{"version":"0.4","data":[{"t":"Demographics","q":[{"name":" AHLIZCIDVA","gend":1,"add":"            DAOR NYWORB   7051                              ","city":"HENRICO                       ","state":"VA","zip":"23238-4504","dob":"1960-05-04","age":"","mstatus":"","insh":"40019518","cliId":"","pno":"9440829907","cno":8044970992,"email":"","ename":"","eno":"","pphy":"ALI, SABINA                                                 ","ppno":"","pcpadd":"5855 Bremo Rd Ste 102","pcpcity":"Richmond                      ","pcpstate":"VA","pcpzip":232261926,"pcpcounty":"","pcpid":"P0060118","pcpname":"MONUMENT INTERNAL MEDICINE","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"CENTRAL","aligned":"","ano":"","add2":"UNIT 103                                                    ","add3":"","madd1":"1507   BROWYN ROAD                                          ","madd2":"UNIT 103                                                    ","madd3":"","mcity":"HENRICO                       ","mstate":"VA","mzip":"23238-4504","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["I10","F32.9","E11.9","E78.00","F41.8","Z68.37","G47.33","Z99.89","J35.1","E66.01","K59.00","Z11.59","R10.13","E11.21","E55.9","Z12.31","M17.0","Z23","Z68.36","J30.1","M25.561","Z12.39","M25.562","H25.13","H35.9","K62.5","K64.9","M17.11","M25.461","K62.89","R19.8","K92.1","L40.9","Z78.0","M85.80","M85.88","R00.1","R07.9","Z00.00","Z68.34","R06.02","Z68.35","M17.10","I50.31","I08.0","Z01.818","Z01.812","Z20.822","Z79.84","Z79.899","Z79.82","Z96.651","F32.A","G89.18"],"date":["2021-10-13","2021-09-23","2021-10-20","2021-06-24","2021-10-20","2021-10-20","2020-12-09","2019-04-25","2019-05-02","2021-09-27","2020-03-02","2019-05-09","2019-05-09","2021-10-20","2021-06-24","2019-09-09","2021-10-20","2021-09-23","2021-02-22","2021-02-22","2021-10-13","2020-10-28","2021-02-22","2020-01-30","2020-01-30","2020-03-12","2020-03-02","2021-10-13","2020-03-02","2020-03-12","2020-03-12","2020-03-18","2021-10-13","2020-11-16","2020-11-16","2020-11-16","2021-09-27","2021-09-27","2021-09-14","2021-09-14","2021-09-27","2021-09-27","2021-09-23","2021-09-27","2021-09-27","2021-10-07","2021-10-07","2021-10-07","2021-10-13","2021-10-13","2021-10-13","2021-11-04","2021-10-20","2021-10-13"],"priorHcc":["","","","","","","","","","","","","","","","","","","","",null,"","","","","","","","","","","","","","","","","","","","","","","","","","","","","","",null,"",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":[["","99073070827","FREESTYLE TES LITE","LITE","100","Select","Select",""],["","68462051389","DESONIDE","0.05%","118","Select","Select",""],["","68645052254","SERTRALINE","50MG","90","Select","Select",""],["","65162083366","DICLOFENAC","1%","100","Select","Select",""],["","45802013135","HALOBETASOL","0.05%","15","Select","Select",""],["","80681016801","VITAMIN","25MCG","30","Select","Select",""],["","62332021030","TELMISA\/HCTZ","80-12.5","90","Select","Select",""],["","64380076921","PEG-3350\/KCL","\/SODIUM","4,000.00","Select","Select",""],["","00228202950","ALPRAZOLAM","0.5MG","30","Select","Select",""],["","68645019059","METOPROL","50MG","60","Select","Select",""],["","99073013001","FREESTYLE MIS LANCETS","LANCETS","100","Select","Select",""],["","68645058259","METFORMIN","500MG","90","Select","Select",""],["","31604004070","D3","1000UNIT","30","Select","Select",""],["","16714068403","SIMVASTATIN","40MG","90","Select","Select",""],["","99073070914","FREESTYLE KIT FREEDOM","FREEDOM","1","Select","Select",""],["","99073070805","FREESTYLE MIS LITE","LITE","1","Select","Select",""],["","68382005105","MELOXICAM","15MG","30","Select","Select",""],["","45802057178","FEXOFENADINE","180MG","30","Select","Select",""],["","64980032430","PROCTOZONE","-HC 2.5%","30","Select","Select",""],["","45802086802","POLYETH","3350 NF","238","Select","Select",""],["","80777027310","MODERNA","COVID-19","0.5","Select","Select",""],["","99073070827","FREESTYLE    TES LITE","TES LITE","100","Select","Select",""],["","68462051389","DESONIDE ","LOT 0.0005","118","Select","Select",""],["","68645052254","SERTRALINE ","TAB 50MG","90","Select","Select",""],["","65162083366","DICLOFENAC ","GEL 0.01","100","Select","Select",""],["","45802013135","HALOBETASOL ","OIN 0.0005","15","Select","Select",""],["","80681016801","VITAMIN ","TAB 25MCG","30","Select","Select",""],["","68382005005","MELOXICAM ","TAB 7.5MG","30","Select","Select",""],["","62332021030","TELMISA\/HCTZ ","TAB 80-12.5","90","Select","Select",""],["","64380076921","PEG-3350\/KCL ","SOL \/SODIUM","4,000.00","Select","Select",""],["","00228202950","ALPRAZOLAM ","TAB 0.5MG","30","Select","Select",""],["","68645014059","FAMOTIDINE ","TAB 20MG","60","Select","Select",""],["","42858000101","OXYCODONE ","TAB 5MG","42","Select","Select",""],["","69547035302","NARCAN ","SPR ","2","Select","Select",""],["","00904679480","ASPIRIN ","CHW 81MG","60","Select","Select",""],["","68645019059","METOPROL ","TAB 50MG","60","Select","Select",""],["","99073013001","FREESTYLE    MIS LANCETS","MIS LANCETS","100","Select","Select",""],["","68645058259","METFORMIN ","TAB 500MG","90","Select","Select",""],["","31604004070","D3 ","TAB 1000UNIT","30","Select","Select",""],["","16714068403","SIMVASTATIN ","TAB 40MG","90","Select","Select",""],["","99073070914","FREESTYLE    KIT FREEDOM","KIT FREEDOM","1","Select","Select",""],["","99073070805","FREESTYLE    MIS LITE","MIS LITE","1","Select","Select",""],["","45802057178","FEXOFENADINE ","TAB 180MG","30","Select","Select",""],["","64980032430","PROCTOZONE ","CRE -HC 2.5%","30","Select","Select",""],["","45802086802","POLYETH ","POW 3350 NF","238","Select","Select",""],["","80777027310","MODERNA ","INJ COVID-19","0.5","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":""}]}]}