interface/new/new_comprehensive.php

   1 <?php
   2 /**
   3  * New patient or search patient.
   4  *
   5  * @package   OpenEMR
   6  * @link      http://www.open-emr.org
   7  * @author    Rod Roark <rod@sunsetsystems.com>
   8  * @author    Brady Miller <brady.g.miller@gmail.com>
   9  * @copyright Copyright (c) 2009-2017 Rod Roark <rod@sunsetsystems.com>
  10  * @copyright Copyright (c) 2017-2018 Brady Miller <brady.g.miller@gmail.com>
  11  * @license   https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  12  */
  13
  14
  15 require_once("../globals.php");
  16 require_once("$srcdir/acl.inc");
  17 require_once("$srcdir/options.inc.php");
  18 require_once("$srcdir/patient.inc");
  19 require_once("$srcdir/erx_javascript.inc.php");
  20 require_once("$srcdir/validation/LBF_Validation.php");
  21 require_once("$srcdir/patientvalidation.inc.php");
  22
  23 use OpenEMR\Core\Header;
  24
  25 // Check authorization.
  26 if (!acl_check('patients', 'demo', '', array('write','addonly'))) {
  27     die(xlt("Adding demographics is not authorized."));
  28 }
  29
  30 $CPR = 4; // cells per row
  31
  32 $searchcolor = empty($GLOBALS['layout_search_color']) ?
  33   '#ffff55' : $GLOBALS['layout_search_color'];
  34
  35 $WITH_SEARCH = ($GLOBALS['full_new_patient_form'] == '1' || $GLOBALS['full_new_patient_form'] == '2' );
  36 $SHORT_FORM  = ($GLOBALS['full_new_patient_form'] == '2' || $GLOBALS['full_new_patient_form'] == '3' || $GLOBALS['full_new_patient_form'] == '4');
  37
  38 $grparr = array();
  39 getLayoutProperties('DEM', $grparr);
  40
  41 function getLayoutRes()
  42 {
  43     global $SHORT_FORM;
  44     return sqlStatement("SELECT * FROM layout_options " .
  45     "WHERE form_id = 'DEM' AND uor > 0 AND field_id != '' " .
  46     ($SHORT_FORM ? "AND ( uor > 1 OR edit_options LIKE '%N%' ) " : "") .
  47     "ORDER BY group_id, seq");
  48 }
  49
  50 // Determine layout field search treatment from its data type:
  51 // 1 = text field
  52 // 2 = select list
  53 // 0 = not searchable
  54 //
  55 function getSearchClass($data_type)
  56 {
  57     switch ($data_type) {
  58         case 1: // single-selection list
  59         case 10: // local provider list
  60         case 11: // provider list
  61         case 12: // pharmacy list
  62         case 13: // squads
  63         case 14: // address book list
  64         case 26: // single-selection list with add
  65         case 35: // facilities
  66             return 2;
  67         case 2: // text field
  68         case 3: // textarea
  69         case 4: // date
  70             return 1;
  71     }
  72
  73     return 0;
  74 }
  75
  76 $fres = getLayoutRes();
  77 ?>
  78 <html>
  79 <head>
  80 <?php Header::setupHeader(['common','datetime-picker', 'jquery-ui']); ?>
  81 <title><?php echo xlt("Search or Add Patient"); ?></title>
  82
  83 <style>
  84 body {
  85  padding: 5pt 5pt 5pt 5pt;
  86 }
  87
  88 div.section {
  89  border: solid;
  90  border-width: 1px;
  91  border-color: #0000ff;
  92  margin: 0 0 0 10pt;
  93  padding: 5pt;
  94 }
  95
  96 .form-control {
  97     width: auto;
  98     display: inline;
  99     height: auto;
 100 }
 101 </style>
 102
 103 <?php include_once("{$GLOBALS['srcdir']}/options.js.php"); ?>
 104
 105 <SCRIPT LANGUAGE="JavaScript"><!--
 106 //Visolve - sync the radio buttons - Start
 107 if((top.window.parent) && (parent.window)){
 108         var wname = top.window.parent.left_nav;
 109         fname = (parent.window.name)?parent.window.name:window.name;
 110         wname.syncRadios();
 111 }//Visolve - sync the radio buttons - End
 112
 113 var mypcc = <?php echo js_escape($GLOBALS['phone_country_code']); ?>;
 114
 115 // This may be changed to true by the AJAX search script.
