{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"  LATSYRCRELLAW R ","gend":1,"add":"           191 XOB ECIFFO TSOP                              ","city":"ALTAVISTA                     ","state":"VA","zip":"24517-0191","dob":"1976-03-14","age":"","mstatus":"","insh":"50013323","cliId":"","pno":"3543442574","cno":4345347524,"email":"","ename":"","eno":"","pphy":"BURROUGHS, JOEL                                             ","ppno":"","pcpadd":"925 Village Hwy","pcpcity":"Rustburg                      ","pcpstate":"VA","pcpzip":245884591,"pcpcounty":"","pcpid":"P9307464","pcpname":"PRIVIA MEDICAL GROUP LLC","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"WESTERN\/ CHARLOTTESVILLE","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"POST OFFICE BOX 191                                         ","madd2":"                                                            ","madd3":"","mcity":"ALTAVISTA                     ","mstate":"VA","mzip":"24517-0191","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F31.9","J11.1","E87.1","F17.210","Z79.899","R51","J02.9","R19.7","I67.89","R20.2","J95.859","Z00.00","E03.9","E53.8","E55.9","Z12.4","A60.00","L30.9","R56.9","Z12.39","Z71.6","F17.200","F39","D50.9","F41.9","E66.9","R10.2","R10.9","Z88.2","N39.0","Z98.84","R30.0","N76.4","Z88.1","L02.214","Z72.0","Z23","Z12.31","Z68.30","N12","F31.62","Z01.419","Z87.891","J98.8","Z20.828","R05","J34.0","B37.3","L29.8","L29.9","R07.89","Z88.8","Z95.0","R07.9","R00.1","S06.0X9A","M25.511","V43.52XA","M54.2","S49.91XA","S09.90XA","S19.9XXA","M47.812","M48.02","S06.0X0A","H83.2X9","S06.0X0D","R42","M43.6","S16.1XXA","R39.15","E16.2","M22.41","M25.561","R82.90","R82.998","J34.89","Z68.31","J06.9","G56.00","Z11.59","M54.9","R09.81","Z68.32"],"date":["2021-04-15","2019-02-10","2019-02-10","2020-12-28","2020-11-16","2019-02-10","2021-10-14","2019-02-16","2019-02-28","2019-02-28","2019-02-28","2019-03-19","2021-04-15","2021-04-15","2021-04-15","2019-03-19","2021-04-15","2019-03-19","2021-04-15","2021-04-15","2019-03-19","2019-03-19","2021-04-15","2021-04-15","2020-09-20","2019-10-23","2019-09-08","2019-10-23","2019-10-23","2019-10-23","2021-04-15","2020-10-01","2020-01-09","2020-11-05","2020-01-09","2021-08-13","2020-09-17","2020-10-15","2020-02-27","2020-05-05","2021-11-09","2020-06-04","2021-10-14","2020-09-20","2021-10-14","2020-09-20","2020-09-24","2020-10-01","2020-10-01","2020-10-01","2020-11-05","2020-11-05","2020-11-05","2020-11-05","2020-11-05","2020-11-16","2020-11-16","2020-11-16","2021-01-11","2020-11-16","2020-11-17","2020-11-17","2020-11-17","2020-11-17","2020-12-01","2021-04-15","2021-04-15","2021-01-11","2020-12-28","2021-01-08","2021-02-22","2021-04-15","2021-04-30","2021-04-30","2021-07-26","2021-07-26","2021-07-26","2021-07-26","2021-08-13","2021-09-27","2021-10-14","2021-10-14","2021-10-14","2021-10-14"],"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":[["","00093010901","CARBAMAZEPIN","200MG","30","Select","Select",""],["","65862053750","LEVOFLOXACIN","500MG","7","Select","Select",""],["","65862039010","ONDANSETRON","4MG ODT","10","Select","Select",""],["","68462010340","FLUCONAZOLE","150MG","1","Select","Select",""],["","75826011510","PHENAZOPYRID","200MG","6","Select","Select",""],["","00143992801","CIPROFLOXACN","500MG","20","Select","Select",""],["","50111056102","TRAZODONE","100MG","56","Select","Select",""],["","13668001101","CITALOPRAM","40MG","28","Select","Select",""],["","14539067501","HYDROXYZ","50MG","60","Select","Select",""],["","00093520006","BUSPIRONE","30MG","60","Select","Select",""],["","67877032105","IBUPROFEN","800MG","60","Select","Select",""],["","70069000510","CYANOCOBALAM","1000MCG","1","Select","Select",""],["","00904759180","FEROSUL","325MG","30","Select","Select",""],["","69315090405","LORAZEPAM","0.5MG","15","Select","Select",""],["","31722077701","ACYCLOVIR","400MG","180","Select","Select",""],["","08290309581","3ML","25GX1\"","1","Select","Select",""],["","69238183901","LEVOTHYROXIN","175MCG","90","Select","Select",""],["","64380073706","VITAMIN","50000UNT","4","Select","Select",""],["","00904759180","FERROUS","325MG","30","Select","Select",""],["","99073070822","FREESTYLE