{"version":"0.4","data":[{"t":"Demographics","q":[{"name":" S   YHTAKIRERTSILAB","gend":1,"add":"R EULB 0187EVIRD EGDI","city":"HURT","state":"VA","zip":"24563-3860","dob":"1961-02-07","age":"","mstatus":"","insh":"50018731","cliId":"","pno":"2443483396","cno":4344269338,"email":"","ename":"","eno":"","pphy":"ROBERTSON, SANDRA JO","ppno":5409498241,"pcpadd":"428 S Magnolia Ave, Ste 1","pcpcity":"Waynesboro","pcpstate":"VA","pcpzip":229803629,"pcpcounty":"","pcpid":"","pcpname":"","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"WESTERN\/ CHARLOTTESVILLE","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"7810 BLUE RIDGE DRIVE","madd2":"                                                            ","madd3":"","mcity":"HURT","mstate":"VA","mzip":"24563-3860","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["E66.2","J96.12","L03.115","I89.0","I13.0","I50.32","E11.22","N18.3","D64.9","E03.9","G47.33","Z99.81","I50.9","J96.10","E11.9","E55.9","L60.0","I27.81","E66.01","L98.7","L30.4","R60.9","E65","R73.03","Z86.79","Z01.810","I10","I12.9","Z12.31","Z80.3","Z23","Z87.2","Z68.45","Z79.82","Z79.899","L03.116","I87.2","L97.321","Z91.19","L03.90","E11.41","B35.1","M79.671","M79.672","R60.0"],"date":["2021-04-22","2021-04-22","2019-08-23","2019-09-11","2019-08-23","2019-08-23","2019-10-02","2020-01-08","2019-10-02","2020-12-10","2019-08-23","2019-08-23","2021-04-08","2021-04-08","2020-12-10","2020-12-10","2020-10-21","2021-04-22","2020-12-10","2019-04-30","2019-04-30","2020-01-08","2019-04-30","2019-04-30","2019-04-30","2019-07-01","2020-12-10","2020-01-08","2019-08-28","2019-08-28","2020-12-10","2019-08-22","2019-08-22","2019-08-22","2019-08-22","2019-10-02","2019-10-02","2019-10-02","2019-10-02","2019-09-11","2020-10-21","2020-10-21","2020-10-21","2020-10-21","2020-10-21"],"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":[["","80777027399","MODERNA ","INJ COVID-19","0.5","Select","Select",""],["","00527134901","LEVOTHYROXIN ","TAB 150MCG","30","Select","Select",""],["","69315011710","FUROSEMIDE ","TAB 40MG","30","Select","Select",""],["","00093015001","APAP\/CODEINE ","TAB 300-30MG","20","Select","Select",""],["","33332041910","AFLURIA ","INJ 2019-20","0.5","Select","Select",""],["","58160081912","SHINGRIX ","INJ 50MCG","1","Select","Select",""],["","70010049105","METFORMIN ","ORAL TAB","60","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":""}]}]}