
  34    die(xl('Adding demographics is not authorized.'));
  35  }
  36
  37 $CPR = 4; // cells per row
  38
  39 // $statii = array('married','single','divorced','widowed','separated','domestic partner');
  40 // $langi = getLanguages();
  41 // $ethnoraciali = getEthnoRacials();
  42 // $provideri = getProviderInfo();
  43
  44 $insurancei = getInsuranceProviders();
  45
  46 $fres = sqlStatement("SELECT * FROM layout_options " .
  47   "WHERE form_id = 'DEM' AND uor > 0 " .
  48   "ORDER BY group_name, seq");
  49 ?>
  50 <html>
  51 <head>
  52 <?php html_header_show();?>
  53
  54 <link rel="stylesheet" href="<?php echo $css_header; ?>" type="text/css">
  55
  56 <style type="text/css">@import url(../../../library/dynarch_calendar.css);</style>
  57
  58 <script type="text/javascript" src="../../../library/dialog.js"></script>
  59 <script type="text/javascript" src="../../../library/textformat.js"></script>
  60 <script type="text/javascript" src="../../../library/dynarch_calendar.js"></script>
  61 <?php include_once("{$GLOBALS['srcdir']}/dynarch_calendar_en.inc.php"); ?>
  62 <script type="text/javascript" src="../../../library/dynarch_calendar_setup.js"></script>
  63
  64 <script type="text/javascript" src="../../../library/js/jquery.1.3.2.js"></script>
  65 <script type="text/javascript" src="../../../library/js/common.js"></script>
  66
  67 <script type="text/javascript" src="../../../library/js/fancybox/jquery.fancybox-1.2.6.js"></script>
  68
  69 <link rel="stylesheet" type="text/css" href="../../../library/js/fancybox/jquery.fancybox-1.2.6.css" media="screen" />
  70
  71 <script type="text/javascript">
  72 $(document).ready(function(){
  73     tabbify();
  74     enable_modals();
  75
  76     // special size for
  77         $(".medium_modal").fancybox( {
  78                 'overlayOpacity' : 0.0,
  79                 'showCloseButton' : true,
  80                 'frameHeight' : 460,
  81                 'frameWidth' : 650
  82         });
  83
  84 });
  85
  86 var mypcc = '<?php echo $GLOBALS['phone_country_code'] ?>';
  87
  88 //code used from http://tech.irt.org/articles/js037/
  89 function replace(string,text,by) {
  90  // Replaces text with by in string
  91  var strLength = string.length, txtLength = text.length;
  92  if ((strLength == 0) || (txtLength == 0)) return string;
  93
  94  var i = string.indexOf(text);
  95  if ((!i) && (text != string.substring(0,txtLength))) return string;
  96  if (i == -1) return string;
  97
  98  var newstr = string.substring(0,i) + by;
  99
 100  if (i+txtLength < strLength)
 101   newstr += replace(string.substring(i+txtLength,strLength),text,by);
 102
 103  return newstr;
 104 }
 105
 106 function upperFirst(string,text) {
 107  return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
 108 }
 109
 110 <?php for ($i=1;$i<=3;$i++) { ?>
 111 function auto_populate_employer_address<?php echo $i ?>(){
 112  var f = document.demographics_form;
 113  if (f.form_i<?php echo $i?>subscriber_relationship.options[f.form_i<?php echo $i?>subscriber_relationship.selectedIndex].value == "self")
 114  {
 115   f.i<?php echo $i?>subscriber_fname.value=f.form_fname.value;
 116   f.i<?php echo $i?>subscriber_mname.value=f.form_mname.value;
 117   f.i<?php echo $i?>subscriber_lname.value=f.form_lname.value;
 118   f.i<?php echo $i?>subscriber_street.value=f.form_street.value;
 119   f.i<?php echo $i?>subscriber_city.value=f.form_city.value;
 120   f.form_i<?php echo $i?>subscriber_state.value=f.form_state.value;
 121   f.i<?php echo $i?>subscriber_postal_code.value=f.form_postal_code.value;
 122   if (f.form_country_code)
 123     f.form_i<?php echo $i?>subscriber_country.value=f.form_country_code.value;
 124   f.i<?php echo $i?>subscriber_phone.value=f.form_phone_home.value;
