{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"E   NAOJKEJEIC ","gend":1,"add":"B .O.P642 XO","city":"AMELIA","state":"VA","zip":"23002-0246","dob":"1956-10-18","age":"","mstatus":"","insh":"40016658","cliId":"","pno":"6540894701","cno":8045610749,"email":"","ename":"","eno":"","pphy":"PARK, HYO KWON","ppno":8044693731,"pcpadd":"8631 Namozine Rd, ","pcpcity":"Amelia Court House","pcpstate":"VA","pcpzip":230023410,"pcpcounty":"","pcpid":"","pcpname":"","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"CENTRAL","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"P.O. BOX 246","madd2":"                                                            ","madd3":"","mcity":"AMELIA","mstate":"VA","mzip":"23002-0246","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["E11.65","I10","Z79.4","E10.65","N18.3","E11.29","E55.9","E78.2","D51.0","Z23","E11.9","E78.5","E66.9","N76.0","N18.30","D51.8","K29.70","R11.11","K92.0","M54.5","K21.9","M54.41","E11.22","A41.9","R65.20","A08.4","E11.10","Z79.84","E11.43","K31.84","F41.9","R00.0","N17.9","E87.1","G93.41","E87.2","E11.69","A41.89","K20.9","R53.83","Z68.29","Z12.31","E10.9","E04.1","E05.90","R11.2","E66.3","Z68.28","E13.10"],"date":["2021-05-03","2021-05-03","2021-04-01","2020-07-10","2019-02-01","2019-02-01","2021-04-01","2019-10-02","2021-01-05","2020-10-05","2021-04-01","2021-04-01","2021-04-01","2021-04-01","2021-05-03","2019-10-30","2020-03-09","2020-03-09","2020-03-12","2021-05-03","2021-05-03","2021-05-03","2021-05-03","2020-03-10","2020-03-09","2020-03-09","2020-03-10","2020-03-09","2020-03-09","2020-03-09","2020-03-09","2020-03-10","2020-03-10","2020-03-09","2020-03-10","2020-03-09","2020-03-12","2020-03-12","2020-03-12","2020-05-26","2021-01-05","2021-01-05","2019-10-30","2020-03-10","2020-03-10","2020-03-10","2020-10-05","2020-10-05","2020-03-09"],"priorHcc":["","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","",""]}},{"a":[]}]},{"t":"Covid Screening","q":[{"a":[]}]},{"t":"Self-Assessment and Social History","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Activities of Daily Living","q":[{"a":[]}]},{"t":"Medical History","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Family History","q":[{"a":[]}]},{"t":"Preventive Care","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Allergies \/ Medications","q":[{"a":[]},{"a":{"comment":"","sub":[["","68180045901","AMLOD\/BENAZP ","CAP 5-20MG","30","Select","Select",""],["","00378718705","METFORMIN ","TAB 1000MG","60","Select","Select",""],["","99073070822","FREESTYLE    TES LITE","TES LITE","50","Select","Select",""],["","00169368512","NOVOLOG ","INJ 70\/30","10","Select","Select",""],["","60505006501","OMEPRAZOLE ","CAP 20MG","30","Select","Select",""],["","57237000511","FLUCONAZOLE ","TAB 150MG","1","Select","Select",""],["","08290328468","INSULIN ","MIS 0.5\/31G","10","Select","Select",""],["","52817033200","CYCLOBENZAPR ","TAB 10MG","90","Select","Select",""],["","65162075450","BENAZEPRIL ","TAB 40MG","90","Select","Select",""],["","00088222033","LANTUS ","INJ 100\/ML","10","Select","Select",""],["","68180072003","AMLODIPINE ","TAB 5MG","90","Select","Select",""],["","00169643810","LEVEMIR ","INJ FLEXTOUC","9","Select","Select",""],["","00378003210","METOPROL ","TAB 50MG","60","Select","Select",""],["","00378395005","ATORVASTATIN ","TAB 10MG","90","Select","Select",""],["","70069000510","CYANOCOBALAM ","INJ 1000MCG","3","Select","Select",""],["","00172572860","FAMOTIDINE ","20MG","90","Select","Select",""]]}},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Review of Systems and Diagnoses","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Pain","q":[{"a":[]}]},{"t":"Vital Signs","q":[{"a":[]},{"a":[]}]},{"t":"Exam Review","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Screenings Needed","q":[[["Yes","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""]]]},{"t":"Mini-Cog","q":[{"a":[]}]},{"t":"Home Safety & Personal Goals","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Active Problem Conditions","q":[{"a":[]}]},{"t":"Patient Summary","q":[{"a1":"","a2":"","a3":"","a4":"","a5":"","a6":"","a7":[],"a8":"","a9":"","a10":[],"a11":"","a12":""}]}]}