<%@ Page Language="C#" AutoEventWireup="false" CodeBehind="PersonalInformationEditOldVersion.aspx.cs" Inherits="Axium.Web.Users.PersonalInformationEditOldVersion" %>

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    <head id="Head1" runat="server">
        <title></title>

        <meta http-equiv="X-UA-Compatible" content="IE=8" />
        <meta name="viewport" content="width=device-width, initial-scale=1.0, minimum-scale=1.0, maximum-scale=1.0, user-scalable=no">
        <script src="../Includes/JQueryUI/js/jquery-3.5.1.min.js" type="text/javascript"></script>
        <script src="../Includes/JQueryUI/js/jquery-migrate-3.3.2.min.js" type="text/javascript"></script>
        <script src="../Includes/Scripts/json2.min.js" type="text/javascript"></script>
        <script src="../Includes/Scripts/utilities.js" type="text/javascript"></script>
        <script src="../Includes/Scripts/jquery.numeric.js" type="text/javascript"></script>
        <script src="../Includes/Scripts/jqModal-r14.js" type="text/javascript"></script>
        <script src="../Includes/Scripts/ui.datepicker.js" type="text/javascript"></script>
        <script src="../Includes/Scripts/dateControl.js" type="text/javascript"></script>
        <script src="../Includes/Scripts/jquery.maxlength-1.0.3.min.js" type="text/javascript"></script>    
        <script src="../Includes/Scripts/jquery.timer.js" type="text/javascript"></script>
        <script src="../Includes/Scripts/jquery.validate-1.19.2.min.js" type="text/javascript"></script>
        <script src="../Includes/Scripts/personalInformationOldVersion.250.js" type="text/javascript"></script>      <%--39647133--%>
        <script src="../Includes/Scripts/iframe.231520.js" type="text/javascript"></script>
        <script src="../Includes/Scripts/general.240530.js" type="text/javascript"></script>
        <script src="../Includes/JQueryUI/js/jquery-ui-1.13.2.custom.min.js" type="text/javascript"></script>
        <style type="text/css" runat="server" ID="logicCss"></style>

        <style>

            h1 {
                border-bottom: 0px !important;
            }

            .messageBox {
                background-color: white !important;
            }

        </style>


    </head>
    <body id="personalInfoEditPage" >    
    <input id="hdnPatSerial" type="hidden" runat="server"/>         <%-- AX-17079 --%>
    <form name="FormPat" id="FormPat"  runat="server">
    <input id="hdnAllowBlankTitle" type="hidden" runat="server" />
    <input id="hdnBirthdate" type="hidden" runat="server" />
    <input id="hdnBirthdateEditable" type="hidden" runat="server" />
    <input id="hdnCityReseted" type="hidden" runat="server" />
	<input id="hdnZip" type="hidden" runat="server" />
    <input id="hdnCity" type="hidden" runat="server"/>
    <input id="hdnCountry" type="hidden" runat="server"/>
    <input id="hdnState" type="hidden" runat="server"/>
    <input id="hdnPrefLangInactive" type="hidden" runat="server"/>
    <input id="hdnPrefLangInactiveValue" type="hidden" runat="server"/>
    <input id="hdnEthnicityInactive" type="hidden" runat="server"/>
    <input id="hdnEthnicityInactiveValue" type="hidden" runat="server"/>
    <%--<input id="hdnRacesSelected" type="hidden" runat="server"/>--%>
    <input id="hdnRacesSelectedJson" type="hidden" runat="server"/>
    <input id="hdnRacesJson" type="hidden"/>
	<input id="hdnCustomCodes" type="hidden" runat="server"/>
	<input id="hdnCustomCodesValidate" type="hidden" runat="server"/>
	<input id="hdnIsEditableZipPostalCode" type="hidden" runat="server"/>
	<input id="hdnIsEditableFirstName" type ="hidden" runat="server"/>
	<input id="hdnIsEditableLastName" type ="hidden" runat="server"/>
	<input id="hdnValidateEmergAddress" type="hidden" runat="server"/>
    <input id="hdnEmergCityReseted" type="hidden" runat="server" />
	<input id="hdnEmergZip" type="hidden" runat="server" />
    <input id="hdnEmergCity" type="hidden" runat="server"/>
    <input id="hdnEmergState" type="hidden" runat="server"/>
    <input id="hdnEmergRelation" type="hidden" runat="server"/>
    <input id="hdnUserId" type="hidden" runat="server"/>
    <input id="hdnSettingLeaveUnsavedPatHeader" type="hidden" runat="server"/>          <%-- AX-17079 --%>
    <input id="hdnSettingLeaveUnsavedPatMessage" type="hidden" runat="server"/>         <%-- AX-17079 --%>

