{"version":"0.4","data":[{"t":"Demographics","q":[{"name":" YROMEREMRAF","gend":0,"add":"           DAOR TNOMLE   94411                              ","city":"ASHLAND                       ","state":"VA","zip":"23005-7711","dob":"2003-05-19","age":"","mstatus":"","insh":"90013839","cliId":"","pno":"7740857059","cno":8047795075,"email":"","ename":"","eno":"","pphy":"YOUNG, CHRISTINE M                                          ","ppno":"","pcpadd":"306 ASHCAKE RD","pcpcity":"ASHLAND                       ","pcpstate":"VA","pcpzip":230052323,"pcpcounty":"","pcpid":"P0149257","pcpname":"BON SECOURS INTERNAL MEDICINE OF ASHLAND","plan":"VPHP","program":"MEDICAID","lob":"VPM4","region":"CENTRAL","aligned":"","ano":"","add2":"APARTMENT 4                                                 ","add3":"","madd1":"11449   ELMONT ROAD                                         ","madd2":"APARTMENT 4                                                 ","madd3":"","mcity":"ASHLAND                       ","mstate":"VA","mzip":"23005-7711","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["S60.052A","S69.90XA","W21.01XA","Y93.61","S69.92XA","Y93.89","F12.20","M20.022","M79.645","M25.571","S93.401A","X58.XXXA","R53.1","R53.83","F32.9"],"date":["2019-07-18","2019-07-18","2019-07-18","2019-09-30","2019-07-18","2019-07-18","2019-07-31","2019-09-11","2019-07-24","2019-09-30","2019-09-30","2019-09-30","2019-10-23","2019-10-23","2021-08-13"],"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":[]},{"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","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["No","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":""}]}]}