{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"C   AHSRAHARAYINAHC ","gend":1,"add":"R EREMSDROF 125729600700579 D","city":"CHESAPEAKE","state":"VA","zip":"23322-9998","dob":"1953-05-26","age":"","mstatus":"","insh":"04000910*853","cliId":"3NR1YE9JF96","pno":"63\/4345980-3","cno":"434\/363-0895","email":"","ename":"","eno":"","pphy":"ISMAELI-CAMPBELL, ATTIYAH MD","ppno":"757\/983-1777","pcpadd":"213 RIVER WALK PKWY STE 101","pcpcity":"CHESAPEAKE","pcpstate":"VA","pcpzip":23320,"pcpcounty":"","pcpid":700507,"pcpname":"","plan":"OHP","program":"MEDICARE","lob":"DSNP","region":"TIDEWATER","aligned":"Y","ano":"Non-DSNP","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["I10.","E11.22","N18.30","E11.9","I73.9","Z12.31","Z23.","I25.10","I50.42","Z79.84","H25.813","H04.123","H16.143","M79.674","M79.675","E53.8","E78.2","L03.113","Z76.0","Z12.11","Z95.1","E78.5","I27.22"],"date":["2021-07-23","2021-05-28","2021-05-28","2021-07-23","2021-03-17","2020-10-08","2020-10-30","2021-07-23","2021-07-23","2020-11-10","2020-11-10","2020-11-10","2020-11-10","2021-03-03","2021-03-03","2021-05-28","2021-05-28","2021-03-26","2021-07-06","2021-05-23","2021-07-23","2021-07-23","2021-07-23"],"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":[["","67877021905","CEPHALEXIN","CAP 500MG","-28","Select","Select",""],["","49281072010","FLUBLOK QUAD","INJ 2020-21","0","Select","Select",""],["","53885024510","ONETOUCH","TES ULTRA","-100","Select","Select",""],["","16729000101","GLIMEPIRIDE","TAB 1MG","90","Select","Select",""],["","68382009405","CARVEDILOL","TAB 12.5MG","180","Select","Select",""],["","68180098003","LISINOPRIL","TAB 10MG","90","Select","Select",""],["","67877041401","METFORMIN","TAB 750MG ER","90","Select","Select",""],["","53885000810","ONETOUCH DEL","MIS PLUS 33G","100","Select","Select",""],["","80777027399","MODERNA VAC","INJ COVID-19","0","Select","Select",""],["","6483703","PNEUMOVAX 23","INJ 25\/0.5","0","Select","Select",""],["","70377003012","ATORVASTATIN","TAB 80MG","90","Select","Select",""],["","53885000810","ONETOUCH DELICA PLUS LANCETS EXTRA FINE 33G ","","100","Select","Select",""],["","67877041401","METFORMIN HYDROCHLORIDE ER","","90","Select","Select",""],["","53885024510","ONETOUCH ULTRA","","100","Select","Select",""],["","49281072010","FLUBLOK QUADRIVALENT 2020-2021","","0","Select","Select",""],["","70377003012","ATORVASTATIN CALCIUM ","","90","Select","Select",""],["","80777027399","MODERNA COVID-19 VACCINE","","0","Select","Select",""],["","53885000810","ONETOUCH DELICA PLUS LANCETS EXTRA FINE 33G","","200","Select","Select",""],["","70377003012","ATORVASTATIN CALCIUM","","90","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","",""],["Yes","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["N\/A","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":""}]}]}