 125   f.i<?php echo $i?>subscriber_DOB.value=f.form_DOB.value;
 126   f.i<?php echo $i?>subscriber_ss.value=f.form_ss.value;
 127   f.form_i<?php echo $i?>subscriber_sex.value = f.form_sex.value;
 128   f.i<?php echo $i?>subscriber_employer.value=f.form_em_name.value;
 129   f.i<?php echo $i?>subscriber_employer_street.value=f.form_em_street.value;
 130   f.i<?php echo $i?>subscriber_employer_city.value=f.form_em_city.value;
 131   f.form_i<?php echo $i?>subscriber_employer_state.value=f.form_em_state.value;
 132   f.i<?php echo $i?>subscriber_employer_postal_code.value=f.form_em_postal_code.value;
 133   if (f.form_em_country)
 134     f.form_i<?php echo $i?>subscriber_employer_country.value=f.form_em_country.value;
 135  }
 136 }
 137
 138 <?php } ?>
 139
 140 function popUp(URL) {
 141  day = new Date();
 142  id = day.getTime();
 143  top.restoreSession();
 144  eval("page" + id + " = window.open(URL, '" + id + "', 'toolbar=0,scrollbars=1,location=0,statusbar=0,menubar=0,resizable=1,width=400,height=300,left = 440,top = 362');");
 145 }
 146
 147 function checkNum () {
 148  var re= new RegExp();
 149  re = /^\d*\.?\d*$/;
 150  str=document.demographics_form.monthly_income.value;
 151  if(re.exec(str))
 152  {
 153  }else{
 154   alert("<?php xl('Please enter a monetary amount using only numbers and a decimal point.','e'); ?>");
 155  }
 156 }
 157
 158 // Indicates which insurance slot is being updated.
 159 var insurance_index = 0;
 160
 161 // The OnClick handler for searching/adding the insurance company.
 162 function ins_search(ins) {
 163         insurance_index = ins;
 164         return false;
 165 }
 166
 167 // The ins_search.php window calls this to set the selected insurance.
 168 function set_insurance(ins_id, ins_name) {
 169  var thesel = document.forms[0]['i' + insurance_index + 'provider'];
 170  var theopts = thesel.options; // the array of Option objects
 171  var i = 0;
 172  for (; i < theopts.length; ++i) {
 173   if (theopts[i].value == ins_id) {
 174    theopts[i].selected = true;
 175    return;
 176   }
 177  }
 178  // no matching option was found so create one, append it to the
 179  // end of the list, and select it.
 180  theopts[i] = new Option(ins_name, ins_id, false, true);
 181 }
 182
 183 // This capitalizes the first letter of each word in the passed input
 184 // element.  It also strips out extraneous spaces.
 185 function capitalizeMe(elem) {
 186  var a = elem.value.split(' ');
 187  var s = '';
 188  for(var i = 0; i < a.length; ++i) {
 189   if (a[i].length > 0) {
 190    if (s.length > 0) s += ' ';
 191    s += a[i].charAt(0).toUpperCase() + a[i].substring(1);
 192   }
 193  }
 194  elem.value = s;
 195 }
 196
 197 function divclick(cb, divid) {
 198  var divstyle = document.getElementById(divid).style;
 199  if (cb.checked) {
 200   divstyle.display = 'block';
 201  } else {
 202   divstyle.display = 'none';
 203  }
 204  return true;
 205 }
 206
 207 // Compute the length of a string without leading and trailing spaces.
 208 function trimlen(s) {
 209  var i = 0;
 210  var j = s.length - 1;
 211  for (; i <= j && s.charAt(i) == ' '; ++i);
 212  for (; i <= j && s.charAt(j) == ' '; --j);
 213  if (i > j) return 0;
 214  return j + 1 - i;
 215 }
 216
 217 function validate(f) {
 218  var errCount = 0;
 219  var errMsgs = new Array();
 220 <?php generate_layout_validation('DEM'); ?>
 221
 222  var msg = "";
 223  msg += "<?php xl('The following fields are required', 'e' ); ?>:\n\n";
 224  for ( var i = 0; i < errMsgs.length; i++ ) {
 225         msg += errMsgs[i] + "\n";
 226  }
 227  msg += "\n<?php xl('Please fill them in before continuing.', 'e'); ?>";
 228
 229  if ( errMsgs.length > 0 ) {
 230         alert(msg);
 231  }
 232
 233 // Some insurance validation.