 116 var force_submit = false;
 117
 118 //code used from http://tech.irt.org/articles/js037/
 119 function replace(string,text,by) {
 120  // Replaces text with by in string
 121  var strLength = string.length, txtLength = text.length;
 122  if ((strLength == 0) || (txtLength == 0)) return string;
 123
 124  var i = string.indexOf(text);
 125  if ((!i) && (text != string.substring(0,txtLength))) return string;
 126  if (i == -1) return string;
 127
 128  var newstr = string.substring(0,i) + by;
 129
 130  if (i+txtLength < strLength)
 131   newstr += replace(string.substring(i+txtLength,strLength),text,by);
 132
 133  return newstr;
 134 }
 135
 136 <?php for ($i=1; $i<=3; $i++) { ?>
 137 function auto_populate_employer_address<?php echo $i ?>(){
 138  var f = document.demographics_form;
 139  if (f.form_i<?php echo $i?>subscriber_relationship.options[f.form_i<?php echo $i?>subscriber_relationship.selectedIndex].value == "self") {
 140   f.i<?php echo $i?>subscriber_fname.value=f.form_fname.value;
 141   f.i<?php echo $i?>subscriber_mname.value=f.form_mname.value;
 142   f.i<?php echo $i?>subscriber_lname.value=f.form_lname.value;
 143   f.i<?php echo $i?>subscriber_street.value=f.form_street.value;
 144   f.i<?php echo $i?>subscriber_city.value=f.form_city.value;
 145   f.form_i<?php echo $i?>subscriber_state.value=f.form_state.value;
 146   f.i<?php echo $i?>subscriber_postal_code.value=f.form_postal_code.value;
 147   if (f.form_country_code)
 148     f.form_i<?php echo $i?>subscriber_country.value=f.form_country_code.value;
 149   f.i<?php echo $i?>subscriber_phone.value=f.form_phone_home.value;
 150   f.i<?php echo $i?>subscriber_DOB.value=f.form_DOB.value;
 151   f.i<?php echo $i?>subscriber_ss.value=f.form_ss.value;
 152   f.form_i<?php echo $i?>subscriber_sex.value = f.form_sex.value;
 153   f.i<?php echo $i?>subscriber_employer.value=f.form_em_name.value;
 154   f.i<?php echo $i?>subscriber_employer_street.value=f.form_em_street.value;
 155   f.i<?php echo $i?>subscriber_employer_city.value=f.form_em_city.value;
 156   f.form_i<?php echo $i?>subscriber_employer_state.value=f.form_em_state.value;
 157   f.i<?php echo $i?>subscriber_employer_postal_code.value=f.form_em_postal_code.value;
 158   if (f.form_em_country)
 159     f.form_i<?php echo $i?>subscriber_employer_country.value=f.form_em_country.value;
 160  }
 161 }
 162
 163 <?php } ?>
 164
 165 function upperFirst(string,text) {
 166  return replace(string,text,text.charAt(0).toUpperCase() + text.substring(1,text.length));
 167 }
 168
 169 // The ins_search.php window calls this to set the selected insurance.
 170 function set_insurance(ins_id, ins_name) {
 171  var thesel = document.forms[0]['i' + insurance_index + 'provider'];
 172  var theopts = thesel.options; // the array of Option objects
 173  var i = 0;
 174  for (; i < theopts.length; ++i) {
 175   if (theopts[i].value == ins_id) {
 176    theopts[i].selected = true;
 177    return;
 178   }
 179  }
 180  // no matching option was found so create one, append it to the
 181  // end of the list, and select it.
 182  theopts[i] = new Option(ins_name, ins_id, false, true);
 183 }
 184
 185 // Indicates which insurance slot is being updated.
 186 var insurance_index = 0;
 187
 188 // The OnClick handler for searching/adding the insurance company.
 189 function ins_search(ins) {
 190  insurance_index = ins;
 191  return false;
 192 }
 193
 194 function checkNum () {
 195  var re= new RegExp();
 196  re = /^\d*\.?\d*$/;
 197  str=document.forms[0].monthly_income.value;
 198  if(re.exec(str))
 199  {
 200  }else{
 201   alert(<?php echo xlj("Please enter a dollar amount using only numbers and a decimal point."); ?>);
 202  }
 203 }
 204
 205 // This capitalizes the first letter of each word in the passed input
 206 // element.  It also strips out extraneous spaces.
 207 function capitalizeMe(elem) {
 208  var a = elem.value.split(' ');
 209  var s = '';
 210  for(var i = 0; i < a.length; ++i) {
 211   if (a[i].length > 0) {
 212    if (s.length > 0) s += ' ';
 213    s += a[i].charAt(0).toUpperCase() + a[i].substring(1);
 214   }
 215  }
 216  elem.value = s;
 217 }
 218
 219 // Onkeyup handler for policy number.  Allows only A-Z and 0-9.
 220 function policykeyup(e) {
 221  var v = e.value.toUpperCase();
 222  var filteredString="";
 223  for (var i = 0; i < v.length; ++i) {
 224   var c = v.charAt(i);
 225   if ((c >= '0' && c <= '9') ||
 226      (c >= 'A' && c <= 'Z') ||
 227      (c == '*') ||
 228      (c == '-') ||
 229      (c == '_') ||
 230      (c == '(') ||
 231      (c == ')') ||
 232      (c == '#'))
 233      {
 234          filteredString+=c;
 235      }
 236  }
 237  e.value = filteredString;
 238  return;
 239 }
 240
 241 function divclick(cb, divid) {
 242  var divstyle = document.getElementById(divid).style;
 243  if (cb.checked) {
 244   divstyle.display = 'block';
 245  } else {
 246   divstyle.display = 'none';
 247  }
 248  return true;
 249 }
 250
 251 // Compute the length of a string without leading and trailing spaces.
