{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"  ETTEZOJNOXID L ","gend":1,"add":"           TEERTS KRAM TS   15                              ","city":"PETERSBURG                    ","state":"VA","zip":"23803-5830","dob":"1973-09-09","age":"","mstatus":"","insh":"40017478","cliId":"","pno":"2940842816","cno":8048217234,"email":"","ename":"","eno":"","pphy":"FLEENOR, ELLEN T                                            ","ppno":"","pcpadd":"9950 Courthouse Rd,2116 W Laburnum Ave Ste 100","pcpcity":"Charles City                  ","pcpstate":"VA","pcpzip":230303434,"pcpcounty":"","pcpid":"","pcpname":"","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"CENTRAL","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"51   ST MARK STREET                                         ","madd2":"                                                            ","madd3":"","mcity":"PETERSBURG                    ","mstate":"VA","mzip":"23803-5830","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","1","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F31.2","F25.0","F31.32","M54.12","M25.512","M79.602","M54.2","M54.9","Z88.0","Z87.891","R52","Z12.31","Z71.89","Z13.220","Z71.3","Z01.419","K92.1","J30.2","Z80.0","R05","E78.5","Z23","Z11.1","K52.9","R11.2","B34.9","Z79.899","R11.0","R68.89","N64.4","N61.1","R92.8","F43.20","F25.9","X58.XXXA","Y92.9","E66.9","S40.211A","F41.9","Z20.822","Z62.810","Z98.51","Z85.3","Z83.3","Z68.33","F31.9","F22","F29","F31.5","Z80.3","F31.89","F33.1","F23","F31.30","H54.61","G47.00","Z91.410","H53.8","D32.9","R03.0","F31.64","J45.909","Z11.4","Z11.3"],"date":["2021-07-13","2021-08-13","2021-11-20","2019-03-27","2019-03-27","2019-04-05","2019-03-27","2019-03-27","2021-06-27","2021-06-27","2020-03-04","2019-11-04","2020-07-21","2019-04-11","2020-07-21","2019-04-17","2019-06-18","2021-08-27","2021-06-03","2019-08-02","2021-08-27","2019-11-04","2019-11-11","2020-03-04","2020-03-04","2020-03-04","2021-06-27","2020-03-04","2020-05-15","2021-08-27","2020-07-30","2021-03-11","2021-06-12","2021-06-27","2021-06-03","2021-06-03","2021-06-03","2021-06-04","2021-06-13","2021-06-27","2021-06-03","2021-06-13","2021-06-03","2021-06-13","2021-06-03","2021-06-04","2021-06-04","2021-09-20","2021-06-13","2021-06-13","2021-06-14","2021-06-25","2021-06-27","2021-06-27","2021-06-27","2021-06-27","2021-06-27","2021-06-27","2021-06-27","2021-06-27","2021-08-09","2021-08-27","2021-08-27","2021-08-27"],"priorHcc":["","",null,"","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","",""]}},{"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":[["","80777027398","MODERNA","COVID-19","0.5","Select","Select",""],["","43547034306","RISPERIDONE","3MG","30","Select","Select",""],["","50111043301","TRAZODONE","50MG","60","Select","Select",""],["","68001018300","QUETIAPINE","300MG","30","Select","Select",""],["","50383079216","VALPROIC","250\/5ML","600","Select","Select",""],["","65862084605","CLOZAPINE","100MG","14","Select","Select",""],["","00093005101","CARVEDILOL","3.125MG","60","Select","Select",""],["","63304069301","CLINDAMYCIN","300MG","21","Select","Select",""],["","60432060416","PROMETHAZINE","DM","200","Select","Select",""],["","50383070016","FLUTICASONE","50MCG","16","Select","Select",""],["","45802065087","LORATADINE","10MG","30","Select","Select",""],["","00536105224","PEG3350","","238","Select","Select",""],["","68180016013","AZITHROMYCIN","250MG","6","Select","Select",""],["","68180012201","CEPHALEXIN","500MG","40","Select","Select",""],["","65862042001","SMZ\/TMP","800-160","20","Select","Select",""],["","67877032105","IBUPROFEN","800MG","30","Select","Select",""],["","00904673080","ACETAMIN","500MG","12","Select","Select",""],["","00093317431","ALBUTEROL","E","8.5","Select","Select",""],["","68462010530","ONDANSETRON","4MG","10","Select","Select",""],["","70377000712","ROSUVASTATIN","10MG","90","Select","Select",""],["","55111053201","DIVALPROEX","125MG","270","Select","Select",""],["","80777027398","MODERNA ","INJ COVID-19","0.5","Select","Select",""],["","43547034306","RISPERIDONE ","TAB 3MG","30","Select","Select",""],["","50111043301","TRAZODONE ","TAB 50MG","60","Select","Select",""],["","68001018300","QUETIAPINE ","TAB 300MG","30","Select","Select",""],["","50383079216","VALPROIC ","SOL 250\/5ML","600","Select","Select",""],["","65862084605","CLOZAPINE ","TAB 100MG","14","Select","Select",""],["","00093005101","CARVEDILOL ","TAB 3.125MG","60","Select","Select",""],["","63304069301","CLINDAMYCIN ","CAP 300MG","21","Select","Select",""],["","60432060416","PROMETHAZINE ","SYP DM","200","Select","Select",""],["","50383070016","FLUTICASONE ","SPR 50MCG","16","Select","Select",""],["","45802065087","LORATADINE ","TAB 10MG","30","Select","Select",""],["","00536105224","PEG3350 ","POW ","238","Select","Select",""],["","68180016013","AZITHROMYCIN ","TAB 250MG","6","Select","Select",""],["","68180012201","CEPHALEXIN ","CAP 500MG","40","Select","Select",""],["","65862042001","SMZ\/TMP ","TAB 800-160","20","Select","Select",""],["","67877032105","IBUPROFEN ","TAB 800MG","30","Select","Select",""],["","00904673080","ACETAMIN ","TAB 500MG","12","Select","Select",""],["","00093317431","ALBUTEROL ","FAT E","8.5","Select","Select",""],["","68462010530","ONDANSETRON ","TAB 4MG","10","Select","Select",""],["","70377000712","ROSUVASTATIN ","TAB 10MG","90","Select","Select",""],["","55111053201","DIVALPROEX ","CAP 125MG","270","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":[[["No","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["No","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":""}]}]}