{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"   EIBBEDXODDAM S","gend":1,"add":"                TEERTS HT5 461                              ","city":"MADISON HEIGHTS               ","state":"VA","zip":"24572-2203","dob":"1972-07-04","age":"","mstatus":"","insh":"50015303","cliId":"","pno":"4843472847","cno":4343638120,"email":"","ename":"","eno":"","pphy":"BOLUSA-SABUGO, AHGNES U                                     ","ppno":"","pcpadd":"320 Federal St","pcpcity":"Lynchburg                     ","pcpstate":"VA","pcpzip":245042306,"pcpcounty":"","pcpid":"P9058759","pcpname":"JOHNSON HEALTH CENTER","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"WESTERN\/ CHARLOTTESVILLE","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"164 5TH STREET                                              ","madd2":"                                                            ","madd3":"","mcity":"MADISON HEIGHTS               ","mstate":"VA","mzip":"24572-2203","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F33.9","M79.7","G89.4","I10","Z51.81","J06.9","J20.9","F32.9","E66.9","Z72.0","E78.00","E55.9","E78.5","Z68.1","Z68.22","S00.83XA","M25.562","M47.816","M54.5","Z79.891","J45.909","F41.1","G47.00","M72.0","J30.2","M54.9","N39.0","W19.XXXA","S00.91XA","Z79.899","L03.116","F17.210","M79.89","L03.90","M25.462","E87.6","L02.92","R65.10","L02.416","D64.9","T63.301A","F31.9","R68.89","S70.362D","G93.5","F11.20","R73.03","Z48.00","Z09","L02.415","J30.9","Z68.33","S61.411A","W01.0XXA","Z23","S69.91XA","F41.0","L08.9","S61.431A","Z71.3","S31.632A","S61.431D","T14.8XXA","R05","Z20.828","F33.1"],"date":["2020-10-30","2021-08-18","2021-08-18","2020-07-22","2021-08-18","2019-02-04","2019-02-20","2020-05-20","2020-06-29","2021-08-18","2019-03-05","2020-05-20","2020-06-01","2019-07-11","2019-07-11","2020-07-22","2019-08-30","2021-08-18","2021-08-18","2021-08-18","2020-06-01","2021-04-02","2021-04-02","2020-01-20","2020-04-09","2020-04-23","2020-04-23","2020-04-23","2020-04-23","2020-04-23","2020-06-01","2021-02-02","2020-05-14","2020-05-20","2020-05-14","2020-06-01","2020-05-20","2020-05-20","2020-06-01","2020-06-01","2020-05-19","2020-07-22","2020-05-22","2020-06-01","2020-06-01","2020-06-01","2020-06-01","2020-05-25","2020-05-29","2020-05-29","2020-06-29","2020-06-29","2020-07-22","2020-07-22","2020-07-22","2020-07-22","2020-10-30","2020-08-14","2020-08-04","2020-08-04","2020-08-14","2020-08-14","2020-08-14","2020-09-02","2020-09-02","2021-04-02"],"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":[["","16714008310","HYDROXYZ","50MG","360","Select","Select",""],["","57237001930","DULOXETINE","60MG","60","Select","Select",""],["","69097012312","TOPIRAMATE","50MG","60","Select","Select",""],["","68382080701","TRAZODONE","150MG","30","Select","Select",""],["","13668021830","ARIPIPRAZOLE","10MG","30","Select","Select",""],["","59310057922","PROAIR","","8.5","Select","Select",""],["","45802008801","ALBUTEROL","HFA","8.5","Select","Select",""],["","00228202950","ALPRAZOLAM","0.5MG","30","Select","Select",""],["","00093312501","DICLOXACILL","500MG","40","Select","Select",""],["","00093005805","TRAMADOL","50MG","60","Select","Select",""],["","16729018201","HYDROCHLOROT","12.5MG","90","Select","Select",""],["","66993068330","OLANZAPINE","10MG","30","Select","Select",""],["","55111018015","TIZANIDINE","4MG","90","Select