{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"   AICITELREINRAV A","gend":1,"add":"IRAM 0342EVIRD AN","city":"N CHESTERFIELD","state":"VA","zip":"23234-5144","dob":"1964-05-21","age":"","mstatus":"","insh":"50012211","cliId":"","pno":"0740872934","cno":8047043927,"email":"","ename":"","eno":"","pphy":"TAYLOR, GAIL L","ppno":8044235050,"pcpadd":"13700 St Francis Blvd, Ste 302","pcpcity":"Midlothian","pcpstate":"VA","pcpzip":231143222,"pcpcounty":"","pcpid":"","pcpname":"","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"CENTRAL","aligned":"","ano":"","add2":"APT D","add3":"","madd1":"2430 MARINA DRIVE","madd2":"APT D","madd3":"","mcity":"N CHESTERFIELD","mstate":"VA","mzip":"23234-5144","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["I21.4","I25.5","I25.10","Z95.5","F31.32","Z12.11","R10.13","K44.9","D12.4","K64.1","M54.6","M51.36","E11.40","M54.9","M47.22","Z98.1","M62.838","M54.2","M62.81","R29.3","F43.20","R56.9","Z86.010","G89.29","E11.9","G40.909","J45.909","E16.2","Z79.890","M54.5","R47.01","J06.9","B97.89","Z68.25","Z01.411","N95.2","Z90.710","Z78.0","Z79.899","J02.9","J04.0","K21.9","Z88.0","R07.9","I16.1","I42.0","E11.51","E78.5","F31.9","G89.4","I10","I25.2","J44.9","Z72.0","Z79.84","I05.1","I05.8","R93.1","R10.84","R10.9","R11.2","R19.7","Z90.49","Z82.49","Z88.2","K64.8","M41.9","Z12.31","Z68.24","M50.321","M54.12","M48.02","R55","I95.9","Z01.812","Z20.828","Z23","F43.12","Z01.818","R42","Z86.79","N17.9","F17.210","F41.8","I73.9","F41.9","R47.9","E87.6","M50.121","N95.1","N39.3","Z76.0","Z13.9","G56.21","G56.01","Z01.810","R68.89","Z88.5","G43.019","F41.1","M15.9","F32.9","E66.3","D64.9","F33.9","M19.90","Z87.39"],"date":["2019-06-08","2019-06-08","2019-10-03","2019-06-08","2021-03-22","2019-12-24","2020-07-07","2019-08-28","2019-12-24","2019-12-24","2020-02-10","2020-01-27","2020-02-10","2020-08-11","2020-08-21","2021-04-22","2020-08-21","2021-05-05","2021-04-22","2021-04-22","2019-06-03","2020-10-20","2019-12-24","2020-01-27","2020-10-20","2020-01-27","2020-10-20","2020-01-27","2020-01-27","2020-01-27","2020-10-09","2020-04-24","2019-03-04","2019-06-19","2019-05-09","2019-05-09","2021-02-04","2019-05-09","2020-07-07","2019-05-22","2019-05-22","2020-10-20","2019-08-09","2019-10-03","2019-06-06","2019-06-06","2019-06-06","2019-10-03","2019-06-06","2019-10-03","2019-10-03","2019-06-06","2019-10-03","2019-06-06","2019-06-06","2019-06-07","2019-06-07","2019-06-07","2019-08-09","2019-08-09","2019-08-09","2019-08-09","2019-08-09","2019-08-09","2019-08-09","2019-12-24","2020-02-10","2021-02-03","2020-04-24","2020-09-18","2020-10-20","2020-10-20","2020-10-09","2020-10-09","2020-10-16","2020-10-16","2021-04-18","2019-02-20","2020-10-07","2020-10-09","2019-10-03","2019-10-03","2019-10-03","2019-10-03","2019-10-03","2020-10-09","2020-10-09","2019-06-24","2020-10-20","2021-02-04","2021-02-04","2021-02-04","2019-08-28","2020-09-22","2020-09-22","2020-10-07","2019-03-08","2019-05-22","2020-07-27","2020-07-27","2020-07-27","2020-07-27","2020-07-27","2020-07-27","2019-08-28","2019-08-28","2019-12-18"],"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":[["","58160082311","SHINGRIX ","INJ 50MCG","1","Select","Select",""],["","64380080807","IBUPROFEN ","TAB 600MG","40","Select","Select",""],["","51991074890","DULOXETINE ","CAP 60MG","30","Select","Select",""],["","49281071910","FLUBLOK ","INJ 2019-20","0.5","Select","Select",""],["","00555088702","ESTRADIOL ","TAB 2MG","30","Select","Select",""],["","55111064530","OMEPRAZOLE ","CAP 40MG","30","Select","Select",""],["","55111029309","SUMATRIPTAN ","TAB 100MG","9","Select","Select",""],["","62332000231","FAMOTIDINE ","TAB 40MG","30","Select","Select",""],["","60505018300","CARBAMAZEPIN ","TAB 200MG","120","Select","Select",""],["","63402030430","LATUDA ","TAB 40MG","30","Select","Select",""],["","61442010201","DICLOFENAC ","TAB 50MG DR","20","Select","Select",""],["","69097084615","CYCLOBENZAPR ","TAB 10MG","15","Select","Select",""],["","64380080404","RANITIDINE ","TAB 300MG","30","Select","Select",""],["","62756018488","OXCARBAZEPIN ","TAB 300MG","32","Select","Select",""],["","29300012501","MELOXICAM ","TAB 15MG","30","Select","Select",""],["","64380071306","BENZONATATE ","CAP 200MG","30","Select","Select",""],["","51672131200","MUPIROCIN ","OIN 0.02","22","Select","Select",""],["","74312019377","VITAMIN ","CAP 5000UNIT","60","Select","Select",""],["","10572030201","PEG-3350\/KCL ","SOL \/SODIUM","4,000.00","Select","Select",""],["","59762444002","METHYLPRED ","TAB 4MG","21","Select","Select",""],["","00193731221","CONTOUR ","TES NEXT","100","Select","Select",""],["","00904759180","FERROUS ","TAB 325MG","30","Select","Select",""],["","00193658621","MICROLET ","MIS LANCETS","100","Select","Select",""],["","49884068901","METOCLOPRAM ","TAB 10MG","50","Select","Select",""],["","68180012202","CEPHALEXIN ","CAP 500MG","28","Select","Select",""],["","50383077504","LIDOCAINE ","SOL 2% VISC","100","Select","Select",""],["","10702001801","OXYCODONE ","TAB 5MG","50","Select","Select",""],["","00536106229","STOOL ","CAP 100MG","60","Select","Select",""],["","31722053301","METHOCARBAM ","TAB 500MG","30","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":""}]}]}