 252 function trimlen(s) {
 253  var i = 0;
 254  var j = s.length - 1;
 255  for (; i <= j && s.charAt(i) == ' '; ++i);
 256  for (; i <= j && s.charAt(j) == ' '; --j);
 257  if (i > j) return 0;
 258  return j + 1 - i;
 259 }
 260
 261 function validate(f) {
 262   var errMsgs = new Array();
 263     <?php generate_layout_validation('DEM'); ?>
 264     <?php if ($GLOBALS['erx_enable']) { ?>
 265   alertMsg='';
 266   for(i=0;i<f.length;i++){
 267     if(f[i].type=='text' && f[i].value)
 268     {
 269       if(f[i].name == 'form_fname' || f[i].name == 'form_mname' || f[i].name == 'form_lname')
 270       {
 271         alertMsg += checkLength(f[i].name,f[i].value,35);
 272         alertMsg += checkUsername(f[i].name,f[i].value);
 273       }
 274       else if(f[i].name == 'form_street' || f[i].name == 'form_city')
 275       {
 276         alertMsg += checkLength(f[i].name,f[i].value,35);
 277         alertMsg += checkAlphaNumericExtended(f[i].name,f[i].value);
 278       }
 279       else if(f[i].name == 'form_phone_home')
 280       {
 281        alertMsg += checkPhone(f[i].name,f[i].value);
 282       }
 283     }
 284   }
 285   if(alertMsg)
 286   {
 287     alert(alertMsg);
 288     return false;
 289   }
 290     <?php } ?>
 291   var msg = "";
 292   msg += <?php echo xlj('The following fields are required'); ?> + ":\n\n";
 293   for ( var i = 0; i < errMsgs.length; i++ ) {
 294          msg += errMsgs[i] + "\n";
 295   }
 296   msg += "\n" + <?php echo xlj('Please fill them in before continuing.'); ?>;
 297
 298
 299 //Misc  Deceased Date Validation for Future Date
 300 var dateVal = document.getElementById("form_deceased_date").value;
 301 var currentDate;
 302 var d = new Date();
 303 month = '' + (d.getMonth() + 1),
 304 day = '' + d.getDate(),
 305 year = d.getFullYear();
 306 if (month.length < 2) month = '0' + month;
 307 if (day.length < 2) day = '0' + day;
 308 currentDate = year+'-'+month+'-'+day;
 309 if(errMsgs.length > 0 || dateVal > currentDate)
 310 {
 311 if(errMsgs.length > 0)
 312     alert(msg);
 313 if(dateVal > currentDate)
 314     alert (<?php echo xlj("Deceased Date should not be greater than Today"); ?>);
 315     return false;
 316 }
 317  return true;
 318 }
 319
 320 function toggleSearch(elem) {
 321  var f = document.forms[0];
 322 <?php if ($WITH_SEARCH) { ?>
 323  // Toggle background color.
 324  if (elem.style.backgroundColor == '')
 325   elem.style.backgroundColor = <?php echo js_escape($searchcolor); ?>;
 326  else
 327   elem.style.backgroundColor = '';
 328 <?php } ?>
 329  if (force_submit) {
 330   force_submit = false;
 331   f.create.value = <?php echo xlj('Create New Patient'); ?>;
 332  }
 333  return true;
 334 }
 335
 336 // If a <select> list is dropped down, this is its name.
 337 var open_sel_name = '';
 338
 339 function selClick(elem) {
 340  if (open_sel_name == elem.name) {
 341   open_sel_name = '';
 342  }
 343  else {
 344   open_sel_name = elem.name;
 345   toggleSearch(elem);
 346  }
 347  return true;
 348 }
 349
 350 function selBlur(elem) {
 351  if (open_sel_name == elem.name) {
 352   open_sel_name = '';
 353  }
 354  return true;
 355 }
 356
 357 // This invokes the patient search dialog.
 358 function searchme() {
 359  var f = document.forms[0];
 360  var url = '../main/finder/patient_select.php?popup=1&csrf_token_form=<?php echo attr_url(collectCsrfToken()); ?>';
 361
 362 <?php
 363 $lres = getLayoutRes();
 364
 365 while ($lrow = sqlFetchArray($lres)) {
 366     $field_id  = $lrow['field_id'];
 367     if (strpos($field_id, 'em_') === 0) {
 368         continue;
 369     }
 370
 371     $data_type = $lrow['data_type'];
 372     $fldname = "form_$field_id";
 373     switch (getSearchClass($data_type)) {
 374         case 1:
 375             echo
 376             " if (f." . attr($fldname) . ".style.backgroundColor != '' && trimlen(f." . attr($fldname) . ".value) > 0) {\n" .
 377             "  url += '&" . attr($field_id) . "=' + encodeURIComponent(f." . attr($fldname) . ".value);\n" .
 378             " }\n";
 379             break;
 380         case 2:
 381             echo
 382             " if (f." . attr($fldname) . ".style.backgroundColor != '' && f." . attr($fldname) . ".selectedIndex > 0) {\n" .
 383             "  url += '&" . attr($field_id) . "=' + encodeURIComponent(f." . attr($fldname) . ".options[f." . attr($fldname) . ".selectedIndex].value);\n" .
