{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"ENITSIRHC ECNEPS D ","gend":1,"add":"RAF 8022ENAL REM","city":"CHESAPEAKE","state":"VA","zip":"23324-4026","dob":"1977-08-20","age":"","mstatus":"","insh":"60015455","cliId":"","pno":",68729497576484553757 ","cno":7573587006,"email":"","ename":"","eno":"","pphy":"UNKNOWN PROVIDER QNXT PCP","ppno":"               ","pcpadd":"UNKNOWN STREET, ","pcpcity":"RICHMOND","pcpstate":"VA","pcpzip":232190000,"pcpcounty":"","pcpid":"","pcpname":"","plan":"VPHP - VIRGINIA PREMIER","program":"MEDICAID","lob":"MLTSS","region":"TIDEWATER","aligned":"","ano":"","add2":"APARTMENT 1","add3":"","madd1":"2208 FARMER LANE","madd2":"APARTMENT 1","madd3":"","mcity":"CHESAPEAKE","mstate":"VA","mzip":"23324-4026","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z74.09","G11.3","R26.89","R10.9","R10.2","Z85.09","M54.2","W18.30XA","R29.6","F41.9","I10","E11.40","Z82.49","Z79.899","Z79.84","Z88.6","Z88.5","S19.9XXA","M48.061","M79.604","M54.10","Z91.81","N39.41","M62.81","R15.9","E13.40","E23.2","M25.532","H10.31","H57.11","R10.84","Z01.419","Z90.710","Z11.3","Z12.31","Z12.72","M79.606","S99.929A","S92.315A","S93.602A","S93.402A","S96.912A","M48.062","G62.9","I82.432","M48.00","M25.572","M79.672","I82.402","R68.89","E11.42","Z74.1","S93.612D","Z91.89","E66.9","Z68.31","W06.XXXA","Y92.003","Z90.49","J01.00","E11.51","Z93.3","Z68.29","M54.31","M25.561","M25.562","E11.9","H25.093","I82.462","M79.605","R00.0","R91.1","T14.90XA","M54.5","E11.8","G11.2","D64.9","Z76.0","Z68.28","K42.9","R10.10","R07.1","K43.9","M79.89","E78.5","H04.123","R07.81","M17.0","G89.29"],"date":["2019-06-10","2020-08-03","2019-06-10","2019-09-16","2019-06-03","2020-12-31","2019-08-12","2019-08-12","2019-08-12","2019-12-19","2021-04-01","2020-07-28","2020-07-28","2020-07-28","2020-07-28","2020-07-28","2020-07-28","2019-08-12","2019-11-20","2019-11-20","2019-11-20","2020-02-25","2021-03-15","2021-03-15","2021-03-15","2021-04-27","2021-04-27","2019-03-05","2019-03-05","2019-03-05","2019-03-05","2019-06-18","2019-09-16","2019-06-18","2019-08-22","2019-06-18","2019-12-19","2019-12-19","2020-07-16","2020-07-16","2020-11-18","2020-07-16","2020-08-03","2021-03-17","2020-08-03","2021-03-15","2020-11-18","2020-11-18","2020-11-18","2020-11-25","2020-03-17","2020-03-17","2020-03-17","2020-03-17","2020-03-17","2021-03-17","2019-12-19","2019-12-19","2020-07-28","2019-01-08","2019-03-04","2019-01-08","2019-11-15","2020-02-25","2020-02-25","2020-02-25","2020-05-19","2020-05-19","2020-07-28","2020-07-28","2020-07-28","2020-07-28","2019-08-12","2020-03-03","2021-03-17","2021-03-17","2019-03-04","2019-03-04","2019-03-04","2019-06-03","2019-09-16","2019-09-16","2019-06-03","2019-06-03","2019-08-08","2019-08-08","2019-09-16","2020-02-25","2020-02-25"],"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":[["","00904549213","THERA-M ","TAB ","30","Select","Select",""],["","00904053913","THERA ","TAB ","30","Select","Select",""],["","00536466038","THEREMS ","TAB ","30","Select","Select",""],["","50428043400","ONE ","TAB ESSENTL","30","Select","Select",""],["","00245010801","FERROUS ","TAB 325MG EC","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","",""],["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":""}]}]}