  
        
    <div class="container-lg">
        <div id="PersonalInfoEdit">
        <h1>Personal Information</h1>
        <asp:Literal ID="Notifications" runat="server" Visible="false" EnableViewState="false" />
        <div id="FormsPersonalInfoEdit">
            <div id="NameDemographicsOutput" class="PersonalInfoContent">
                <div class="HeaderSection">Name and Demographics</div>
                <div class="InfoSection">
                    <div id="TitleDiv" class="CtrlGroup LeftCtrlGroup">
                        <asp:Label ID="TitleLabel" runat="server" AssociatedControlID="TitleDropDown" EnableViewState="false" CssClass="TitleElement">Title:</asp:Label>
				        <asp:Image ID="TitleDropDownImgError" runat="server" ImageUrl="../Includes/images/unchecked.png" CssClass="imgErrorHide" AlternateText="Title Error" />
                        <asp:DropDownList ID="TitleDropDown" runat="server" CssClass="TitleField"/>
                    </div>
                    <div id="FirstNameDiv" class="CtrlGroup">
                        <asp:Label ID="FirstNameLabel" runat="server" AssociatedControlID="FirstNameTxt" EnableViewState="false" CssClass="TitleElement">First Name:</asp:Label>
                        <asp:Image id="FirstNameTxtImgError" runat="server" ImageUrl="../Includes/images/unchecked.png" CssClass="imgErrorHide" AlternateText="First Name Error"/>
                        <asp:TextBox ID="FirstNameTxt" runat="server" CssClass="FirstNameField text required mobile_text" MaxLength="15" />
                    </div>
                    <div id="MiddleNameDiv" class="CtrlGroup">
                        <asp:Label ID="MiddleNameLabel" runat="server" AssociatedControlID="MiddleNameTxt" EnableViewState="false" CssClass="TitleElement">Middle Name:</asp:Label>
                        <asp:TextBox ID="MiddleNameTxt" runat="server" CssClass="MiddleNameField text mobile_text" MaxLength="15" />
                    </div>
                    <div id="LastNameDiv" class="CtrlGroup LeftCtrlGroup">
                        <asp:Label ID="LastNameLabel" runat="server" AssociatedControlID="LastNameTxt" EnableViewState="false" CssClass="TitleElement">Last Name:</asp:Label>
                        <asp:Image id="LastNameTxtImgError" runat="server" AlternateText="Last Name Error" ImageUrl="../Includes/images/unchecked.png" CssClass="imgErrorHide"/>
                        <asp:TextBox ID="LastNameTxt" runat="server" CssClass="LastNameField text required mobile_text" MaxLength="25" />
                    </div>
                    <div id="PreferredNameDiv" class="CtrlGroup">
                        <asp:Label ID="PreferredNameLabel" runat="server" AssociatedControlID="PreferredNameTxt" EnableViewState="false" CssClass="TitleElement">Preferred Name:</asp:Label>
                        <asp:TextBox ID="PreferredNameTxt" runat="server" CssClass="PreferredNameField text mobile_text" MaxLength="15" />
                    </div>
                    <div id="BirthdayDiv" class="CtrlGroup LeftCtrlGroup">
                        <asp:Label ID="BirthdayLabel" runat="server" EnableViewState="false" CssClass="TitleElement">Birth Date:</asp:Label>
                        <asp:Image ID="BirthdayDateCImgError" runat="server" ImageUrl="../Includes/Images/unchecked.png" CssClass="imgErrorHide" AlternateText="Birthday Date" />
                        <div class="BirthDayDiv">
                            <div id="BirthdayDateControlDiv" runat="server"></div>                
                        </div>
                    </div>
                    <div id="PreferredLanguageDiv" class="CtrlGroup" runat="server">
                        <asp:Label ID="PreferredLanguageLabel" runat="server" AssociatedControlID="PreferredLanguageDropDown" EnableViewState="false" CssClass="TitleElement">Preferred Language:</asp:Label>
                        <asp:Image ID="PreferredLanguageDropDownImgError" runat="server" ImageUrl="../Includes/images/unchecked.png" CssClass="imgErrorHide" AlternateText="Preferred Language Error" />
                        <asp:DropDownList ID="PreferredLanguageDropDown" runat="server" CssClass="PreferredLanguageField"/>
                    </div>
                    <div id="DeclineAnswerDiv" class="CtrlGroup LeftCtrlGroup" runat="server">
                        <asp:CheckBox ID="DeclineAnswerChkBox" runat="server" CssClass="DeclineAnswerField" onclick="checkedDeclineAnswer()" Text="&nbsp;I decline to answer questions about ethnicity and race."/>
                    </div>
                    <div id="EthnicityDiv" class="CtrlGroup" runat="server">
                        <asp:Label ID="EthnicityLabel" runat="server" AssociatedControlID="EthnicityDropDown" EnableViewState="false" CssClass="TitleElement">Ethnicity:</asp:Label>                        
                        <asp:Image ID="EthnicityDropDownImgError" runat="server" ImageUrl="../Includes/images/unchecked.png" CssClass="imgErrorHide" AlternateText="Ethnicity Error"/>
                        <asp:DropDownList ID="EthnicityEmptyDropDown" runat="server" CssClass="EthnicityField" Enabled="False" />
                        <asp:DropDownList ID="EthnicityDropDown" runat="server" CssClass="EthnicityField" />
                    </div>
                    <div id="RaceDiv" class="CtrlGroup" runat="server">
                        <asp:Label ID="RaceLabel" runat="server" EnableViewState="false" CssClass="TitleElement">Race(s):</asp:Label>
                        <asp:Image ID="RaceImgError" runat="server" ImageUrl="../Includes/images/unchecked.png" CssClass="imgErrorHide" AlternateText="Race Error" />
                        <div id="RaceDivListDp" runat="server"></div>
                        <div id="RaceDivAddMore" runat="server"></div>
                        <div id="RaceDivEmpty" runat="server">
                            <asp:DropDownList ID="RaceEmptyList" runat="server" Enabled="False" CssClass="RaceDefaultField"/>
                        </div>
                    </div>
                    <div class="FooterRow">&nbsp;</div>
                </div>
                
