466 lines
29 KiB
PHP
Executable File
466 lines
29 KiB
PHP
Executable File
<div class="app-content content">
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<section class="content-wrapper">
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<div class="row">
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<div class="col-12">
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<div class="card">
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<div class="card-header">
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<div class="row">
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<div class="col-12">
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<h3 class="font-weight-bold"><?php echo lang('ICD'); ?></h3>
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</div>
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</div>
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</div>
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<hr class="mt-0 mb-0" />
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<div class="card-body">
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<div class="row">
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<div class="col-md-10">
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<!-- widged section -->
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<div class="wizard wizard-circle">
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<div class="steps">
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<ul class="nav nav-tabs" id="myTab" role="tablist" style="border: none;">
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<li class="nav-item first current <?php echo $tab1; ?>">
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<a class="nav-link " id="base-tab31" data-toggle="tab" href="#tab31" role="tab" aria-selected="true" style="padding-top: 52px !important; border: none; cursor: pointer;"><span class="step">1</span>General Information</a>
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</li>
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<li class="nav-item first current <?php echo $tab2; ?>" >
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<a class="nav-link" id="base-tab32" data-toggle="tab" href="#tab32" role="tab" aria-selected="false" style="padding-top: 52px !important; border: none; cursor: pointer;"><span class="step">2</span>Designate</a>
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</li>
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<li class="nav-item first current <?php echo $tab3; ?>">
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<a class="nav-link" id="base-tab33" data-toggle="tab" href="#tab33" role="tab" aria-selected="false" style="padding-top: 52px !important; border: none; cursor: pointer;"><span class="step">3</span>Service Needed</a>
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</li>
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<li class="nav-item first current <?php echo $tab4; ?>">
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<a class="nav-link" id="base-tab34" data-toggle="tab" href="#tab34" role="tab" aria-selected="false" style="padding-top: 52px !important; border: none; cursor: pointer;"><span class="step">4</span>Insurance Information</a>
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</li>
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</ul>
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</div>
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</div>
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<!-- widged section -->
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<div role="tabpanel" class="tab-pane <?php echo $tabPane1; ?>" id="tab31" aria-expanded="true" aria-labelledby="base-tab31">
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<form role="form" action="patient/addNewGenInfo?type=<?=$type?>" method="post" enctype="multipart/form-data" name="newGenInfo" onsubmit="return validateForm1()">
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<div class="row">
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<div class="col-md-6">
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<div class="form-group">
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<label for="firstName3">
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<?php echo lang('Referral Source'); ?>
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<span class="danger">*</span>
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</label>
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<select class="form-control required" id="ref_info" name="pt_refrance_type">
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<option value="New Patient">New Patient</option>
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<option value="Reffered by Patient">Reffered by Patient</option>
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<option value="Reffered by Vendor">Reffered by Vendor</option>
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</select>
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</div>
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</div>
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<div class="col-md-6" id="ref_by_ptn" style="display: none;">
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<div class="form-group">
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<label for="lastName3">
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<?php echo lang('Patient Id'); ?>
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<span class="danger">*</span>
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</label>
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<input type="text" class="form-control required" id="ref_pt_id" name="pt_refrance_value">
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</div>
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</div>
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<div class="col-md-6" id="ref_by_vendor" style="display: none;">
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<div class="form-group">
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<label for="lastName3">
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<?php echo lang('Vendor'); ?>
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<span class="danger">*</span>
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</label>
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<select class="form-control required" id="ref_vnd_id" name="vend_refrance_value">
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<option value="" selected>Choose...</option>
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<?php foreach ($vendorList as $value) { ?>
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<option value="<?php echo $value->id; ?>"><?php echo $value->vedor_name; ?></option>
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<?php } ?>
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</select>
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</div>
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</div>
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<script type="text/javascript">
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$(function(){
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$("#ref_info").change(function(){
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var selVal = $(this).val();
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if(selVal == 'Reffered by Patient')
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{
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$("#ref_by_ptn").show();
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$("#ref_by_vendor").hide();
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}
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else if(selVal == 'Reffered by Vendor'){
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$("#ref_by_ptn").hide();
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$("#ref_by_vendor").show();
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}
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else{
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$("#ref_by_ptn").hide();
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$("#ref_by_vendor").hide();
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}
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})
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});
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</script>
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</div>
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<div class="row">
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<div class="col-md-6">
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<div class="form-group">
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<label for="firstName3">
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<?php echo lang('First name'); ?>
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<span class="danger">*</span>
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</label>
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<input type="text" class="form-control required" id="firstName3" name="fname" value="<?php echo set_value('fname'); ?>">
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</div>
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</div>
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<div class="col-md-6">
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<div class="form-group">
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<label for="lastName3">
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<?php echo lang('Last name'); ?>
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<span class="danger">*</span>
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</label>
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<input type="text" class="form-control required" id="lastName3" name="lname">
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</div>
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</div>
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</div>
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<div class="row">
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<div class="col-md-12">
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<div class="form-group">
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<label for="firstName3">
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<?php echo lang('email'); ?>
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<span class="danger">*</span>
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</label>
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<input type="email" class="form-control required" id="emailAddress5" name="email">
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</div>
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</div>
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</div>
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<div class="row">
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<div class="col-md-6">
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<div class="form-group">
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<label for="location">
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<?php echo lang('Gender'); ?>
