{"version":"0.4","data":[{"t":"Demographics","q":[{"name":" YBBOB SELWOB","gend":0,"add":"IVELRAHC 0065923 TPA TC XO","city":"RICHMOND","state":"VA","zip":"23224-9998","dob":"1959-03-22","age":"","mstatus":"","insh":"73000910*074","cliId":"","pno":"05\/4080907-3","cno":"804\/503-7090, ","email":"","ename":"","eno":"","pphy":"","ppno":"","pcpadd":"","pcpcity":"","pcpstate":"","pcpzip":"","pcpcounty":"","pcpid":"","pcpname":"","plan":"OHP - OPTIMA","program":"MEDICARE","lob":"DSNP","region":"CENTRAL","aligned":"Y","ano":"804\/503-7090, ","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":["S20.229A","S10.93XA","M54.2","M54.5","M15.9","M54.40","Z04.1","V89.2XXA","B20.","I10.","F17.210","E78.5","R27.0","G62.9","N52.9","F10.10","Z79.899","Z11.59","R91.1","Z21.","Z68.28","E55.9","F12.10","Z23.","Z20.828"],"date":["2020-03-26","2020-03-26","2021-04-27","2021-04-27","2020-06-11","2020-04-27","2020-03-16","2020-03-16","2021-02-15","2021-02-15","2020-12-23","2021-02-15","2020-12-04","2020-12-04","2020-12-04","2020-12-04","2021-02-10","2020-08-24","2020-12-23","2020-03-16","2020-03-26","2021-02-10","2020-04-16","2020-02-24","2020-12-28"],"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":[["","68382097001","CHLORTHALID","TAB 25MG","90","Select","Select",""],["","69097084615","CYCLOBENZAPR","TAB 10MG","30","Select","Select",""],["","65162019050","NAPROXEN","TAB 500MG","60","Select","Select",""],["","172392770","DIAZEPAM","TAB 10MG","30","Select","Select",""],["","27241006903","SILDENAFIL","TAB 100MG","30","Select","Select",""],["","61958250101","BIKTARVY","TAB ","30","Select","Select",""],["","58160082311","SHINGRIX","INJ 50\/0.5ML","-1","Select","Select",""],["","68180072103","AMLODIPINE","TAB 10MG","90","Select","Select",""],["","67877032105","IBUPROFEN","TAB 800MG","30","Select","Select",""],["","93317431","ALBUTEROL","AER HFA","-8","Select","Select",""],["","33332032001","AFLURIA QUAD","INJ 2020-21","0","Select","Select",""],["","31722070090","LOSARTAN POT","TAB 25MG","90","Select","Select",""],["","70377003012","ATORVASTATIN","TAB 80MG","90","Select","Select",""],["","378064110","PREDNISONE","TAB 10MG","20","Select","Select",""],["","57664064888","CHLORTHALIDONE","","30","Select","Select",""],["","66993001968","ALBUTEROL SULFATE HFA","","18","Select","Select",""],["","68180072103","AMLODIPINE BESYLATE","","90","Select","Select",""],["","70377003012","ATORVASTATIN CALCIUM ","","90","Select","Select",""],["","67877032105","IBUPROFEN ","","30","Select","Select",""],["","27241006903","SILDENAFIL CITRATE ","","30","Select","Select",""],["","591565810","CYCLOBENZAPRINE HYDROCHLORIDE","","21","Select","Select",""],["","33332032001","AFLURIA QUADRIVALENT 2020-2021","","0","Select","Select",""],["","31722070090","LOSARTAN POTASSIUM ","","90","Select","Select",""],["","69047103","CHANTIX STARTING MONTH PAK","","-53","Select","Select",""],["","69680013300","POTASSIUM CHLORIDE ER","","90","Select","Select",""],["","27241016801","DOXEPIN HYDROCHLORIDE","","90","Select","Select",""],["","70377003012","ATORVASTATIN CALCIUM","","90","Select","Select",""],["","27241006903","SILDENAFIL CITRATE","","30","Select","Select",""],["","31722070090","LOSARTAN POTASSIUM","","90","Select","Select",""],["","00069046903","CHANTIX CONTINUING MONTH PAK","","-56","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","",""],["No","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["No","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":""}]}]}