            </div>
            <div id="AddressOutput" class="PersonalInfoContent">
                <div class="HeaderSection">Address</div>
                <div class="InfoSection">
                    <div id="AddressDiv" class="CtrlGroup LeftCtrlGroup">
                        <asp:Label ID="AddressLabel" runat="server" AssociatedControlID="Address" CssClass="TitleElement">Address:</asp:Label>
                        <asp:Image id="AddressImgError" runat="server" ImageUrl="../Includes/Images/unchecked.png" CssClass="imgErrorHide" AlternateText="Address Error"/>
                        <asp:TextBox ID="Address" runat="server" CssClass="AddressField textLong required"  MaxLength="30"  />
                        <asp:TextBox ID="Address2Txt" runat="server" CssClass="Address2Field textLong" MaxLength="30" />
                    </div>
                    <div id="ZipCodeDiv" class="CtrlGroup">
                        <div class="ZipTitle">
                            <asp:Label ID="ZipLabel" runat="server" AssociatedControlID="Zip" EnableViewState="false" CssClass="TitleElement">ZIP/Postal Code:</asp:Label>
                            <asp:Image ID="ZipImgError" runat="server" ImageUrl="../Includes/Images/unchecked.png" CssClass="imgErrorHide" AlternateText="Zip Error" />
                        </div>
                        <div class="ZipCityDiv">
                            <asp:TextBox ID="Zip" runat="server" CssClass="ZipField zipCode required" MaxLength="15" onkeydown="ResetCity(this);" onkeyup="ResetCity(this);" oninput="ResetCity(this);" onblur="ResetCity(this);" onchange="ResetCity(this);"/>
                            <input id="GetInfoBtn" type="button" runat="server" value="Get City" class="GetCityBtn cancel" onclick="getCityClick(this);"/>