 384             " }\n";
 385             break;
 386     }
 387 }
 388 ?>
 389
 390  dlgopen(url, '_blank', 700, 500);
 391 }
 392 function srchDone(pid){
 393     top.restoreSession();
 394     document.location.href = "./../../patient_file/summary/demographics.php?set_pid=" + encodeURIComponent(pid);
 395 }
 396 //-->
 397
 398 </script>
 399 </head>
 400
 401 <body class="body_top">
 402
 403 <?php
 404 /*Get the constraint from the DB-> LBF forms accordinf the form_id*/
 405 $constraints = LBF_Validation::generate_validate_constraints("DEM");
 406 ?>
 407 <script> var constraints = <?php echo $constraints;?>; </script>
 408     <div class="container">
 409         <div class="row">
 410             <div class="col-xs-12">
 411                 <div class="page-header">
 412                     <h2><?php echo xlt('Search or Add Patient');?></h2>
 413                 </div>
 414             </div>
 415         </div>
 416         <div class="row">
 417             <div class="col-xs-12">
 418                 <div class="btn-group">
 419                     <?php if ($WITH_SEARCH) { ?>
 420                         <button type="button" class="btn btn-default btn-search" id="search" value="<?php echo xla('Search'); ?>">
 421                             <?php echo xlt('Search'); ?>
 422                         </button>
 423                     <?php } ?>
 424                     <button type="button" class="btn btn-default btn-save" name='create' id="create" value="<?php echo xla('Create New Patient'); ?>">
 425                         <?php echo xlt('Create New Patient'); ?>
 426                     </button>
 427                 </div>
 428             </div>
 429         </div>
 430         <br>
 431         <div class="row">
 432             <div class="col-sm-12">
 433                 <form action='new_comprehensive_save.php' name='demographics_form' id="DEM"  method='post' onsubmit='return submitme(<?php echo $GLOBALS['new_validate'] ? 1 : 0;?>,event,"DEM",constraints)'>
 434                     <input type="hidden" name="csrf_token_form" value="<?php echo attr(collectCsrfToken()); ?>" />
 435                     <table width='100%' cellpadding='0' cellspacing='8'>
 436                     <tr>
 437                       <td align='left' valign='top'>
 438                     <?php
 439                     if ($SHORT_FORM) {
 440                         echo "  <center>\n";
 441                     } ?>
 442                     <?php
 443
 444                     function end_cell()
 445                     {
 446                         global $item_count, $cell_count;
 447                         if ($item_count > 0) {
 448                             echo "</td>";
 449                             $item_count = 0;
 450                         }
 451                     }
 452
 453                     function end_row()
 454                     {
 455                         global $cell_count, $CPR;
 456                         end_cell();
 457                         if ($cell_count > 0) {
 458                             for (; $cell_count < $CPR;
 459                             ++$cell_count) {
 460                                 echo "<td></td>";
 461                             }
 462
 463                             echo "</tr>\n";
 464                             $cell_count = 0;
 465                         }
 466                     }
 467
 468                     function end_group()
 469                     {
 470                         global $last_group, $SHORT_FORM;
 471                         if (strlen($last_group) > 0) {
 472                             end_row();
 473                             echo " </table>\n";
 474                             if (!$SHORT_FORM) {
 475                                 echo "</div>\n";
 476                             }
 477                         }
 478                     }
 479
 480                     $last_group    = '';
 481                     $cell_count    = 0;
 482                     $item_count    = 0;
 483                     $display_style = 'block';
 484                     $group_seq     = 0; // this gives the DIV blocks unique IDs
 485
 486                     $condition_str = '';
 487
 488                     while ($frow = sqlFetchArray($fres)) {
 489                         $this_group = $frow['group_id'];
 490                         $titlecols  = $frow['titlecols'];
 491                         $datacols   = $frow['datacols'];
 492                         $data_type  = $frow['data_type'];
 493                         $field_id   = $frow['field_id'];
 494                         $list_id    = $frow['list_id'];
 495                         $currvalue  = '';
 496
 497                         // Accumulate action conditions into a JSON expression for the browser side.
 498                         accumActionConditions($field_id, $condition_str, $frow['conditions']);
 499
 500                         if (strpos($field_id, 'em_') === 0) {
 501                             $tmp = substr($field_id, 3);
 502                             if (isset($result2[$tmp])) {
 503                                 $currvalue = $result2[$tmp];
 504                             }
 505                         } else {
 506                             if (isset($result[$field_id])) {
 507                                 $currvalue = $result[$field_id];
 508                             }
 509                         }
 510
 511                   // Handle a data category (group) change.
 512                         if (strcmp($this_group, $last_group) != 0) {
 513                             if (!$SHORT_FORM) {
 514                                 end_group();
 515                                 $group_seq++;    // ID for DIV tags
 516                                 $group_name = $grparr[$this_group]['grp_title'];
 517
 518                                 if (strlen($last_group) > 0) {
 519                                     echo "<br />";
 520                                 }
 521
 522                                 echo "<span class='bold'><input type='checkbox' name='form_cb_" . attr($group_seq) . "' id='form_cb_" . attr($group_seq) . "' value='1' " .
 523                                 "onclick='return divclick(this," . attr_js("div_" . $group_seq) . ");'";
 524                                 if ($display_style == 'block') {
 525                                     echo " checked";
 526                                 }
 527
 528                                 // Modified 6-09 by BM - Translate if applicable
 529                                 echo " /><b>" . text(xl_layout_label($group_name)) . "</b></span>\n";
 530
 531                                 echo "<div id='div_" . attr($group_seq) . "' class='section' style='display:$display_style;'>\n";
 532                                 echo " <table border='0' cellpadding='0'>\n";
 533                                 $display_style = 'none';
 534                             } elseif (strlen($last_group) == 0) {
 535                                 echo " <table border='0' cellpadding='0'>\n";
 536                             }
 537
 538                                 $last_group = $this_group;
 539                         }
 540
 541                       // Handle starting of a new row.
 542                         if (($titlecols > 0 && $cell_count >= $CPR) || $cell_count == 0) {
 543                             end_row();
 544                             echo "  <tr>";
 545                         }
 546
 547                         if ($item_count == 0 && $titlecols == 0) {
 548                             $titlecols = 1;
 549                         }
 550
 551                         $field_id_label='label_'.$frow['field_id'];
 552                       // Handle starting of a new label cell.