TES LITE","LITE","50","Select","Select",""],["","50228043605","NAPROXEN","500MG","14","Select","Select",""],["","21922000909","DICLOFENAC","1%","100","Select","Select",""],["","55111029309","SUMATRIPTAN","100MG","9","Select","Select",""],["","70000051202","NICOTINE","21MG\/24H","28","Select","Select",""],["","99073070805","FREESTYLE MIS LITE","LITE","1","Select","Select",""],["","45802046564","KETOCONAZOLE","2%","120","Select","Select",""],["","63402030830","LATUDA","80MG","30","Select","Select",""],["","00904675859","ROBAFEN","10-100MG","300","Select","Select",""],["","00093317431","ALBUTEROL","E","8.5","Select","Select",""],["","00054981729","PREDNISONE","10MG","33","Select","Select",""],["","52817033210","CYCLOBENZAPR","10MG","30","Select","Select",""],["","47781030301","NITROFURANTN","100MG","10","Select","Select",""],["","50383077504","LIDOCAINE","2% VISC","100","Select","Select",""],["","80777027399","MODERNA","COVID-19","0.5","Select","Select",""],["","68180012202","CEPHALEXIN","500MG","20","Select","Select",""],["","00093101042","MUPIROCIN","2%","22","Select","Select",""],["","56151014701","TRUPLUS","33G","100","Select","Select",""],["","00093010901","CARBAMAZEPIN ","TAB 200MG","30","Select","Select",""],["","65862053750","LEVOFLOXACIN ","TAB 500MG","7","Select","Select",""],["","65862039010","ONDANSETRON ","TAB 4MG ODT","10","Select","Select",""],["","68462010340","FLUCONAZOLE ","TAB 150MG","1","Select","Select",""],["","75826011510","PHENAZOPYRID ","TAB 200MG","6","Select","Select",""],["","00143992801","CIPROFLOXACN ","TAB 500MG","20","Select","Select",""],["","50111056102","TRAZODONE ","TAB 100MG","56","Select","Select",""],["","13668001101","CITALOPRAM ","TAB 40MG","28","Select","Select",""],["","14539067501","HYDROXYZ ","CAP 50MG","90","Select","Select",""],["","68382018314","BUSPIRONE ","TAB 30MG","60","Select","Select",""],["","69315090405","LORAZEPAM ","TAB 0.5MG","15","Select","Select",""],["","31722077701","ACYCLOVIR ","TAB 400MG","180","Select","Select",""],["","69238183901","LEVOTHYROXIN ","TAB 175MCG","90","Select","Select",""],["","67877032105","IBUPROFEN ","TAB 800MG","60","Select","Select",""],["","70069000510","CYANOCOBALAM ","INJ 1000MCG","1","Select","Select",""],["","00904759180","FEROSUL ","TAB 325MG","30","Select","Select",""],["","08290309581","3ML ","MIS 25GX1\"","1","Select","Select",""],["","64380073706","VITAMIN ","CAP 50000UNT","4","Select","Select",""],["","00904759180","FERROUS ","TAB 325MG","30","Select","Select",""],["","99073070822","FREESTYLE    TES LITE","TES LITE","50","Select","Select",""],["","50228043605","NAPROXEN ","TAB 500MG","14","Select","Select",""],["","21922000909","DICLOFENAC ","GEL 0.01","100","Select","Select",""],["","55111029309","SUMATRIPTAN ","TAB 100MG","9","Select","Select",""],["","70000051202","NICOTINE ","DIS 21MG\/24H","28","Select","Select",""],["","99073070805","FREESTYLE    MIS LITE","MIS LITE","1","Select","Select",""],["","45802046564","KETOCONAZOLE ","SHA 0.02","120","Select","Select",""],["","63402030830","LATUDA ","TAB 80MG","30","Select","Select",""],["","00904675859","ROBAFEN ","LIQ 10-100MG","300","Select","Select",""],["","00093317431","ALBUTEROL ","FAT E","8.5","Select","Select",""],["","00054981729","PREDNISONE ","TAB 10MG","33","Select","Select",""],["","52817033210","CYCLOBENZAPR ","TAB 10MG","30","Select","Select",""],["","47781030301","NITROFURANTN ","CAP 100MG","10","Select","Select",""],["","50383077504","LIDOCAINE ","SOL 2% VISC","100","Select","Select",""],["","80777027399","MODERNA ","INJ COVID-19","0.5","Select","Select",""],["","68180012202","CEPHALEXIN ","CAP 500MG","20","Select","Select",""],["","00093101042","MUPIROCIN ","OIN 0.02","22","Select","Select",""],["","56151014701","TRUPLUS ","MIS 33G","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","",""],["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":""}]}]}