                            <asp:Image ID="GetInfoBtnImgError" runat="server" ImageUrl="../Includes/Images/unchecked.png" CssClass="imgErrorHide" AlternateText="Zip Instruction Error" />
							<div ID="ZipInstruction" runat="server" class="ZipInstruction">Please enter your ZIP or postal code and click "Get City" to fill in the fields below.</div>
                        </div>
                    </div>
                    <div id="CityDiv" class="CtrlGroup LeftCtrlGroup">
                        <asp:Label ID="CityLabel" runat="server" AssociatedControlID="Zip" EnableViewState="false" CssClass="TitleElement">City:</asp:Label>
                        <asp:Image ID="CityImgError" runat="server" ImageUrl="../Includes/Images/unchecked.png" CssClass="imgErrorHide" AlternateText="City Error" />
                        <div id="CityTextBoxDiv" runat="server">
                            <asp:TextBox ID="City" runat="server" CssClass="CityField text required" MaxLength="24" />
                        </div>
                        <div id="CityDropDownDiv" runat="server">
                            <select id="CityDropDown" runat="server" class="CityDpField" onchange="setCityField()"></select>
                        </div>
                    </div>
                    <div id="CountryDiv" class="CtrlGroup">
                        <asp:Label ID="CountryLabel" runat="server" AssociatedControlID="Zip" EnableViewState="false" CssClass="TitleElement">Country:</asp:Label>
                        <asp:Image ID="CountryDropDownImageError" runat="server" ImageUrl="../Includes/Images/unchecked.png" CssClass="imgErrorHide" AlternateText="Country Error"/>
                        <asp:DropDownList ID="CountryDropDown" runat="server" CssClass="CountryField"/>
                    </div>
                    <div id="StateDiv" class="CtrlGroup LeftCtrlGroup">
                        <asp:Label ID="StateLabel" runat="server" AssociatedControlID="Zip" EnableViewState="false" CssClass="TitleElement">State/Province:</asp:Label>
                        <asp:Image ID="StateDropDownImageError" runat="server" ImageUrl="../Includes/Images/unchecked.png" CssClass="imgErrorHide" AlternateText="State Error" />
                        <asp:DropDownList ID="StateDropDown" runat="server" CssClass="StateField"/>
                    </div>
                    <div id="CountyDiv" class="CtrlGroup">
                        <asp:Label ID="CountyLabel" runat="server" AssociatedControlID="Zip" EnableViewState="false" CssClass="TitleElement">County:</asp:Label>
                        <asp:TextBox ID="CountyTxt" runat="server" CssClass="CountyField text" MaxLength="15" />
                    </div>
                    <div class="FooterRow">&nbsp;</div>
                </div>
            </div>