 234  for (var i = 1; i <= 3; ++i) {
 235   subprov = 'i' + i + 'provider';
 236   if (!f[subprov] || f[subprov].selectedIndex <= 0) continue;
 237   var subpfx = 'i' + i + 'subscriber_';
 238   var subrelat = f['form_' + subpfx + 'relationship'];
 239   var samename =
 240    f[subpfx + 'fname'].value == f.form_fname.value &&
 241    f[subpfx + 'mname'].value == f.form_mname.value &&
 242    f[subpfx + 'lname'].value == f.form_lname.value;
 243   var samess = f[subpfx + 'ss'].value == f.form_ss.value;
 244   if (subrelat.options[subrelat.selectedIndex].value == "self") {
 245    if (!samename) {
 246     if (!confirm("<?php xl('Subscriber relationship is self but name is different! Is this really OK?','e'); ?>"))
 247      return false;
 248    }
 249    if (!samess) {
 250     alert("<?php xl('Subscriber relationship is self but SS number is different!','e'); ?>");
 251     return false;
 252    }
 253   } // end self
 254   else {
 255    if (samename) {
 256     if (!confirm("<?php xl('Subscriber relationship is not self but name is the same! Is this really OK?','e'); ?>"))
 257      return false;
 258    }
 259    if (samess) {
 260     alert("<?php xl('Subscriber relationship is not self but SS number is the same!','e'); ?>");
 261     return false;
 262    }
 263   } // end not self
 264  } // end for
 265
 266  return errMsgs.length < 1;
 267 }
 268
 269 function submitme() {
 270  var f = document.forms[0];
 271  if (validate(f)) {
 272   top.restoreSession();
 273   f.submit();
 274  }
 275 }
 276
 277 // Onkeyup handler for policy number.  Allows only A-Z and 0-9.
 278 function policykeyup(e) {
 279  var v = e.value.toUpperCase();
 280  for (var i = 0; i < v.length; ++i) {
 281   var c = v.charAt(i);
 282   if (c >= '0' && c <= '9') continue;
 283   if (c >= 'A' && c <= 'Z') continue;
 284   if (c == '*') continue;
 285   if (c == '-') continue;
 286   if (c == '_') continue;
 287   if (c == '(') continue;
 288   if (c == ')') continue;
 289   if (c == '#') continue;
 290   v = v.substring(0, i) + v.substring(i + i);
 291   --i;
 292  }
 293  e.value = v;
 294  return;
 295 }
 296
 297 // Added 06/2009 by BM to make compatible with list_options table and functions - using jquery
 298 $(document).ready(function() {
 299
 300  <?php for ($i=1;$i<=3;$i++) { ?>
 301   $("#form_i<?php echo $i?>subscriber_relationship").change(function() { auto_populate_employer_address<?php echo $i?>(); });
 302  <?php } ?>
 303
 304 });
 305
 306 </script>
 307 </head>
 308
 309 <body class="body_top">
 310 <form action='demographics_save.php' name='demographics_form' method='post' onsubmit='return validate(this)'>
 311 <input type='hidden' name='mode' value='save' />
 312 <input type='hidden' name='db_id' value="<?php echo $result['id']?>" />
 313 <table cellpadding='0' cellspacing='0' border='0'>
 314         <tr>
 315                 <td>
 316                         <?php if ($GLOBALS['concurrent_layout']) { ?>
 317                         <a href="demographics.php" onclick="top.restoreSession()">
 318                         <?php } else { ?>
 319                         <a href="patient_summary.php" target="Main" onclick="top.restoreSession()">
 320                         <?php } ?>
 321                         <font class=title><?php xl('Current Patient','e'); ?></font>
 322                         </a>
 323                         &nbsp;&nbsp;
 324                 </td>
 325                 <td>
 326                         <a href="javascript:submitme();" class='css_button'>
 327                                 <span><?php xl('Save','e'); ?></span>
 328                         </a>
 329                 </td>
 330                 <td>
 331                         <?php if ($GLOBALS['concurrent_layout']) { ?>
 332                         <a class="css_button" href="demographics.php" onclick="top.restoreSession()">
 333                         <?php } else { ?>
 334                         <a href="patient_summary.php" target="Main" onclick="top.restoreSession()">
 335                         <?php } ?>
 336                         <span><?php xl('Cancel','e'); ?></span>
 337                         </a>
 338                 </td>
 339         </tr>
 340 </table>
 341 <?php
 342
 343 function end_cell() {
 344   global $item_count, $cell_count;
 345   if ($item_count > 0) {
 346     echo "</td>";
 347     $item_count = 0;
 348   }
 349 }
 350
 351 function end_row() {
 352   global $cell_count, $CPR;
 353   end_cell();
 354   if ($cell_count > 0) {
 355     for (; $cell_count < $CPR; ++$cell_count) echo "<td></td>";
 356     echo "</tr>\n";
 357     $cell_count = 0;