 553                         if ($titlecols > 0) {
 554                             end_cell();
 555                             echo "<td colspan='" . attr($titlecols) . "' id='" . attr($field_id_label) . "'";
 556                             echo ($frow['uor'] == 2) ? " class='required'" : " class='bold'";
 557                             if ($cell_count == 2) {
 558                                 echo " style='padding-left:10pt'";
 559                             }
 560
 561                             echo ">";
 562                             $cell_count += $titlecols;
 563                         }
 564
 565                         ++$item_count;
 566
 567                         echo "<b>";
 568
 569                       // Modified 6-09 by BM - Translate if applicable
 570                         if ($frow['title']) {
 571                             echo (text(xl_layout_label($frow['title'])) . ":");
 572                         } else {
 573                             echo "&nbsp;";
 574                         }
 575
 576                         echo "</b>";
 577
 578                       // Handle starting of a new data cell.
 579                         if ($datacols > 0) {
 580                             $id_field_text = "text_".$frow['field_id'];
 581                             end_cell();
 582                             echo "<td colspan='" . attr($datacols) . "' class='text data'";
 583                             if ($cell_count > 0) {
 584                                 echo " style='padding-left:5pt'". " id='" . attr($id_field_text) . "'";
 585                             }
 586
 587                             echo ">";
 588                             $cell_count += $datacols;
 589                         }
 590
 591                         ++$item_count;
 592                         generate_form_field($frow, $currvalue);
 593                     }
 594
 595                     end_group();
 596                     ?>
 597
 598                     <?php
 599                     if (! $GLOBALS['simplified_demographics']) {
 600                         $insurancei = getInsuranceProviders();
 601                         $pid = 0;
 602                         $insurance_headings = array(xl("Primary Insurance Provider"), xl("Secondary Insurance Provider"), xl("Tertiary Insurance provider"));
 603                         $insurance_info = array();
 604                         $insurance_info[1] = getInsuranceData($pid, "primary");
 605                         $insurance_info[2] = getInsuranceData($pid, "secondary");
 606                         $insurance_info[3] = getInsuranceData($pid, "tertiary");
 607
 608                         echo "<br /><span class='bold'><input type='checkbox' name='form_cb_ins' value='1' " .
 609                         "onclick='return divclick(this,\"div_ins\");'";
 610                         if ($display_style == 'block') {
 611                             echo " checked";
 612                         }
 613
 614                         echo " /><b>" . xlt('Insurance') . "</b></span>\n";
 615                         echo "<div id='div_ins' class='section' style='display:$display_style;'>\n";
 616
 617                         for ($i=1; $i<=3; $i++) {
 618                             $result3 = $insurance_info[$i];
 619                         ?>
 620                         <table border="0">
 621                             <tr>
 622                                 <td valign='top' colspan='2'>
 623                                     <span class='required'><?php echo text($insurance_headings[$i -1]).":"?></span>
 624                                     <select name="i<?php echo attr($i); ?>provider" class="form-control">
 625                                         <option value=""><?php echo xlt('Unassigned'); ?></option>
 626                                         <?php
 627                                         foreach ($insurancei as $iid => $iname) {
 628                                             echo "<option value='" . attr($iid) . "'";
 629                                             if (strtolower($iid) == strtolower($result3{"provider"})) {
 630                                                 echo " selected";
 631                                             }
 632                                             echo ">" . text($iname) . "</option>\n";
 633                                         }
 634                                         ?>
 635                                     </select>&nbsp;<a class='medium_modal' href='../practice/ins_search.php' onclick='ins_search(<?php echo attr($i); ?>)'>
 636                                     <span> <?php echo xlt('Search/Add Insurer'); ?></span></a>
 637                                 </td>
 638                             </tr>
 639                             <tr>
 640                                 <td valign=top>
 641                                     <table border="0">
 642                                         <tr>
 643                                             <td>
 644                                                 <span class='required'><?php echo xlt('Plan Name'); ?>: </span>
 645                                             </td>
 646                                             <td>
 647                                                 <input type='entry' class='form-control' size='20' name='i<?php echo attr($i); ?>plan_name' value="<?php echo attr($result3{"plan_name"}); ?>"
 648                                                 onchange="capitalizeMe(this);" />&nbsp;&nbsp;
 649                                             </td>
 650                                         </tr>
 651
 652                                         <tr>
 653                                             <td>
 654                                                 <span class='required'><?php echo xlt('Effective Date'); ?>: </span>
 655                                             </td>
 656                                             <td>
 657                                                 <input type='entry' size='11' class='datepicker form-control' name='i<?php echo attr($i); ?>effective_date'
 658                                                 id='i<?php echo attr($i); ?>effective_date'
 659                                                 value='<?php echo attr($result3['date']); ?>' />
 660                                             </td>
 661                                         </tr>
 662
 663                                         <tr>
 664                                             <td><span class=required><?php echo xlt('Policy Number'); ?>: </span></td>
 665                                             <td><input type='entry' class='form-control' size='16' name='i<?php echo attr($i); ?>policy_number' value="<?php echo attr($result3{"policy_number"}); ?>"
 666                                                 onkeyup='policykeyup(this)'>
 667                                             </td>
 668                                         </tr>
 669
 670                                         <tr>
 671                                             <td><span class=required><?php echo xlt('Group Number'); ?>: </span></td>
 672                                             <td><input type=entry class='form-control' size=16 name='i<?php echo attr($i); ?>group_number' value="<?php echo attr($result3{"group_number"}); ?>" onkeyup='policykeyup(this)'></td>
 673                                         </tr>