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<span class="danger">*</span>
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</label>
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<select class="form-control required" id="inputGroupSelect01" name="gender">
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<option value="" selected>Choose...</option>
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<option value="male">Male</option>
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<option value="female">Female</option>
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<option value="others">Others</option>
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</select>
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</div>
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</div>
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<div class="col-md-6">
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<div class="form-group">
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<label for="location">
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<?php echo lang('Primary language'); ?>
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<span class="danger">*</span>
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</label>
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<select class="form-control required" id="inputGroupSelect01" name="pnalguage">
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<option value="" selected>Choose...</option>
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<option value="1">English</option>
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<option value="2">Hindi</option>
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</select>
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</div>
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</div>
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</div>
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<div class="row">
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<div class="col-md-4">
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<div class="form-group">
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<label for="firstName3">
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<?php echo lang('Date of Birth'); ?>
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<span class="danger">*</span>
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</label>
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<input type="date" class="form-control" name="dob" id="ptdob">
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</div>
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</div>
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<div class="col-md-4">
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<div class="form-group">
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<label for="lastName3">
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<?php echo lang('Soc Sec #'); ?>
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<span class="danger">*</span>
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</label>
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<input type="text" class="form-control socialSec" name="socsec" value="" minlength="9" maxlength="9">
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</div>
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</div>
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<div class="col-md-4">
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<div class="form-group">
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<label for="lastName3">
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<?php echo lang('Marital Status'); ?>
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</label>
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<select class="form-control required" id="inputGroupSelect01" name="merital_stat">
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<option value="" selected>Choose...</option>
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<option value="Married">Married</option>
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<option value="Unmarried">Unmarried</option>
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</select>
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</div>
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</div>
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</div>
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<div class="row">
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<div class="col-md-4">
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<div class="form-group">
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<label for="firstName3">
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<?php echo lang('Height: feet'); ?>
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</label>
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<!-- <input type="text" class="form-control" name="height" id="exampleInputEmail1"> -->
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<select class="form-control" name="height" data-error="Please enter a valid height.">
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<option value="" selected disabled>Select</option>
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<?php for($i=1;$i<10;$i++){ ?>
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<option value="<?php echo $i; ?>" <?php if($height[0]==$i) echo 'selected'; ?>><?php echo $i; ?></option>
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<?php } ?>
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</select>
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</div>
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</div>
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<div class="col-md-4">
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<div class="form-group">
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<label for="firstName3">
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<?php echo lang('Inch'); ?>
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</label>
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<select class="form-control" name="heightInch" required data-error="Please enter a valid height.">
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<option value="" selected disabled>Select</option>
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<?php for($i=0;$i<12;$i++){ ?>
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<option value="<?php echo $i; ?>" <?php if($height[1]==$i) echo 'selected'; ?>><?php echo $i; ?></option>
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<?php } ?>
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</select>
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</div>
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</div>
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<div class="col-md-4">
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<div class="form-group">
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<label for="lastName3">
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<?php echo lang('Weight (LBS)'); ?>
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</label>
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<input type="text" onkeypress="return isNumberKey(event)" class="form-control" name="weight" id="exampleInputEmail1" value='' placeholder="">
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</div>
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</div>
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</div>
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<div class="row">
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<div class="col-md-4">
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<div class="form-group">
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<label for="firstName3">
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<?php echo lang('Telephone'); ?>
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</label>
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<input type="text" onkeypress="return isNumberKey(event)" onkeyup="formatPhoneNumber(this.value,this)" class="form-control" name="telephone" value='' placeholder="">
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</div>
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</div>
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<div class="col-md-4">
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<div class="form-group">
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<label for="lastName3">
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<?php echo lang('Cell phone'); ?>
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<span class="danger">*</span>
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</label>
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<input type="text" onkeypress="return isNumberKey(event)" onkeyup="formatPhoneNumber(this.value,this)" class="form-control" name="cellphone" value='' placeholder="">
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</div>
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</div>
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<div class="col-md-4">
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<div class="form-group">
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<label for="lastName3">
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<?php echo lang('Other number'); ?>
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</label>
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<input type="text" onkeypress="return isNumberKey(event)" onkeyup="formatPhoneNumber(this.value,this)" class="form-control" name="otr_number" value='' placeholder="">
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</div>
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</div>
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</div>
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<div class="row">
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<div class="col-md-12">
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<label for="firstName3">
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<h3><?php echo lang('Address'); ?></h3>
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</label>
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</div>
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<div class="col-md-4">
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<div class="form-group">
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<label for="firstName3"><?php echo lang('House Number and Street Name'); ?>
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<span class="danger">*</span>
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</label>
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<input type="text" class="form-control" name="address" id="exampleInputEmail1">
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</div>
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</div>
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<div class="col-md-4">
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<div class="form-group">
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<label for="firstName3"><?php echo lang('Apartment # (if applicable)'); ?>
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</label>