 358   }
 359 }
 360
 361 function end_group() {
 362   global $last_group;
 363   if (strlen($last_group) > 0) {
 364     end_row();
 365     echo " </table>\n";
 366     echo "</div>\n";
 367   }
 368 }
 369
 370 $last_group = '';
 371 $cell_count = 0;
 372 $item_count = 0;
 373 $display_style = 'block';
 374
 375 $group_seq=0; // this gives the DIV blocks unique IDs
 376
 377 ?>
 378 <br>
 379   <div class="section-header">
 380    <span class="text"><b> <?php xl("Demographics", "e" )?></b></span>
 381 </div>
 382
 383 <div id="DEM" >
 384
 385         <ul class="tabNav">
 386            <?php display_layout_tabs('DEM', $result, $result2); ?>
 387         </ul>
 388
 389         <div class="tabContainer">
 390                 <?php display_layout_tabs_data_editable('DEM', $result, $result2); ?>
 391         </div>
 392 </div>
 393 <br>
 394   <div class="section-header">
 395     <span class="text"><b><?php xl("Insurance", "e" )?></b></span>
 396 </div>
 397 <div id="DEM" >
 398
 399
 400 <?php
 401  if (! $GLOBALS['simplified_demographics']) {
 402
 403           $insurance_headings = array(xl("Primary Insurance Provider"), xl("Secondary Insurance Provider"), xl("Tertiary Insurance provider"));
 404           $insurance_info = array();
 405           $insurance_info[1] = getInsuranceData($pid,"primary");
 406           $insurance_info[2] = getInsuranceData($pid,"secondary");
 407           $insurance_info[3] = getInsuranceData($pid,"tertiary");
 408
 409         ?>
 410         <div id="INSURANCE" >
 411                 <ul class="tabNav">
 412                 <?php
 413                 foreach (array('primary','secondary','tertiary') as $instype) {
 414                         ?><li <?php echo $instype == 'primary' ? 'class="current"' : '' ?>><a href="/play/javascript-tabbed-navigation/"><?php $CapInstype=ucfirst($instype); xl($CapInstype,'e'); ?></a></li><?php
 415                 }
 416                 ?>
 417                 </ul>
 418
 419         <div class="tabContainer">
 420
 421         <?php
 422           for($i=1;$i<=3;$i++) {
 423            $result3 = $insurance_info[$i];
 424         ?>
 425
 426                 <div class="tab <?php echo $i == 1 ? 'current': '' ?>" style='height:auto;width:auto'>          <!---display icky, fix to auto-->
 427
 428                 <table border="0">
 429
 430                  <tr>
 431                   <td valign=top width="430">
 432                    <table border="0">
 433
 434                          <tr>
 435                           <td valign='top'>
 436                            <span class='required'><?php echo $insurance_headings[$i -1]."&nbsp;"?></span>
 437                           </td>
 438                           <td class='required'>:</td>
 439                           <td>
 440                            <a href="../../practice/ins_search.php" class="iframe medium_modal css_button" onclick="ins_search(<?php echo $i?>)">
 441                                 <span><?php echo xl('Search/Add') ?></span>
 442                                 </a>
 443                                 <select name="i<?php echo $i?>provider">
 444                                 <option value=""><?php xl('Unassigned','e'); ?></option>
 445                                 <?php
 446                                  foreach ($insurancei as $iid => $iname) {
 447                                   echo "<option value='" . $iid . "'";
 448                                   if (strtolower($iid) == strtolower($result3{"provider"}))
 449                                    echo " selected";
 450                                   echo ">" . $iname . "</option>\n";
 451                                  }
 452                                 ?>
 453                            </select>
 454
 455                           </td>
 456                          </tr>
 457
 458                         <tr>
 459                          <td>
 460                           <span class='required'><?php xl('Plan Name','e'); ?> </span>
 461                          </td>
 462                          <td class='required'>:</td>
 463                          <td>
 464                           <input type='entry' size='20' name='i<?php echo $i?>plan_name' value="<?php echo $result3{"plan_name"} ?>"
 465                            onchange="capitalizeMe(this);" />&nbsp;&nbsp;
 466                          </td>
 467                         </tr>
 468
 469                         <tr>
 470                          <td>
 471                           <span class='required'><?php xl('Effective Date','e'); ?></span>
 472                          </td>