 674
 675                                         <tr <?php echo ($GLOBALS['omit_employers']) ? " style='display:none'" : ""; ?>>
 676                                             <td class='required'><?php echo xlt('Subscriber Employer (SE)'); ?><br><span style='font-weight:normal'>
 677                                               (<?php echo xlt('if unemployed enter Student'); ?>,<br><?php echo xlt('PT Student, or leave blank'); ?>): </span>
 678                                             </td>
 679                                             <td><input type=entry class='form-control' size=25 name=i<?php echo attr($i); ?>subscriber_employer
 680                                                 value="<?php echo attr($result3{"subscriber_employer"}); ?>"
 681                                                 onchange="capitalizeMe(this);" />
 682                                            </td>
 683                                         </tr>
 684
 685                                         <tr <?php echo ($GLOBALS['omit_employers']) ? " style='display:none'" : ""; ?>>
 686                                             <td><span class=required><?php echo xlt('SE Address'); ?>: </span></td>
 687                                             <td><input type=entry class='form-control' size=25 name=i<?php echo attr($i); ?>subscriber_employer_street
 688                                             value="<?php echo attr($result3{"subscriber_employer_street"}); ?>"
 689                                             onchange="capitalizeMe(this);" /></td>
 690                                         </tr>
 691
 692                                         <tr <?php echo ($GLOBALS['omit_employers']) ? " style='display:none'" : ""; ?>>
 693                                             <td colspan="2">
 694                                                 <table>
 695                                                     <tr>
 696                                                         <td><span class=required><?php echo xlt('SE City'); ?>: </span></td>
 697                                                         <td><input type=entry class='form-control' size=15 name=i<?php echo attr($i); ?>subscriber_employer_city
 698                                                             value="<?php echo attr($result3{"subscriber_employer_city"}); ?>"
 699                                                             onchange="capitalizeMe(this);" />
 700                                                         </td>
 701                                                         <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('SE State') : xlt('SE Locality') ?>: </span></td>
 702                                                         <td>
 703                                                         <?php
 704                                                         // Modified 7/2009 by BM to incorporate data types
 705                                                         generate_form_field(array('data_type'=>$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'), $result3['subscriber_employer_state']);
 706                                                         ?>
 707                                                         </td>
 708                                                     </tr>
 709                                                     <tr>
 710                                                         <td><span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('SE Zip Code') : xlt('SE Postal Code') ?>: </span></td>
 711                                                         <td><input type=entry class='form-control' size=10 name=i<?php echo $i?>subscriber_employer_postal_code value="<?php echo attr($result3{"subscriber_employer_postal_code"}); ?>"></td>
 712                                                         <td><span class=required><?php echo xlt('SE Country'); ?>: </span></td>
 713                                                         <td>
 714                                                             <?php
 715                                                           // Modified 7/2009 by BM to incorporate data types
 716                                                             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'), $result3['subscriber_employer_country']);
 717                                                             ?>
 718                                                         </td>
 719                                                     </tr>
 720                                                 </table>
 721                                             </td>
 722                                         </tr>
 723                                     </table>
 724                                 </td>
 725
 726                                 <td valign=top>
 727                                     <span class=required><?php echo xlt('Subscriber'); ?>: </span>
 728                                     <input type=entry class='form-control' size=10 name=i<?php echo attr($i); ?>subscriber_fname
 729                                     value="<?php echo attr($result3{"subscriber_fname"}); ?>"
 730                                     onchange="capitalizeMe(this);" />
 731                                     <input type=entry class='form-control' size=3 name=i<?php echo attr($i); ?>subscriber_mname
 732                                     value="<?php echo attr($result3{"subscriber_mname"}); ?>"
 733                                     onchange="capitalizeMe(this);" />
 734                                     <input type=entry class='form-control' size=10 name=i<?php echo attr($i); ?>subscriber_lname
 735                                     value="<?php echo attr($result3{"subscriber_lname"}); ?>"
 736                                     onchange="capitalizeMe(this);" />
 737                                     <br>
 738                                     <span class=required><?php echo xlt('Relationship'); ?>: </span>
 739                                     <?php
 740                                     // Modified 6/2009 by BM to use list_options and function
 741                                     generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_relationship'),'list_id'=>'sub_relation','empty_title'=>' '), $result3['subscriber_relationship']);
 742                                     ?>
 743                                     <a href="javascript:popUp('../../interface/patient_file/summary/browse.php?browsenum=<?php echo attr_url($i); ?>')" class=text>(<?php echo xlt('Browse'); ?>)</a><br />
 744
 745                                     <span class=bold><?php echo xlt('D.O.B.'); ?>: </span>
 746                                     <input type='entry' size='11' class='datepicker form-control' name='i<?php echo attr($i); ?>subscriber_DOB'
 747                                     id='i<?php echo attr($i); ?>subscriber_DOB'
 748                                     value='<?php echo attr($result3['subscriber_DOB']); ?>' />
 749
 750                                     <span class=bold><?php echo xlt('S.S.'); ?>: </span>
 751                                     <input type=entry class='form-control' size=11 name=i<?php echo attr($i); ?>subscriber_ss value="<?php echo attr($result3{"subscriber_ss"}); ?>">&nbsp;
 752                                     <span class=bold><?php echo xlt('Sex'); ?>: </span>
 753                                     <?php
