001 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN">
002 <%@ page contentType="text/html;charset=UTF-8" language="java" %>
003 <%@ taglib uri="/WEB-INF/struts-bean.tld" prefix="bean" %>
004 <%@ taglib uri="/WEB-INF/struts-logic.tld" prefix="logic" %>
005 <%@ taglib uri="/WEB-INF/struts-html.tld" prefix="html" %>
006 <%@ taglib uri="/WEB-INF/sslext.tld" prefix="sslext"%>
007 <%@ page import="com.bea.medrec.beans.AddressBean,
008 com.bea.medrec.utils.MedRecWebAppUtils"%>
009
010 <jsp:useBean id="patientBean" class="com.bea.medrec.beans.PatientBean" scope="session"/>
011 <%
012 AddressBean theAddressBean = patientBean.getAddress();
013 %>
014
015 <html:html>
016 <head>
017 <html:base/>
018 <title><bean:message key="title.MedRec"/></title>
019 <link rel="stylesheet" type="text/css" HREF="stylesheet.css">
020 </head>
021 <body bgcolor="white" topmargin="0" leftmargin="0">
022
023 <!-- START Header -->
024 <jsp:include page="Header.jsp" flush="true"/>
025 <!-- END Header -->
026
027 <!-- START Padding for Content -->
028 <table width="100%" border="0" cellspacing="1" cellpadding="10">
029 <tr>
030 <td>
031
032 <!-- Content -->
033 <sslext:link page="/medicalrecord.do"><span class="pagetitle-patient"><bean:message key="link.home"/></span></sslext:link> >
034 <span class="pagetitle-patient"><bean:message key="page.title.patient.profile.edit"/></span>
035 <br/><br/>
036
037 <sslext:form method="<%=MedRecWebAppUtils.getHttpMethod()%>" action="/editprofile.do" focus="firstName">
038 <table border="0" cellspacing="0" cellpadding="3">
039 <tr>
040 <td class="label"><bean:message key="FirstName"/></td>
041 <td><html:text
042 name="patientBean"
043 property="firstName"
044 size="20"
045 maxlength="60"
046 value="<%=patientBean.getFirstName()%>"
047 tabindex="1"
048 />
049 </td>
050 <td class="label"><bean:message key="Address"/>:</td>
051 <td></td>
052 </tr>
053 <tr>
054 <td></td>
055 <td align="left">
056 <html:messages id="error" property="firstName">
057 <bean:write name="error" filter="false"/>
058 </html:messages>
059 </td>
060 </tr>
061 <tr>
062 <td class="label"><bean:message key="LastName"/></td>
063 <td><html:text
064 name="patientBean"
065 property="lastName"
066 size="20"
067 maxlength="60"
068 value="<%=patientBean.getLastName()%>"
069 tabindex="2"
070 />
071 </td>
072 <td class="label"><bean:message key="Street"/></td>
073 <td><html:text
074 name="patientBean"
075 property="address.streetName1"
076 size="20"
077 maxlength="60"
078 value="<%=patientBean.getAddress().getStreetName1()%>"
079 tabindex="9"
080 />
081 </td>
082 </tr>
083 <tr>
084 <td></td>
085 <td align="left">
086 <html:messages id="error" property="lastName">
087 <bean:write name="error" filter="false"/>
088 </html:messages>
089 </td>
090 <td></td>
091 <td align="left">
092 <html:messages id="error" property="address.streetName">
093 <bean:write name="error" filter="false"/>
094 </html:messages>
095 </td>
096 </tr>
097 <tr>
098 <td class="label"><bean:message key="MiddleName"/></td>
099 <td><html:text
100 name="patientBean"
101 property="middleName"
102 size="20"
103 maxlength="60"
104 value="<%=patientBean.getMiddleName()%>"
105 tabindex="3"
106 />
107 </td>
108 <td class="label"></td>
109 <td><html:text
110 name="patientBean"
111 property="address.streetName2"
112 size="20"
113 maxlength="60"
114 value="<%=theAddressBean.getStreetName2()%>"
115 tabindex="10"
116 />
117 </td>
118 </tr>
119 <tr>
120 <td></td>
121 <td align="left">
122 <html:messages id="error" property="middleName">
123 <bean:write name="error" filter="false"/>
124 </html:messages>
125 </td>
126 </tr>
127 <tr>
128 <td class="label"><bean:message key="Gender"/></td>
129 <td><html:select property="gender"
130 value="<%=patientBean.getGender()%>"
131 tabindex="4">
132 <html:option value="1"><bean:message key="ChooseGender"/></html:option>
133 <html:option value="2">-------------</html:option>
134 <html:option value="Male"><bean:message key="Male"/></html:option>
135 <html:option value="Female"><bean:message key="Female"/></html:option>
136 </html:select>
137 </td>
138 <td class="label"><bean:message key="City"/></td>