 473                          <td class='required'>:</td>
 474                          <td>
 475                           <input type='entry' size='16' id='i<?php echo $i ?>effective_date' name='i<?php echo $i ?>effective_date'
 476                            value='<?php echo $result3['date'] ?>'
 477                            onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)'
 478                            title='yyyy-mm-dd' />
 479                           <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'); ?>'>
 480                          </td>
 481                         </tr>
 482
 483                         <tr>
 484                          <td><span class=required><?php xl('Policy Number','e'); ?></span></td>
 485                          <td class='required'>:</td>
 486                          <td><input type='entry' size='16' name='i<?php echo $i?>policy_number' value="<?php echo $result3{"policy_number"}?>"
 487                           onkeyup='policykeyup(this)'></td>
 488                         </tr>
 489
 490                         <tr>
 491                          <td><span class=required><?php xl('Group Number','e'); ?></span></td>
 492                          <td class='required'>:</td>
 493                          <td><input type=entry size=16 name=i<?php echo $i?>group_number value="<?php echo $result3{"group_number"}?>" onkeyup='policykeyup(this)'></td>
 494                         </tr>
 495
 496                         <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 497                          <td class='required'><?php xl('Subscriber Employer (SE)','e'); ?><br><span style='font-weight:normal'>
 498                           (<?php xl('if unemployed enter Student','e'); ?>,<br><?php xl('PT Student, or leave blank','e'); ?>) </span></td>
 499                           <td class='required'>:</td>
 500                          <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer
 501                           value="<?php echo $result3{"subscriber_employer"}?>"
 502                            onchange="capitalizeMe(this);" /></td>
 503                         </tr>
 504
 505                         <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 506                          <td><span class=required><?php xl('SE Address','e'); ?></span></td>
 507                          <td class='required'>:</td>
 508                          <td><input type=entry size=25 name=i<?php echo $i?>subscriber_employer_street
 509                           value="<?php echo $result3{"subscriber_employer_street"}?>"
 510                            onchange="capitalizeMe(this);" /></td>
 511                         </tr>
 512
 513                         <tr<?php if ($GLOBALS['omit_employers']) echo " style='display:none'"; ?>>
 514                          <td colspan="3">
 515                           <table>
 516                            <tr>
 517                                 <td><span class=required><?php xl('SE City','e'); ?>: </span></td>
 518                                 <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_city
 519                                  value="<?php echo $result3{"subscriber_employer_city"}?>"
 520                                   onchange="capitalizeMe(this);" /></td>
 521                                 <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE State','e') : xl('SE Locality','e') ?>: </span></td>
 522                         <td>
 523                                  <?php
 524                                   // Modified 7/2009 by BM to incorporate data types
 525                           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'), $result3['subscriber_employer_state']);
 526                                  ?>
 527                                 </td>
 528                            </tr>
 529                            <tr>
 530                                 <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('SE Zip Code','e') : xl('SE Postal Code','e') ?>: </span></td>
 531                                 <td><input type=entry size=15 name=i<?php echo $i?>subscriber_employer_postal_code value="<?php echo $result3{"subscriber_employer_postal_code"}?>"></td>
 532                                 <td><span class=required><?php xl('SE Country','e'); ?>: </span></td>
 533                         <td>
 534                                  <?php
 535                                   // Modified 7/2009 by BM to incorporate data types
 536                           generate_form_field(array('data_type'=>$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'), $result3['subscriber_employer_country']);