            <div id="ContactInformationOutput" class="PersonalInfoContent">
                <div class="HeaderSection">Contact Information</div>
                <div class="InfoSection">
                    <div id="EmailDiv" class="CtrlGroup LeftCtrlGroup">
                        <asp:Label ID="EmailLabel" runat="server" AssociatedControlID="Email" EnableViewState="false" CssClass="TitleElement">Email:</asp:Label>
                        <img id="EmailImgError" alt="" src="../Includes/Images/unchecked.png" class="imgErrorHide"/>
                        <asp:TextBox ID="Email" runat="server" CssClass="EmailField textLong email" MaxLength="100" />
                    </div>
                    <div id="HomePhoneDiv" class="CtrlGroup LeftCtrlGroup">
                        <div class="PhoneTitle">
                            <asp:Label ID="HomePhoneCodeLabel" runat="server" AssociatedControlID="HomePhoneCode" EnableViewState="false" CssClass="TitleElement">Home Phone:</asp:Label>
                            <asp:Image ID="HomePhoneImgError" runat="server" ImageUrl="../Includes/Images/unchecked.png" CssClass="imgErrorHide" AlternateText="Phone Error" />
                        </div>
                        <div class="PhoneFields">
                            <asp:TextBox ID="HomePhoneCode" runat="server" pattern="[0-9]*" CssClass="Phone3 areaCode " MaxLength="3" onkeypress="return onlyNumbers(event);" />
                            <asp:TextBox ID="HomePhone1" runat="server" pattern="[0-9]*" CssClass="Phone3 number1 " MaxLength="3"  onkeypress="return onlyNumbers(event);" />-
                            <asp:TextBox ID="HomePhone2" runat="server" pattern="[0-9]*" CssClass="Phone4 number2 " MaxLength="4"  onkeypress="return onlyNumbers(event);" />
                        </div>
                    </div>
                    <div id="MobilePhoneDiv" class="CtrlGroup" runat="server">
                        <div class="PhoneTitle">
                            <asp:Label ID="MobilePhoneLabel" runat="server" AssociatedControlID="MobilePhoneCode" EnableViewState="false" CssClass="TitleElement">Mobile Phone:</asp:Label>
                            <asp:Image ID="MobilePhoneImgError" runat="server" ImageUrl="../Includes/Images/unchecked.png" CssClass="imgErrorHide" AlternateText="Mobile Phone Error" />
                        </div>
                        <div class="PhoneFields">
                            <asp:TextBox ID="MobilePhoneCode" runat="server" pattern="[0-9]*" CssClass="Phone3 areaCode " MaxLength="3" onkeypress="return onlyNumbers(event);" />
                            <asp:TextBox ID="MobilePhone1" runat="server" pattern="[0-9]*" CssClass="Phone3 number1 " MaxLength="3" onkeypress="return onlyNumbers(event);" />-
                            <asp:TextBox ID="MobilePhone2" runat="server" pattern="[0-9]*" CssClass="Phone4 number2 " MaxLength="4" onkeypress="return onlyNumbers(event);" />
                        </div>
                    </div>
                    
                    <div id="WorkPhoneDiv" class="CtrlGroup LeftCtrlGroup">
                        <div class="PhoneTitle">
                            <asp:Label ID="WorkPhoneLabel" runat="server" AssociatedControlID="WorkPhoneCode" EnableViewState="false" CssClass="TitleElement">Work Phone:</asp:Label>
                            <asp:Image ID="WorkPhoneImgError" runat="server" ImageUrl="../Includes/Images/unchecked.png" CssClass="imgErrorHide" AlternateText="Work Phone Error" />
                        </div>
                        <div class="PhoneFields">
                            <asp:TextBox ID="WorkPhoneCode" runat="server" pattern="[0-9]*" CssClass="Phone3 areaCode " MaxLength="3" onkeypress="return onlyNumbers(event);" />
                            <asp:TextBox ID="WorkPhone1" runat="server" pattern="[0-9]*" CssClass="Phone3 number1 " MaxLength="3" onkeypress="return onlyNumbers(event);" />- 
                            <asp:TextBox ID="WorkPhone2" runat="server" pattern="[0-9]*" CssClass="Phone4 number2 " MaxLength="4" onkeypress="return onlyNumbers(event);" />Ext.
                            <asp:TextBox ID="WorkPhoneExt" runat="server" CssClass="PhoneExt extension" MaxLength="6"  />
                        </div>
                    </div>
                    <div id="ContactTimeDiv" class="CtrlGroup">
                        <asp:Label ID="ContactTimeLabel" runat="server" AssociatedControlID="ContactTimeTxt" EnableViewState="false" CssClass="TitleElement">Preferred Contact Time:</asp:Label>
                        <asp:TextBox ID="ContactTimeTxt" runat="server" CssClass="ContactTimeField text" MaxLength="15"  />
                    </div>

