{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"  AHSRAMFFOH J ","gend":1,"add":"                   SEGATS EFIL                              ","city":"MARTINSVILLE                  ","state":"VA","zip":"24115-3066","dob":"1958-05-08","age":"","mstatus":"","insh":"50011056","cliId":"","pno":"2667233539","cno":2766293533,"email":"","ename":"","eno":"","pphy":"PALLONE, AMANDA W                                           ","ppno":"","pcpadd":"1107 Brookdale St # A","pcpcity":"Martinsville                  ","pcpstate":"VA","pcpzip":241124501,"pcpcounty":"","pcpid":"","pcpname":"","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"ROANOKE\/ ALLEGHANY","aligned":"","ano":"","add2":"PO BOX 3066                                                 ","add3":"","madd1":"LIFE STAGES                                                 ","madd2":"PO BOX 3066                                                 ","madd3":"","mcity":"MARTINSVILLE                  ","mstate":"VA","mzip":"24115-3066","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F20.9","R39.81","F20.0","E11.9","Z04.6","E78.5","K21.9","Z87.891","Z79.4","Z88.8","F25.0","I10","E78.00","Z79.899","R68.89","E11.8","E03.9","E66.9","Z12.11","Z12.31","R92.1","R51","L30.9","Z51.81","R19.7","R00.2","L82.1","Z23","R35.0","E11.42","B35.1","I70.90","Z86.711","R82.90","R81","I82.409","I82.492","R22.42","Z79.02","R60.0","R60.9","I82.4Y2","Z12.39","E55.9","R05","Z20.828","J18.9","R06.02","U07.1","E11.65","Z88.0","J18.8","J06.9","S70.02XA","M25.552","W18.30XA","S92.912A","Z72.0","S92.505A","W01.0XXA","Z79.01"],"date":["2021-11-22","2021-07-19","2020-12-02","2021-11-19","2019-01-28","2021-11-19","2020-12-09","2020-12-10","2021-11-19","2020-12-09","2019-01-29","2021-06-03","2019-01-29","2021-06-08","2021-02-24","2019-12-10","2021-11-19","2020-10-02","2020-11-10","2021-03-25","2019-06-10","2019-06-27","2019-06-27","2019-07-17","2019-08-23","2019-08-23","2019-08-23","2021-11-19","2019-10-22","2019-12-04","2019-12-04","2019-12-04","2019-12-10","2020-01-29","2020-01-29","2020-09-23","2020-09-23","2020-09-23","2020-09-23","2020-09-23","2020-09-23","2020-10-02","2020-10-02","2020-10-02","2020-12-02","2020-12-09","2020-12-09","2020-12-09","2020-12-10","2020-12-09","2020-12-09","2020-12-09","2021-07-06","2021-10-13","2021-10-13","2021-10-13","2021-10-13","2021-10-13","2021-10-13","2021-10-13","2021-11-19"],"priorHcc":[null,"","",null,"",null,"","",null,"","","","","","","",null,"","","","","","","","","","",null,"","","","","","","","","","","","","","","","","","","","","","","","","","","","","","",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":[["","68180096609","LEVOTHYROXIN","50MCG","28","Select","Select",""],["","70010006505","METFORMIN","1000MG","56","Select","Select",""],["","00003089421","ELIQUIS","5MG","56","Select","Select",""],["","68180051201","LISINOPRIL","2.5MG","28","Select","Select",""],["","69097094605","ATORVASTATIN","40MG","28","Select","Select",""],["","00169633910","NOVOLOG","FLEXPEN","15","Select","Select",""],["","08470355001","UNIFINE","31GX3\/16","100","Select","Select",""],["","00193731221","CONTOUR","NEXT","100","Select","Select",""],["","00193658621","MICROLET","LANCETS","100","Select","Select",""],["","67457040913","HALOPER","100MG\/ML","2","Select","Select",""],["","10147095303","PALIPERIDONE","ER 6MG","28","Select","Select",""],["","62756079713","DIVALPROEX","250MG DR","84","Select","Select",""],["","13107003105","MIRTAZAPINE","15MG","28","Select","Select",""],["","00169643810","LEVEMIR","FLEXTOUC","15","Select","Select",""],["","64380073706","VITAMIN","50000UNT","4","Select","Select",""],["","59762311001","AZITHROMYCIN","100\/5ML","75","Select","Select",""],["","00054001825","PREDNISONE","20MG","5","Select","Select",""],["","80777027399","MODERNA","COVID-19","0.5","Select","Select",""],["","00193654621","BAYER","LANCETS","100","Select","Select",""],["","68180096609","LEVOTHYROXIN ","TAB 50MCG","28","Select","Select",""],["","70010006505","METFORMIN ","TAB 1000MG","56","Select","Select",""],["","00003089421","ELIQUIS ","TAB 5MG","56","Select","Select",""],["","68180051201","LISINOPRIL ","TAB 2.5MG","28","Select","Select",""],["","69097094605","ATORVASTATIN ","TAB 40MG","28","Select","Select",""],["","00169633910","NOVOLOG ","INJ FLEXPEN","15","Select","Select",""],["","08470355001","UNIFINE ","MIS 31GX3\/16","100","Select","Select",""],["","00193731221","CONTOUR ","TES NEXT","100","Select","Select",""],["","00193658621","MICROLET ","MIS LANCETS","100","Select","Select",""],["","67457040913","HALOPER ","INJ 100MG\/ML","2","Select","Select",""],["","10147095303","PALIPERIDONE ","TAB ER 6MG","28","Select","Select",""],["","62756079713","DIVALPROEX ","TAB 250MG DR","84","Select","Select",""],["","13107003105","MIRTAZAPINE ","TAB 15MG","28","Select","Select",""],["","00169643810","LEVEMIR ","INJ FLEXTOUC","15","Select","Select",""],["","64380073706","VITAMIN ","CAP 50000UNT","4","Select","Select",""],["","59762311001","AZITHROMYCIN ","SUS 100\/5ML","75","Select","Select",""],["","68462019001","NAPROXEN ","TAB 500MG","30","Select","Select",""],["","00054001825","PREDNISONE ","TAB 20MG","5","Select","Select",""],["","80777027399","MODERNA ","INJ COVID-19","0.5","Select","Select",""],["","00193654621","BAYER ","MIS LANCETS","100","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":""}]}]}