 537                                  ?>
 538                         </td>
 539                            </tr>
 540                           </table>
 541                          </td>
 542                         </tr>
 543
 544                    </table>
 545                   </td>
 546
 547                   <td valign=top>
 548                 <table border="0">
 549                         <tr>
 550                                 <td><span class=required><?php xl('Relationship','e'); ?></span></td>
 551                                 <td class=required>:</td>
 552                                 <td colspan=3><?php
 553                                         // Modified 6/2009 by BM to use list_options and function
 554                                         generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_relationship'),'list_id'=>'sub_relation','empty_title'=>' '), $result3['subscriber_relationship']);
 555                                         ?>
 556
 557                                 <a href="javascript:popUp('browse.php?browsenum=<?php echo $i?>')" class=text>(<?php xl('Browse','e'); ?>)</a></td>
 558                                 <td></td><td></td><td></td><td></td>
 559                         </tr>
 560                         <tr>
 561                                 <td width=120><span class=required><?php xl('Subscriber','e'); ?> </span></td>
 562                                 <td class=required>:</td>
 563                                 <td colspan=3><input type=entry size=10 name=i<?php echo $i?>subscriber_fname   value="<?php echo $result3{"subscriber_fname"}?>" onchange="capitalizeMe(this);" />
 564                                 <input type=entry size=3 name=i<?php echo $i?>subscriber_mname value="<?php echo $result3{"subscriber_mname"}?>" onchange="capitalizeMe(this);" />
 565                                 <input type=entry size=10 name=i<?php echo $i?>subscriber_lname value="<?php echo $result3{"subscriber_lname"}?>" onchange="capitalizeMe(this);" /></td>
 566                                 <td></td><td></td><td></td><td></td>
 567                         </tr>
 568                         <tr>
 569                                 <td><span class=bold><?php xl('D.O.B.','e'); ?> </span></td>
 570                                 <td class=required>:</td>
 571                                 <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 $i; ?>dob_date' border='0' alt='[?]' style='cursor:pointer' title='<?php xl('Click here to choose a date','e'); ?>'></td>
 572
 573                                 <td><span class=bold><?php xl('Sex','e'); ?>: </span></td>
 574                                 <td><?php
 575                                         // Modified 6/2009 by BM to use list_options and function
 576                                         generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_sex'),'list_id'=>'sex'), $result3['subscriber_sex']);
 577                                         ?>
 578                                 </td>
 579                                 <td></td><td></td> <td></td><td></td>
 580                         </tr>
 581                         <tr>
 582                                 <td class=leftborder><span class=bold><?php xl('S.S.','e'); ?> </span></td>
 583                                 <td class=required>:</td>
 584                                 <td><input type=entry size=11 name=i<?php echo $i?>subscriber_ss value="<?php echo $result3{"subscriber_ss"}?>"></td>
 585                         </tr>
 586
 587                         <tr>
 588                                 <td><span class=required><?php xl('Subscriber Address','e'); ?> </span></td>
 589                                 <td class=required>:</td>
 590                                 <td><input type=entry size=20 name=i<?php echo $i?>subscriber_street value="<?php echo $result3{"subscriber_street"}?>" onchange="capitalizeMe(this);" /></td>
 591
 592                                 <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xl('State','e') : xl('Locality','e') ?>: </span></td>
 593                                 <td>
 594                                         <?php
 595                                         // Modified 7/2009 by BM to incorporate data types
 596                                         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']);
 597                                 ?>
 598                                 </td>
 599                         </tr>
 600                         <tr>