","Select",""],["","68180044601","QUETIAPINE","50MG","60","Select","Select",""],["","72205001490","PREGABALIN","100MG","60","Select","Select",""],["","05388000924","VITAMIN","1000UNIT","30","Select","Select",""],["","00093520006","BUSPIRONE","30MG","60","Select","Select",""],["","00054327099","FLUTICASONE","50MCG","16","Select","Select",""],["","49035080609","EQ","10MG","30","Select","Select",""],["","68382005105","MELOXICAM","15MG","30","Select","Select",""],["","41100080602","CLARITIN","10MG","30","Select","Select",""],["","68180012202","CEPHALEXIN","500MG","40","Select","Select",""],["","65162027250","SMZ\/TMP","800-160","20","Select","Select",""],["","49281072010","FLUBLOK","2020-21","0.5","Select","Select",""],["","00143314250","DOXYCYCL","100MG","20","Select","Select",""],["","65862007701","CIPROFLOXACN","500MG","20","Select","Select",""],["","80777027399","MODERNA","COVID-19","0.5","Select","Select",""],["","00069046856","CHANTIX","0.5MG","56","Select","Select",""],["","16571040110","CETIRIZINE","5MG","30","Select","Select",""],["","68645048054","ATORVASTATIN","10MG","30","Select","Select",""],["","16714008310","HYDROXYZ ","TAB 50MG","360","Select","Select",""],["","57237001930","DULOXETINE ","CAP 60MG","60","Select","Select",""],["","69097012312","TOPIRAMATE ","TAB 50MG","60","Select","Select",""],["","68382080701","TRAZODONE ","TAB 150MG","30","Select","Select",""],["","13668021830","ARIPIPRAZOLE ","TAB 10MG","30","Select","Select",""],["","59310057922","PROAIR ","AER ","8.5","Select","Select",""],["","45802008801","ALBUTEROL ","AER HFA","8.5","Select","Select",""],["","00228202950","ALPRAZOLAM ","TAB 0.5MG","30","Select","Select",""],["","00093312501","DICLOXACILL ","CAP 500MG","40","Select","Select",""],["","00093005805","TRAMADOL ","TAB 50MG","60","Select","Select",""],["","55111018015","TIZANIDINE ","TAB 4MG","90","Select","Select",""],["","16729018201","HYDROCHLOROT ","TAB 12.5MG","90","Select","Select",""],["","00093005405","BUSPIRONE ","TAB 10MG","90","Select","Select",""],["","66993068330","OLANZAPINE ","TAB 10MG","30","Select","Select",""],["","68180044601","QUETIAPINE ","TAB 50MG","60","Select","Select",""],["","72205001490","PREGABALIN ","CAP 100MG","60","Select","Select",""],["","05388000924","VITAMIN ","CAP 1000UNIT","30","Select","Select",""],["","00054327099","FLUTICASONE ","SPR 50MCG","16","Select","Select",""],["","68382005105","MELOXICAM ","TAB 15MG","30","Select","Select",""],["","49035080609","EQ ","TAB 10MG","30","Select","Select",""],["","41100080602","CLARITIN ","TAB 10MG","30","Select","Select",""],["","68180012202","CEPHALEXIN ","CAP 500MG","40","Select","Select",""],["","65162027250","SMZ\/TMP ","TAB 800-160","20","Select","Select",""],["","49281072010","FLUBLOK ","INJ 2020-21","0.5","Select","Select",""],["","00143314250","DOXYCYCL ","CAP 100MG","20","Select","Select",""],["","65862007701","CIPROFLOXACN ","TAB 500MG","20","Select","Select",""],["","80777027399","MODERNA ","INJ COVID-19","0.5","Select","Select",""],["","00069046856","CHANTIX ","TAB 0.5MG","56","Select","Select",""],["","16571040110","CETIRIZINE ","TAB 5MG","30","Select","Select",""],["","68645048054","ATORVASTATIN ","TAB 10MG","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":[[["No","Select","","","","","Select","",""],["No","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":""}]}]}