<!-- BEGIN outreach/demographics.tt -->
[% demographics = outreach.demographics;
# PROCESS dumper.tt dump = demographics %]
[% PROCESS site/autosuggest.tt %]
<script type="text/javascript">
<!--
function make_blank() {
document.demographics.practice_name.value = "";
}
-->
</script>
<form method="post" enctype="multipart/form-data" name="demographics" id="demographics"
action="[% app_url %]/outreach/demographics/[% request_data.id %]/[% patient_id %]">
<table class="indent borderless">
<tr>
<td rowspan="2" valign="top"><b>Address</b>: [% errs.address %]</td>
<td rowspan="2">
<textarea name="address" cols="25" rows="2">[% demographics.address %]</textarea>
</td>
<td><b>Post code</b>: [% errs.post_code %]</td>
<td>
<input type="text" name="post_code" size="12" value="[% demographics.post_code %]" />
</td>
[% class = demographics.dispatch_to != 'home' ? 'red' : 'normal' %]
<td class="[% class %]"><b>Dispatch to:</b> [% errs.dispatch_to %]</td>
<td>
<select name="dispatch_to">
<option value=""> </option>
[% FOREACH entry IN [ 'GP' 'home' 'alternate'] %]
<option [% 'selected' IF entry == demographics.dispatch_to %]
value="[% entry %]">[% entry %]</option>
[% END %]
</select>
</td>
</tr>
<tr>
<td><b>Telephone</b>: [% errs.telephone_no %]</td>
<td>
<input type="text" name="contact_number" size="15"
value="[% demographics.contact_number %]" />
</td>
[% class = demographics.status == 'dead' ? 'red' : 'normal' %]
<td class="[% class %]" align="right"><b>Status:</b></td>
<td>
<select name="status">
[% FOREACH entry IN [ 'alive' 'dead' ] %]
<option [% 'selected' IF entry == demographics.status %] value="[% entry %]">
[% entry %]
</option>
[% END %]
</select>
</td>
</tr>
<tr>
[% class = demographics.non_participant_practices.item(demographics.practice_id)
? 'red' : 'normal' # flag non-participant practice %]
<td class="[% class %]"><b>Practice</b>:</td>
<td colspan="5">
<input type="text" name="practice_name" id="location_name"
value="[% demographics.display_name %]"
style="width: 600px" onclick="make_blank();" />
<input type="hidden" id="source_id" name="practice_id" />
</td>
</tr>
<tr>
<td class="[% class %]" align="right"><b>GP</b>:</td>
<td>
<select name="gp_id">
<option value="">--select one--</option>
[% FOREACH gp IN demographics.practitioners;
id = gp.first;
name = gp.last;
%]
<option value="[% id %]" [% 'selected' IF id == demographics.gp_id %]>
[% name %]
</option>
[% END %]
<option disabled>---------------</option>
<option value="[% demographics.unknown_gp_id %]"
[% 'selected' IF demographics.gp_id == demographics.unknown_gp_id %]>
[ unlisted ]
</option>
</select>
[% IF class == 'red' %]
<span class="red">[ non-participant practice ]</span>
[% END %]
</td>
<td><b>Blood tube:</b></td>
<td colspan="2">
[% # demographics.tube_type only supplied if practice override in place:
override = demographics.tube_type ? 1 : 0;
default_tube_type = tube_type(demographics.post_code); # callback
%]
<select name="tube_type" [% site.html.disabled %]>
<option 'selected'>
[% demographics.tube_type || default_tube_type %]
</option>
</select>
[% IF override %]
<span class="red">« practice override</span>
[% END %]
</td>
[% INCLUDE outreach_submit %]
</tr>
</table>
</form>
[% IF demographics.dispatch_to.match('alternate') %]
<form method="post" enctype="multipart/form-data"
action="[% app_url %]/outreach/alternate_address/[% request_data.id %]/[% patient_id %]">
<div style="background-color: #ffc; padding:2px; border: dotted 1px #f00;">
<table class="indent borderless">
<tr>
<td><b>Alternate<br />address</b>:</td>
<td>
<textarea name="address" cols="25"
rows="2">[% demographics.alternate_address %]</textarea>
</td>
<td><b>Post code</b>:</td>
<td>
<input type="text" value="[% demographics.alternate_post_code %]"
name="post_code" size="12" />
</td>
[% INCLUDE outreach_submit %]
</tr>
</table>
</div>
</form>
[% END %]
<!-- END outreach/demographics.tt -->