 754                                     // Modified 6/2009 by BM to use list_options and function
 755                                     generate_form_field(array('data_type'=>1,'field_id'=>('i'.$i.'subscriber_sex'),'list_id'=>'sex'), $result3['subscriber_sex']);
 756                                     ?>
 757                                     <br>
 758                                     <span class=required><?php echo xlt('Subscriber Address'); ?>: </span>
 759                                     <input type=entry class='form-control' size=25 name=i<?php echo attr($i); ?>subscriber_street
 760                                     value="<?php echo attr($result3{"subscriber_street"}); ?>"
 761                                     onchange="capitalizeMe(this);" /><br>
 762                                     <span class=required><?php echo xlt('City'); ?>: </span>
 763                                     <input type=entry class='form-control' size=15 name=i<?php echo attr($i); ?>subscriber_city
 764                                     value="<?php echo attr($result3{"subscriber_city"}); ?>"
 765                                     onchange="capitalizeMe(this);" />
 766                                     <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('State') : xlt('Locality') ?>: </span>
 767                                     <?php
 768                                     // Modified 7/2009 by BM to incorporate data types
 769                                     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'), $result3['subscriber_state']);
 770                                     ?>
 771                                     <br />
 772                                     <span class=required><?php echo ($GLOBALS['phone_country_code'] == '1') ? xlt('Zip Code') : xlt('Postal Code') ?>: </span>
 773                                     <input type=entry class='form-control' size=10 name=i<?php echo attr($i); ?>subscriber_postal_code value="<?php echo attr($result3{"subscriber_postal_code"}); ?>">
 774                                     <span class='required'<?php echo ($GLOBALS['omit_employers']) ? " style='display:none'" : ""; ?>>
 775                                     <?php echo xlt('Country'); ?>: </span>
 776                                     <?php
 777                                     // Modified 7/2009 by BM to incorporate data types
 778                                     generate_form_field(array('data_type'=>$GLOBALS['country_data_type'],'field_id'=>('i'.$i.'subscriber_country'),'list_id'=>$GLOBALS['country_list'],'fld_length'=>'10','max_length'=>'63','edit_options'=>'C'), $result3['subscriber_country']);
 779                                     ?>
 780                                     <br />
 781                                     <span class=bold><?php echo xlt('Subscriber Phone'); ?>:
 782                                     <input type='text' class='form-control' size='20' name='i<?php echo attr($i); ?>subscriber_phone' value='<?php echo attr($result3["subscriber_phone"]); ?>' onkeyup='phonekeyup(this,mypcc)' />
 783                                     </span><br />
 784                                     <span class=bold><?php echo xlt('CoPay'); ?>: <input type=text class='form-control' size="6" name=i<?php echo attr($i); ?>copay value="<?php echo attr($result3{"copay"}); ?>">
 785                                     </span><br />
 786                                     <span class='required'><?php echo xlt('Accept Assignment'); ?>: </span>
 787                                     <select class='form-control' name=i<?php echo attr($i); ?>accept_assignment>
 788                                         <option value="TRUE" <?php echo (strtoupper($result3{"accept_assignment"}) == "TRUE") ? "selected" : ""; ?>><?php echo xlt('YES'); ?></option>
 789                                         <option value="FALSE" <?php echo (strtoupper($result3{"accept_assignment"}) == "FALSE") ? "selected" : ""; ?>><?php echo xlt('NO'); ?></option>
 790                                     </select>
 791                                 </td>
 792                             </tr>
 793                         </table>
 794                         <hr />
 795                         <?php
 796                         }
 797
 798                         echo "</div>\n";
 799                     } // end of "if not simplified_demographics"
 800                     ?>
 801
 802                     <?php
 803                     if ($SHORT_FORM) {
 804                         echo "  </center>\n";
 805                     } ?>
 806
 807                             </td>
 808                             <td align='right' valign='top' width='1%' nowrap>
 809                             <!-- Image upload stuff was here but got moved. -->
 810                             </td>
 811                         </tr>
 812                     </table>
 813                 </form>
 814             </div>
 815         </div>
 816     </div> <!--end of container div -->
 817 <!-- include support for the list-add selectbox feature -->
 818 <?php include($GLOBALS['fileroot']."/library/options_listadd.inc"); ?>
 819
 820 </body>
 821
 822 <script language="JavaScript">
 823
 824 // hard code validation for old validation, in the new validation possible to add match rules
 825 <?php if ($GLOBALS['new_validate'] == 0) { ?>
 826
 827 // fix inconsistently formatted phone numbers from the database
 828 var f = document.forms[0];
 829 if (f.form_phone_contact) phonekeyup(f.form_phone_contact,mypcc);
 830 if (f.form_phone_home   ) phonekeyup(f.form_phone_home   ,mypcc);
 831 if (f.form_phone_biz    ) phonekeyup(f.form_phone_biz    ,mypcc);
 832 if (f.form_phone_cell   ) phonekeyup(f.form_phone_cell   ,mypcc);
 833
 834 <?php }?>
 835
 836 <?php echo $date_init; ?>
 837
 838 // -=- jQuery makes life easier -=-
 839
 840 // var matches = 0; // number of patients that match the demographic information being entered
 841 // var override = false; // flag that overrides the duplication warning
 842
 843 $(function () {
 844     $(".medium_modal").on('click', function(e) {
 845         e.preventDefault();e.stopPropagation();
 846         dlgopen('', '', 650, 460, '', '', {
 847             buttons: [
 848                 {text: <?php echo xlj('Close'); ?>, close: true, style: 'default btn-sm'}
 849             ],
 850             //onClosed: 'refreshme',
 851             allowResize: false,
 852             allowDrag: true,
 853             dialogId: '',
 854             type: 'iframe',
 855             url: $(this).attr('href')
 856         });
 857     });
 858     // added to integrate insurance stuff
 859     <?php for ($i=1; $i<=3; $i++) { ?>
 860     $("#form_i<?php echo $i?>subscriber_relationship").change(function() { auto_populate_employer_address<?php echo $i?>(); });
 861     <?php } ?>
 862
 863     $('#search').click(function() { searchme(); });
 864     $('#create').click(function() { check()});
 865
 866     var check = function(e) {
 867         <?php if ($GLOBALS['new_validate']) {?>
 868             var valid = submitme(<?php echo $GLOBALS['new_validate'] ? 1 : 0;?>,e,"DEM",constraints);
 869         <?php } else {?>
 870             top.restoreSession();
 871             var f = document.forms[0];
 872             var valid = validate(f);
 873         <?php }?>
 874         if (valid) {
 875             if (force_submit) {
 876                 // In this case dups were shown already and Save should just save.