 601                                 <td class=leftborder><span class=required><?php xl('City','e'); ?></span></td>
 602                                 <td class=required>:</td>
 603                                 <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>
 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_country'),'list_id'=>$GLOBALS['country_list'],'fld_length'=>'10','max_length'=>'63','edit_options'=>'C'), $result3['subscriber_country']);
 607                                         ?>
 608                                 </td>
 609 </tr>
 610                         <tr>
 611                                 <td><span class=required><?php echo ($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>
 612
 613
 614                                 <td colspan=2>
 615                                 </td><td></td>
 616                         </tr>
 617                         <tr>
 618                                 <td><span class=bold><?php xl('Subscriber Phone','e'); ?></span></td>
 619                                 <td class=required>:</td>
 620                                 <td><input type='text' size='20' name='i<?php echo $i?>subscriber_phone' value='<?php echo $result3["subscriber_phone"] ?>' onkeyup='phonekeyup(this,mypcc)' /></td>
 621                                 <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>
 622                                 <td colspan=2>
 623                                 </td><td></td><td></td>
 624                         </tr>
 625                         <tr>
 626                                 <td colspan=0><span class='required'><?php xl('Accept Assignment','e'); ?></span></td>
 627                                 <td class=required>:</td>
 628                                 <td colspan=2>
 629                                         <select name=i<?php echo $i?>accept_assignment>
 630                                                 <option value="TRUE" <?php if (strtoupper($result3{"accept_assignment"}) == "TRUE") echo "selected"?>><?php xl('YES','e'); ?></option>
 631                                                 <option value="FALSE" <?php if (strtoupper($result3{"accept_assignment"}) == "FALSE") echo "selected"?>><?php xl('NO','e'); ?></option>
 632                                         </select>
 633                                 </td>
 634                                 <td></td><td></td>
 635                                 <td colspan=2>
 636                                 </td><td></td>
 637                         </tr>
 638                 </table>
 639
 640
 641
 642                   </td>
 643                  </tr>
 644                 </table>
 645
 646                 </div>
 647
 648         <?php } //end insurer for loop ?>
 649
 650         </div>
 651 </div>
 652
 653 <?php } // end of "if not simplified_demographics" ?>
 654 </div></div>
 655
 656
 657
 658
 659
 660 </form>
 661
 662 <br>
 663
 664 <script language="JavaScript">
 665
 666  // fix inconsistently formatted phone numbers from the database
 667  var f = document.forms[0];
 668  if (f.form_phone_contact) phonekeyup(f.form_phone_contact,mypcc);
 669  if (f.form_phone_home   ) phonekeyup(f.form_phone_home   ,mypcc);
 670  if (f.form_phone_biz    ) phonekeyup(f.form_phone_biz    ,mypcc);
 671  if (f.form_phone_cell   ) phonekeyup(f.form_phone_cell   ,mypcc);
 672
 673 <?php if (! $GLOBALS['simplified_demographics']) { ?>
 674  phonekeyup(f.i1subscriber_phone,mypcc);
 675  phonekeyup(f.i2subscriber_phone,mypcc);
 676  phonekeyup(f.i3subscriber_phone,mypcc);
 677 <?php } ?>
 678
 679 <?php if ($GLOBALS['concurrent_layout'] && $set_pid) { ?>
 680  parent.left_nav.setPatient(<?php echo "'" . addslashes($result['fname']) . " " . addslashes($result['lname']) . "',$pid,'" . addslashes($result['pubpid']) . "','', ' " . xl('DOB') . ": " . oeFormatShortDate($result['DOB_YMD']) . " " . xl('Age') . ": " . getPatientAge($result['DOB_YMD']) . "'"; ?>);
 681  parent.left_nav.setRadio(window.name, 'dem');
 682 <?php } ?>
 683
 684 <?php echo $date_init; ?>
 685 <?php if (! $GLOBALS['simplified_demographics']) { for ($i=1; $i<=3; $i++): ?>
 686  Calendar.setup({inputField:"i<?php echo $i?>effective_date", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i?>effective_date"});
 687  Calendar.setup({inputField:"i<?php echo $i?>subscriber_DOB", ifFormat:"%Y-%m-%d", button:"img_i<?php echo $i?>dob_date"});
 688 <?php endfor; } ?>
 689 </script>
 690
 691 <!-- include support for the list-add selectbox feature -->
 692 <?php include $GLOBALS['fileroot']."/library/options_listadd.inc"; ?>
 693
 694 </body>
 695
 696 </html>