{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"   EILRAHCSWODAEM L","gend":0,"add":"LAH 9045DR XAFI","city":"CHATHAM","state":"VA","zip":"24531-9998","dob":"1955-11-30","age":"","mstatus":"","insh":"04000910*978","cliId":"7JY1HQ5WT01","pno":"34\/4347448-2","cno":"434\/432-8447","email":"","ename":"","eno":"","pphy":"SHAH, MINESH R MD","ppno":"434\/432-0216","pcpadd":"13908 US HIGHWAY 29","pcpcity":"CHATHAM","pcpstate":"VA","pcpzip":24531,"pcpcounty":"","pcpid":145833,"pcpname":"","plan":"OHP","program":"MEDICARE","lob":"MA-Non DSNP","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"","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":["G47.33","E11.9","H40.1131","E11.65","H40.043","Z20.828","H40.1130","H20.012","H25.13","Z79.4","Z12.11"],"date":["2021-08-19","2021-10-08","2021-09-10","2021-02-15","2021-07-06","2020-12-17","2021-06-08","2021-03-12","2020-11-06","2020-11-06","2021-05-23"],"priorHcc":[null,null,null,"","","","","","","",""]}},{"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":[["","050383023310","DORZOL\/TIMOL ","22.3-6.8","30","Select","Select",""],["","000088221905","LANTUS ","100\/ML","-15","Select","Select",""],["","008290320109","BD  PEN NEEDL","31GX8MM","100","Select","Select",""],["","024208046325","LATANOPROST ","0.01%","8","Select","Select",""],["","000169633910","NOVOLOG ","FLEXPEN","15","Select","Select",""],["","061314063710","PREDNISOLONE ","1% OP","10","Select","Select",""],["","000006057561","JANUMET ","50-500MG","180","Select","Select",""],["","070727052925","ROCKLATAN ","","2","Select","Select",""],["","061314014305","BRIMONIDINE ","0.2% OP","5","Select","Select",""],["","047335022090","KETOROLAC ","0.50%","5","Select","Select",""],["","070377002711","ATORVASTATIN ","10MG","90","Select","Select",""],["","053885013610","ONETOUCH ","LANCETS","200","Select","Select",""],["","070010049110","METFORMIN ","500MG ER","180","Select","Select",""],["","08290320109","","31GX8MM","100","Select","Select",""],["","00088221905","LANTUS","100\/ML","-15","Select","Select",""],["","08290320109","BD PEN NEEDL","31GX8MM","100","Select","Select",""],["","50383023310","DORZOL\/TIMOL","22.3-6.8","30","Select","Select",""],["","24208046325","LATANOPROST","0.01%","8","Select","Select",""],["","70377002711","ATORVASTATIN","10MG","90","Select","Select",""],["","00169633910","NOVOLOG","FLEXPEN","-15","Select","Select",""],["","00006057561","JANUMET","50-500MG","180","Select","Select",""],["","61314063710","PREDNISOLONE","1% OP","10","Select","Select",""],["","61314014305","BRIMONIDINE","0.2% OP","5","Select","Select",""],["","70727052925","ROCKLATAN","","2","Select","Select",""],["","53885019401","ONETOUCH","VERIO FL","-1","Select","Select",""],["","70010049110","METFORMIN","500MG ER","180","Select","Select",""],["","49281012165","FLUZONE","2021-22","1","Select","Select",""],["","47335022090","KETOROLAC","0.50%","5","Select","Select",""],["","49281012165","FLUZONE ","INJ 2021-22","1","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":""}]}]}