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<input type="text" class="form-control" name="AddrApartment" id="exampleInputEmail1">
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</div>
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</div>
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<div class="col-md-4">
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<div class="form-group">
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<label for="firstName3"><?php echo lang('City'); ?>
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<span class="danger">*</span>
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</label>
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<input type="text" class="form-control" name="addrCity" id="exampleInputEmail1">
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</div>
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</div>
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</div>
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<div class="row">
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<div class="col-md-4">
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<div class="form-group">
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<label for="firstName3"><?php echo lang('State'); ?>
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<span class="danger">*</span>
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</label>
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<input type="text" class="form-control" name="addrState" id="exampleInputEmail1">
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</div>
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</div>
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<div class="col-md-4">
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<div class="form-group">
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<label for="firstName3"><?php echo lang('Zip code'); ?>
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<span class="danger">*</span>
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</label>
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<input type="text" class="form-control" name="addrZipcode" id="exampleInputEmail1">
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</div>
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</div>
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<div class="col-md-4">
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<div class="form-group">
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<label for="firstName3"><?php echo lang('County'); ?>
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<span class="danger">*</span>
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</label>
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<input type="text" class="form-control" name="addrCounty" id="exampleInputEmail1">
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</div>
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</div>
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</div>
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<div class="row">
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<div class="col-md-12">
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<label for="firstName3">
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<h3><?php echo lang('Alternating Billing Address'); ?></h3>
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</label>
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</div>
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<div class="col-md-4">
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<div class="form-group">
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<label for="firstName3"><?php echo lang('House Number and Street Name'); ?>
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</label>
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<input type="text" class="form-control" name="alt_address" id="exampleInputEmail1">
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</div>
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</div>
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<div class="col-md-4">
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<div class="form-group">
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<label for="firstName3"><?php echo lang('Apartment # (if applicable)'); ?>
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</label>
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<input type="text" class="form-control" name="altApartment" id="exampleInputEmail1">
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</div>
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</div>
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<div class="col-md-4">
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<div class="form-group">
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<label for="firstName3"><?php echo lang('City'); ?>
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</label>
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<input type="text" class="form-control" name="AltCity" id="exampleInputEmail1">
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</div>
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</div>
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</div>
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<div class="row">
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<div class="col-md-4">
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<div class="form-group">
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<label for="firstName3"><?php echo lang('State'); ?>
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</label>
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<input type="text" class="form-control" name="altState" id="exampleInputEmail1">
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</div>
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</div>
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<div class="col-md-4">
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<div class="form-group">
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<label for="firstName3"><?php echo lang('Zip code'); ?>
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</label>
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<input type="text" class="form-control" name="altZipcode" id="exampleInputEmail1">
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</div>
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</div>
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<div class="col-md-4">
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<div class="form-group">
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<label for="firstName3"><?php echo lang('County'); ?>
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</label>
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<input type="text" class="form-control" name="altCounty" id="exampleInputEmail1">
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</div>
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</div>
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</div>
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<div class="row">
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<div class="col-md-12">
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<div class="form-group">
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<label for="firstName3">
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<?php echo lang('Direction'); ?>
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</label>
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<textarea class="form-control" name="direction" id="exampleInputEmail1" value='' placeholder=""></textarea>
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</div>
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</div>
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</div>
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<button type="submit" name="submit" value="gen_info" class="btn btn-info"><?php echo lang('submit'); ?></button>
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</form>
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</div>
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</div>
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</div>
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</div>
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</div>
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</div>
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</div>
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</div>
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</section>
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</div>
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<script type="text/javascript">
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function validateForm(){
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var fldval = $("#slotEditname").val();
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if(fldval == ""){
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$("#msg_rm").html("<div class='alert alert-danger' role='alert'> Please enter a value</div>");
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return false;
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}
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var fldval = $("#slotEditname").val();
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var currId = $('#nameId').val();
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var msgs = '';
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$.ajax('master_icd/duplicateCheck', {
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type: 'POST', // http method
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data: { val: fldval,currId:currId }, // data to submit
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async: false,
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success: function (data, status, xhr) {
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// $('p').append('status: ' + status + ', data: ' + data);
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// alert(data);
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msgs = data;
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},
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error: function (jqXhr, textStatus, errorMessage) {
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// $('p').append('Error' + errorMessage);
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alert("error duc");
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}
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});
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if(msgs == 'exist'){
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$("#msg_rm").html("<div class='alert alert-danger' role='alert'> Value already exist in the list</div>");
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return false;
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}
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else{
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return true;
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}
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}
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</script>
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