{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"  SINNEDSLLEW L ","gend":0,"add":"INIGRIV 915EN EUNEVA A","city":"NORTON","state":"VA","zip":"24273-1116","dob":"1962-02-05","age":"","mstatus":"","insh":"60017996","cliId":"","pno":"2367258005","cno":2762190246,"email":"","ename":"","eno":"","pphy":"NIDA, MAURICE E","ppno":2764660584,"pcpadd":"410 Stagecoach Rd, ","pcpcity":"Bristol","pcpstate":"VA","pcpzip":242018359,"pcpcounty":"","pcpid":"","pcpname":"","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"SOUTHWEST","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"519 VIRGINIA AVENUE NE","madd2":"                                                            ","madd3":"","mcity":"NORTON","mstate":"VA","mzip":"24273-1116","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R25.1","E72.20","F10.20","M25.522","T81.31XD","T81.31XA","Y83.8","M19.90","I10","J44.9","K21.9","K74.60","F17.210","R07.89","E53.8","M79.89","M86.9","R79.89","Z51.81","Z79.01","T82.528A","F41.9","F32.9","Z72.0","R68.89","M86.10","R27.0","E55.9","K70.9","F10.10","G31.9","K92.2","H25.11","Z96.1","H04.129","Z74.09","R29.898","M25.512","M25.571","G89.29","M25.572","H16.223","H02.88A","H02.88B","M70.22","M25.722","L76.34","T81.42XD","S51.002D","L08.9","I51.7","T14.8XXA","T81.30XA","K76.0","R94.5","Z45.2","T81.30XD","H25.13","H52.03","Y90.8","N17.9","D62","K20.9","K44.9","R53.1","K29.71","K52.9","K65.9","R07.9","R74.0","R53.81","R53.83","E87.1","R74.01","G47.9","G89.21","R06.02","R06.2","Z79.899","I87.2","M86.622","R19.7","R10.13","R10.9","H04.123","H16.143","H26.492","Z13.220","R35.8","R63.1","R26.89","N18.31","T81.89XD","Z48.01","B95.62","F43.10","M70.32","M67.824","G62.9","M86.432","S51.809A","G40.909","S51.002A","H52.221","H52.4","D69.6","M86.8X3","L98.492","D50.9","J30.2","L23.7","L03.114","S46.312A","S56.512A","H25.12","G31.2","K29.21","K92.1","Z79.51","Q13.9","M54.5","R73.03","Z23","F17.200","Z00.00","R52","R73.09","S51.009A","H11.012","R10.33","R11.2","R12","K29.70","Z01.810","R22.32","M77.9","M86.8X2","R50.9","F17.290","Z79.2","X58.XXXA","R70.0","R79.82","R19.5","E87.5","Z87.11","H52.13","H52.223"],"date":["2019-01-02","2019-01-02","2019-10-01","2019-10-31","2019-02-14","2019-02-14","2019-02-14","2019-01-24","2021-04-21","2021-04-21","2021-01-13","2019-01-24","2020-05-08","2020-05-08","2020-11-09","2019-06-29","2019-10-22","2020-02-26","2019-07-12","2019-08-05","2019-07-22","2020-05-08","2020-05-08","2019-07-22","2021-02-25","2019-08-21","2020-06-29","2020-11-09","2020-11-09","2020-05-08","2020-03-27","2020-04-20","2020-08-05","2020-09-03","2020-04-30","2020-06-29","2020-06-29","2020-08-07","2020-07-10","2020-08-07","2020-07-10","2021-02-01","2021-02-01","2021-02-01","2019-01-21","2019-01-21","2019-02-13","2019-02-13","2019-04-02","2019-04-02","2019-04-05","2019-10-22","2019-11-26","2019-06-21","2019-10-31","2019-07-22","2019-10-01","2019-11-11","2020-02-19","2020-04-08","2020-05-08","2020-04-08","2020-04-08","2020-05-08","2020-04-08","2020-04-08","2020-04-08","2020-05-08","2020-05-08","2020-07-10","2020-07-10","2020-07-10","2021-01-13","2021-01-13","2021-01-13","2021-01-13","2019-04-05","2019-06-06","2019-07-31","2019-07-01","2019-07-23","2020-05-08","2020-05-08","2020-04-08","2020-05-15","2020-05-15","2020-08-20","2021-04-21","2021-04-21","2021-04-21","2021-04-21","2021-04-21","2019-02-14","2019-06-01","2019-06-01","2020-05-08","2019-05-28","2019-05-28","2019-07-31","2019-07-31","2019-09-05