{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"   ADNAMAREKANOH R","gend":1,"add":"             ENAL RAMBA   6501                              ","city":"MONTVALE                      ","state":"VA","zip":"24122-2877","dob":"1982-01-25","age":"","mstatus":"","insh":"50010995","cliId":"","pno":"7604558476","cno":5406767485,"email":"","ename":"","eno":"","pphy":"TATE, GLEN E                                                ","ppno":"","pcpadd":"40 Wiley Dr","pcpcity":"Ferrum                        ","pcpstate":"VA","pcpzip":240881100,"pcpcounty":"","pcpid":"P0114064","pcpname":"TRI AREA COMMUNITY HEALTH CENTER","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"ROANOKE\/ ALLEGHANY","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"1056   ABMAR LANE                                           ","madd2":"                                                            ","madd3":"","mcity":"MONTVALE                      ","mstate":"VA","mzip":"24122-2877","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F31.9","K50.90","Z72.0","Z87.898","K02.9","K08.89","F41.9","M54.2","K04.7","M54.9","N39.0","F17.290","Z79.1","R30.0","R51","R50.9","R05","R52","Z82.49","Y99.8","S02.5XXA","Z79.82","Z79.899","X58.XXXA","K03.81","R03.0"],"date":["2020-10-10","2020-07-11","2019-01-09","2019-01-09","2020-07-11","2021-03-20","2020-10-10","2019-12-10","2019-12-10","2019-12-10","2020-01-20","2020-10-10","2020-07-11","2020-01-20","2020-01-21","2020-01-21","2020-01-21","2020-01-21","2020-07-11","2020-07-11","2020-10-10","2020-07-11","2020-07-11","2020-10-10","2021-03-20","2021-01-06"],"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":[["","00781261305","AMOXICILLIN","500MG","40","Select","Select",""],["","49035074162","ARTHRTS","650MG","15","Select","Select",""],["","67877031901","IBUPROFEN","400MG","30","Select","Select",""],["","50383077504","LIDOCAINE","2% VISC","100","Select","Select",""],["","57237004101","PENICILLN","500MG","40","Select","Select",""],["","49035030890","PAIN","500MG","30","Select","Select",""],["","51293081001","PHENAZOPYRID","100MG","10","Select","Select",""],["","65162047810","NITROFURANTN","100MG","14","Select","Select",""],["","60432060416","PROMETHAZINE","DM","120","Select","Select",""],["","69452014430","BENZONATATE","200MG","30","Select","Select",""],["","51862088403","CAMILA","0.35MG","28","Select","Select",""],["","00406012301","HYDROCO\/APAP","5-325MG","20","Select","Select",""],["","00781261305","AMOXICILLIN ","CAP 500MG","40","Select","Select",""],["","49035074162","ARTHRTS ","TAB 650MG","15","Select","Select",""],["","67877031901","IBUPROFEN ","TAB 400MG","30","Select","Select",""],["","50383077504","LIDOCAINE ","SOL 2% VISC","100","Select","Select",""],["","57237004101","PENICILLN ","TAB 500MG","40","Select","Select",""],["","49035030890","PAIN ","TAB 500MG","30","Select","Select",""],["","51293081001","PHENAZOPYRID ","TAB 100MG","10","Select","Select",""],["","65162047810","NITROFURANTN ","CAP 100MG","14","Select","Select",""],["","60432060416","PROMETHAZINE ","SYP DM","120","Select","Select",""],["","69452014430","BENZONATATE ","CAP 200MG","30","Select","Select",""],["","51862088403","CAMILA ","TAB 0.35MG","28","Select","Select",""],["","00406012301","HYDROCO\/APAP ","TAB 5-325MG","20","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","",""],["No","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":""}]}]}