{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"D   DRAWDENOSREBOR ","gend":0,"add":"        DAOR DNOMHCIR DLO 1478                              ","city":"KEELING                       ","state":"VA","zip":"24566-2049","dob":"1978-01-27","age":"","mstatus":"","insh":"50017663","cliId":"","pno":"0743414379","cno":"","email":"","ename":"","eno":"","pphy":"STEPHENS, AMBER                                             ","ppno":"","pcpadd":"2767 Franklin Tpke","pcpcity":"Danville                      ","pcpstate":"VA","pcpzip":245405273,"pcpcounty":"","pcpid":"P0124039","pcpname":"FAMILY HEALTHCARE CENTER OF MOUNT HERMON","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"WESTERN\/ CHARLOTTESVILLE","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"8741 OLD RICHMOND ROAD                                      ","madd2":"                                                            ","madd3":"","mcity":"KEELING                       ","mstate":"VA","mzip":"24566-2049","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["E83.110","E83.19","E83.119","F44.5","G80.9","F17.200","Z79.899","Z88.8","M25.562","S50.811A","W54.0XXA","S61.451A","Z20.3","Z29.14","Y92.410","G40.909","F17.210","H00.014","E55.9","G40.A09","E78.5","G40.814","H53.9","R39.11","G40.219","F81.9","G43.009","L98.8","K74.60","R63.4","K27.9","G40.919","R45.851","Z83.3","Z82.49","Z79.52","G44.209","F07.81","R53.83","R62.7","R19.7","F32.9","G47.00","Z88.0","F44.9","A50.9","B34.8","G40.812","R50.9","R53.81","R56.9","H00.024","J22","K25.9","G40.019","G40.209","K21.9","Z23","F41.1","R07.9","R20.0","Z13.6","R06.02","R03.0","H00.022","S80.861A","W57.XXXA","R06.00","R60.9","W19.XXXA","Z13.9","R41.9","B96.81","G40.319","H53.2","H01.02A","H01.02B","G93.89","M54.6","R07.81"],"date":["2021-10-07","2021-10-07","2021-10-07","2019-08-08","2021-10-07","2021-10-07","2021-10-07","2021-10-07","2019-01-24","2019-02-28","2019-03-05","2019-03-05","2019-03-08","2019-03-08","2019-03-05","2021-10-07","2019-11-07","2019-03-18","2021-05-18","2019-04-02","2021-05-18","2019-05-30","2019-05-30","2019-04-02","2021-08-12","2021-08-12","2021-08-03","2019-04-03","2019-05-31","2019-06-26","2019-08-08","2019-04-29","2019-04-29","2019-04-29","2019-04-29","2019-04-29","2019-08-05","2021-08-12","2019-05-30","2020-04-23","2019-06-26","2021-05-18","2021-08-03","2019-08-08","2019-08-08","2019-08-20","2019-08-20","2019-11-20","2019-08-20","2019-08-20","2021-04-12","2019-08-22","2019-10-06","2021-10-07","2020-11-18","2019-11-21","2019-11-20","2019-11-20","2021-08-12","2021-01-27","2020-06-19","2021-01-27","2021-01-27","2021-01-27","2020-07-07","2020-07-20","2020-07-20","2020-08-05","2020-08-17","2020-08-17","2020-11-03","2020-11-18","2021-10-07","2020-12-29","2021-02-23","2021-02-23","2021-02-23","2021-04-12","2021-04-26","2021-04-26"],"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":[["","70710122600","AMITRIPTYLIN","25MG","30","Select","Select",""],["","17772012301","OXTELLAR","600MG","30","Select","Select",""],["","65862023060","LAMOTRIGINE","200MG","90","Select","Select",""],["","24208091055","ERYTHROMYCIN","5MG\/GM","3.5","Select","Select",""],["","40985027288","VITAMIN","5000UNIT","30","Select","Select",""],["","68180012202","CEPHALEXIN","500MG","14","Select","Select",""],["","61314063705","PREDNISOLONE","1% OP","5","Select","Select",""],["","00093321205","CLONAZEPAM","1MG","60","Select","Select",""],["","57237001401","TAMSULOSIN","0.4MG","30","Select","Select",""],["","68180016013","AZITHROMYCIN","250MG","6","Select","Select",""],["","49281042050","FLUZONE","2020-21","0.5","Select","Select",""],["","70710122600","AMITRIPTYLIN ","TAB 25MG","30","Select","Select",""],["","17772012301","OXTELLAR ","TAB 600MG","30","Select","Select",""],["","65862023060","LAMOTRIGINE ","TAB 200MG","90","Select","Select",""],["","24208091055","ERYTHROMYCIN ","OIN 5MG\/GM","3.5","Select","Select",""],["","40985027288","VITAMIN ","TAB 5000UNIT","30","Select","Select",""],["","68180012202","CEPHALEXIN ","CAP 500MG","14","Select","Select",""],["","61314063705","PREDNISOLONE ","SUS 1% OP","5","Select","Select",""],["","00093321205","CLONAZEPAM ","TAB 1MG","60","Select","Select",""],["","57237001401","TAMSULOSIN ","CAP 0.4MG","30","Select","Select",""],["","68180016013","AZITHROMYCIN ","TAB 250MG","6","Select","Select",""],["","49281042050","FLUZONE ","INJ 2020-21","0.5","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":""}]}]}