139 <td><html:text
140 name="patientBean"
141 property="address.city"
142 size="20"
143 maxlength="60"
144 value="<%=theAddressBean.getCity()%>"
145 tabindex="11"
146 />
147 </td>
148 </tr>
149 <tr>
150 <td></td>
151 <td align="left">
152 <html:messages id="error" property="gender">
153 <bean:write name="error" filter="false"/>
154 </html:messages>
155 </td>
156 <td></td>
157 <td align="left">
158 <html:messages id="error" property="address.city">
159 <bean:write name="error" filter="false"/>
160 </html:messages>
161 </td>
162 </tr>
163 <tr>
164 <td class="label"><bean:message key="DOB"/><br/><font size=1pt>(mm/dd/yyyy)</font></td>
165 <td><html:text
166 name="patientBean"
167 property="dob"
168 size="10"
169 maxlength="10"
170 value="<%=patientBean.getDob()%>"
171 tabindex="5"
172 />
173 </td>
174 <td class="label"><bean:message key="State"/></td>
175 <td><html:text
176 name="patientBean"
177 property="address.state"
178 size="20"
179 maxlength="40"
180 value="<%=theAddressBean.getState()%>"
181 tabindex="12"
182 />
183 </td>
184 </tr>
185 <tr>
186 <td></td>
187 <td align="left">
188 <html:messages id="error" property="dob">
189 <bean:write name="error" filter="false"/>
190 </html:messages>
191 </td>
192 <td></td>
193 <td align="left">
194 <html:messages id="error" property="address.state">
195 <bean:write name="error" filter="false"/>
196 </html:messages>
197 </td>
198 </tr>
199 <tr>
200 <td class="label"><bean:message key="SSN"/><br/><font size=1pt>(xxxxxxxxx)</font></td>
201 <td><html:text
202 name="patientBean"
203 property="ssn"
204 size="9"
205 maxlength="9"
206 value="<%=patientBean.getSsn()%>"
207 tabindex="6"
208 />
209 </td>
210 <td class="label"><bean:message key="Zip"/></td>
211 <td><html:text
212 name="patientBean"
213 property="address.zipCode"
214 size="20"
215 maxlength="10"
216 value="<%=theAddressBean.getZipCode()%>"
217 tabindex="13"
218 />
219 </td>
220 </tr>
221 <tr>
222 <td></td>
223 <td align="left">
224 <html:messages id="error" property="ssn">
225 <bean:write name="error" filter="false"/>
226 </html:messages>
227 </td>
228 <td></td>
229 <td align="left">
230 <html:messages id="error" property="address.zipCode">
231 <bean:write name="error" filter="false"/>
232 </html:messages>
233 </td>
234 </tr>
235 <tr>
236 <td class="label"><bean:message key="Phone"/><br/><font size=1pt>(xxx-xxx-xxxx)</font></td>
237 <td><html:text
238 name="patientBean"
239 property="phone"
240 size="12"
241 maxlength="12"
242 value="<%=patientBean.getPhone()%>"
243 tabindex="7"
244 />
245 </td>
246 <td class="label"><bean:message key="Country"/></td>
247 <td><html:text
248 name="patientBean"
249 property="address.country"
250 size="20"
251 maxlength="40"
252 value="<%=theAddressBean.getCountry()%>"
253 tabindex="14"
254 />
255 </td>
256 </tr>
257 <tr>
258 <td></td>
259 <td align="left">
260 <html:messages id="error" property="phone">
261 <bean:write name="error" filter="false"/>
262 </html:messages>
263 </td>
264 <td></td>
265 <td align="left">
266 <html:messages id="error" property="address.country">
267 <bean:write name="error" filter="false"/>
268 </html:messages>
269 </td>
270 </tr>
271 <tr>
272 <td class="label"><bean:message key="Email"/></td>
273 <td><html:text
274 name="patientBean"
275 property="email"
276 size="20"
277 maxlength="40"
278 value="<%=patientBean.getEmail()%>"
279 readonly="true"
280 styleClass="row1"
281 tabindex="8"
282
283 />
284 </td>
285 </tr>
286 <tr>
287 <td></td>
288 <td align="left">
289 <html:messages id="error" property="email">
290 <bean:write name="error" filter="false"/>
291 </html:messages>
292 </td>
293 </tr>
294 <tr>
295 <td></td>
296 <td>
297 <br/>
298 <html:submit property="action" styleClass="profileButton">
299 <bean:message key="button.Save"/>
300 </html:submit>
301 <html:submit property="action">
302 <bean:message key="button.Cancel"/>
303 </html:submit>
304 </td>
305 </tr>
306 </table>
307 </sslext:form>
308
309 <!-- Content END -->
310 <!-- End Padding for Content -->
311 </tr>
312 </table>
313 </body>
314 </html:html>
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