 877                 top.restoreSession();
 878                 f.submit();
 879                 return;
 880             }
 881
 882         <?php
 883         // D in edit_options indicates the field is used in duplication checking.
 884         // This constructs a list of the names of those fields.
 885         $mflist = "";
 886         $mfres = sqlStatement("SELECT * FROM layout_options " .
 887             "WHERE form_id = 'DEM' AND uor > 0 AND field_id != '' AND " .
 888             "(edit_options LIKE '%D%' OR  edit_options LIKE '%W%' )" .
 889             "ORDER BY group_id, seq");
 890         while ($mfrow = sqlFetchArray($mfres)) {
 891             $field_id  = $mfrow['field_id'];
 892             if (strpos($field_id, 'em_') === 0) {
 893                 continue;
 894             }
 895
 896             if (!empty($mflist)) {
 897                 $mflist .= ",";
 898             }
 899
 900             $mflist .= js_escape($field_id);
 901         }
 902 ?>
 903         <?php if (($GLOBALS['full_new_patient_form'] == '4') && (checkIfPatientValidationHookIsActive())) :?>
 904             // Use zend module patient validation hook to open the controller and send the dup-checker fields.
 905             var url ='<?php echo $GLOBALS['web_root']."/interface/modules/zend_modules/public/patientvalidation"; ?>';
 906         <?php else :?>
 907             // Build and invoke the URL to create the dup-checker dialog.
 908             var url = 'new_search_popup.php';
 909         <?php endif;?>
 910
 911         var flds = new Array(<?php echo $mflist; ?>);
 912         var separator = '?';
 913         for (var i = 0; i < flds.length; ++i) {
 914             var fval = $('#form_' + flds[i]).val();
 915             if (fval && fval != '') {
 916                 url += separator;
 917                 separator = '&';
 918                 url += 'mf_' + flds[i] + '=' + encodeURIComponent(fval);
 919             }
 920         }
 921         url+="&close"
 922         dlgopen(url, '_blank', 700, 500);
 923         } // end function
 924     } // end function
 925
 926 // Set onclick/onfocus handlers for toggling background color.
 927 <?php
 928 $lres = getLayoutRes();
 929 while ($lrow = sqlFetchArray($lres)) {
 930     $field_id  = $lrow['field_id'];
 931     if (strpos($field_id, 'em_') === 0) {
 932         continue;
 933     }
 934
 935     switch (getSearchClass($lrow['data_type'])) {
 936         case 1:
 937             echo "    \$(" . js_escape("#form_".$field_id) . ").click(function() { toggleSearch(this); });\n";
 938             break;
 939         case 2:
 940             echo "    \$(" . js_escape("#form_".$field_id) . ").click(function() { selClick(this); });\n";
 941             echo "    \$(" . js_escape("#form_".$field_id) . ").blur(function() { selBlur(this); });\n";
 942             break;
 943     }
 944 }
 945 ?>
 946
 947   $('.datepicker').datetimepicker({
 948     <?php $datetimepicker_timepicker = false; ?>
 949     <?php $datetimepicker_showseconds = false; ?>
 950     <?php $datetimepicker_formatInput = true; ?>
 951     <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 952     <?php // can add any additional javascript settings to datetimepicker here; need to prepend first setting with a comma ?>
 953   });
 954   $('.datetimepicker').datetimepicker({
 955     <?php $datetimepicker_timepicker = true; ?>
 956     <?php $datetimepicker_showseconds = false; ?>
 957     <?php $datetimepicker_formatInput = true; ?>
 958     <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 959     <?php // can add any additional javascript settings to datetimepicker here; need to prepend first setting with a comma ?>
 960   });
 961
 962 }); // end document.ready
 963
 964 // callback for new patient save confirm from new_search_popup.php
 965 // note that dlgclose() callbacks mostly need to init outside dom.
 966 function srcConfirmSave() {
 967     document.forms[0].submit();
 968 }
 969
 970 </script>
 971 <?php /*Include the validation script and rules for this form*/
 972 $form_id="DEM";
 973 ?>
 974
 975 <?php
 976 //LBF forms use the new validation depending on the global value
 977 $use_validate_js=$GLOBALS['new_validate'];
 978 include_once("$srcdir/validation/validation_script.js.php");?>
 979 <script language='JavaScript'>
 980     // Array of skip conditions for the checkSkipConditions() function.
 981     var skipArray = [
 982         <?php echo $condition_str; ?>
 983     ];
 984     checkSkipConditions();
 985     $("input").change(function() {
 986         checkSkipConditions();
 987     });
 988     $("select").change(function() {
 989         checkSkipConditions();
 990     });
 991 </script>
 992
 993 </html>