                    <div id="OtherPhoneDiv" class="CtrlGroup LeftCtrlGroup">
                        <div class="PhoneTitle">
                            <asp:Label ID="OtherPhoneLabel" runat="server" AssociatedControlID="OtherPhoneCode" EnableViewState="false" CssClass="TitleElement">Other Phone:</asp:Label>
                            <asp:Image ID="OtherPhoneImgError" runat="server" ImageUrl="../Includes/Images/unchecked.png" CssClass="imgErrorHide" AlternateText="Other Phone Error" />
                        </div>
                        <div class="PhoneFields">
                            <asp:TextBox ID="OtherPhoneCode" runat="server" pattern="[0-9]*" CssClass="Phone3 areaCode " MaxLength="3" onkeypress="return onlyNumbers(event);" />
                            <asp:TextBox ID="OtherPhone1" runat="server" pattern="[0-9]*" CssClass="Phone3 number1 " MaxLength="3"  onkeypress="return onlyNumbers(event);" />-
                            <asp:TextBox ID="OtherPhone2" runat="server" pattern="[0-9]*" CssClass="Phone4 number2 " MaxLength="4" onkeypress="return onlyNumbers(event);" />Ext.
                            <asp:TextBox ID="OtherPhoneExt" runat="server" CssClass="PhoneExt extension" MaxLength="6"  />
                        </div>
                    </div>
                    <div id="ContactAtDiv" class="CtrlGroup">
                        <asp:Label ID="ContactAtLabel" runat="server" AssociatedControlID="ContactAtDropDown" EnableViewState="false" CssClass="TitleElement">Contact At:</asp:Label>
                        <asp:DropDownList ID="ContactAtDropDown" runat="server" onchange="validateContactDp()" CssClass="ContactAtField" />
                    </div>
                    <div class="FooterRow">&nbsp;</div>
                </div>
            </div>

			<asp:Panel id="EmergencyContactOutput" class="PersonalInfoContent" runat="server">
                <div class="HeaderSection">Emergency Contact Information</div>
				<asp:Panel id="EmergencyContactSection" class="InfoSection" runat="server"/>
			</asp:Panel>

			<asp:Panel id="AdditionalInformationOutput" class="PersonalInfoContent" runat="server">
                <div class="HeaderSection">Additional Information</div>
				<asp:Panel id="AdditionalInfoSection" class="InfoSection" runat="server"/>
	            
			</asp:Panel>


            <div Id="SubmitMsgBox" class="messageBox" runat="server">
                <asp:Button ID="SubmitBtn" runat="server" EnableViewState="false" CssClass="button btn btn-primary" Text="Submit Changes" OnClientClick="setBirthdate();return (onSubmitSetValues());" OnClick="SubmitBtn_Click" />
                <div id="SubmitText" runat="server" class="messageBoxText"></div>
            </div>
        </div>
        </div>
    </div>
    <asp:PlaceHolder ID="AutoLogout" runat="server" Visible="false" EnableViewState="false" />
    </form>
    <script type="text/javascript">

        history.pushState(null, document.title, location.href);       // AX-17079.2
        window.addEventListener('popstate', checkCanGoBackPatient);      // AX-17079.2

        jQuery(document).ready(function () {
            $(".integer").numeric(false, function () { this.value = ""; this.trigger('focus'); });       // AX-24898.24919.2 .focus()
            var childHeight = $(document).height();
            jQuery('#proIfrmId', window.parent.document).css('height', childHeight);
        });         
    </script>
</body>
</html>