","2019-10-01","2019-11-26","2019-04-30","2020-09-03","2019-05-31","2019-06-29","2019-09-24","2019-10-31","2019-10-31","2019-10-31","2019-11-07","2019-11-07","2019-11-07","2020-02-06","2020-03-27","2020-05-08","2020-05-08","2020-04-08","2020-08-06","2020-11-09","2020-11-09","2020-11-09","2020-11-09","2020-11-09","2019-04-05","2019-05-28","2019-06-04","2019-11-22","2020-05-08","2020-05-08","2020-04-08","2020-04-08","2019-02-14","2019-05-28","2019-05-28","2019-06-29","2019-06-29","2019-06-29","2019-07-16","2019-07-22","2019-10-23","2019-10-23","2020-05-08","2020-05-08","2020-05-08","2020-09-03","2020-09-03"],"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":[["","69680011225","CYANOCOBALAM ","INJ 1000MCG","1","Select","Select",""],["","69452015120","VITAMIN ","CAP 50000UNT","4","Select","Select",""],["","53746010901","HYDROCO\/APAP ","TAB 5-325MG","28","Select","Select",""],["","62175061743","PANTOPRAZOLE ","TAB 40MG","30","Select","Select",""],["","65862020390","LOSARTAN ","TAB 100MG","30","Select","Select",""],["","45802091987","CETIRIZINE ","TAB 10MG","30","Select","Select",""],["","68382002310","ATENOLOL ","TAB 50MG","30","Select","Select",""],["","53489064701","DOXYCYCLINE ","TAB 20MG","60","Select","Select",""],["","68180065001","DOXYCYC ","CAP 50MG","180","Select","Select",""],["","00054327099","FLUTICASONE ","SPR 50MCG","16","Select","Select",""],["","61314063715","PREDNISOLONE ","SUS 1% OP","15","Select","Select",""],["","00904530660","BANOPHEN ","CAP 25MG","30","Select","Select",""],["","69097094312","GABAPENTIN ","CAP 300MG","60","Select","Select",""],["","13668013501","ESCITALOPRAM ","TAB 5MG","30","Select","Select",""],["","24208031510","POLYMYXIN ","SOL TRIMETHP","10","Select","Select",""],["","00023916360","RESTASIS ","EMU 0.0005","180","Select","Select",""],["","00186037020","SYMBICORT ","AER 160-4.5","10.2","Select","Select",""],["","00254100752","ALBUTEROL ","AER HFA","6.7","Select","Select",""],["","68180021709","LOSARTAN\/HCT ","TAB 100-25","30","Select","Select",""],["","08290305270","3ML ","MIS 25GX1\"","4","Select","Select",""],["","00093005805","TRAMADOL ","TAB 50MG","56","Select","Select",""],["","50111033401","METRONIDAZOL ","TAB 500MG","15","Select","Select",""],["","00093221001","SUCRALFATE ","TAB 1GM","56","Select","Select",""],["","68180071160","CEFDINIR ","CAP 300MG","10","Select","Select",""],["","59746000103","METHYLPRED ","TAB 4MG","21","Select","Select",""],["","14539067401","HYDROXYZ ","CAP 25MG","30","Select","Select",""],["","50428006205","SALINE ","SPR 0.0065","88","Select","Select",""],["","68462079817","TRIAMCINOLON ","OIN 0.005","30","Select","Select",""],["","51991074790","DULOXETINE ","CAP 30MG","53","Select","Select",""],["","68180072003","AMLODIPINE ","TAB 5MG","30","Select","Select",""],["","24658031205","DOXYCYCL ","TAB 100MG","30","Select","Select",""],["","68180012202","CEPHALEXIN ","CAP 500MG","56","Select","Select",""],["","65862050320","AMOX\/K ","875-125","20","Select","Select",""],["","53746051401","SPIRONOLACT ","50MG","30","Select","Select",""],["","68462010530","ONDANSETRON ","4MG","6","Select","Select",""],["","53746014601","HYDROCOD\/IBU ","5-200MG","20","Select","Select",""],["","00536589588","NICOTINE ","14MG\/24H","28","Select","Select",""],["","00143992801","CIPROFLOXACN ","500MG","10","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","",""],["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":""}]}]}