{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"  REHCTELFNIFFIRG R ","gend":0,"add":"NILRUT 335DAOR NOTG","city":"SUFFOLK","state":"VA","zip":"23434-9998","dob":"1940-12-14","age":"","mstatus":"","insh":"83000910*827","cliId":"7Q38GG9VW48","pno":"08\/7572623-9","cno":"757\/809-3262","email":"","ename":"","eno":"","pphy":"MUGAISI, HESED N MD","ppno":"757\/738-1375","pcpadd":"148 BURNETTS WAY STE 107","pcpcity":"SUFFOLK","pcpstate":"VA","pcpzip":23434,"pcpcounty":"","pcpid":207896,"pcpname":"BON SECOURS SUFFOLK PRIMARY CARE","plan":"OHP","program":"MEDICARE","lob":"MA-Non DSNP","region":"TIDEWATER","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":["Z01.89","L57.0","L82.1","L81.4","D22.9","Z85.828","Z12.83","Z71.9","S82.831A","S82.821D","K59.00","K21.9","G20.","F41.9","I25.10","D48.5","S99.911A","S82.401A","Z23.","R10.84","K92.1","R68.81","R63.0","R11.0","S82.821A","R09.89","K57.30"],"date":["2020-09-21","2020-11-30","2020-11-30","2020-11-30","2020-11-30","2020-11-30","2020-11-30","2020-11-30","2021-05-13","2021-06-15","2020-03-06","2020-03-06","2020-03-06","2020-03-06","2020-03-06","2021-02-10","2021-05-13","2021-05-13","2020-09-08","2021-08-17","2021-08-17","2021-08-17","2021-08-17","2021-08-17","2021-07-27","2021-10-29","2021-09-14"],"priorHcc":["","","","","","","","","","","","","","","","","","","","","","","","","",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":[["","69097015815","MELOXICAM ","7.5MG","90","Select","Select",""],["","68180035302","SERTRALINE ","100MG","180","Select","Select",""],["","75834002001","VITAMIN ","50000UNT","13","Select","Select",""],["","00536105429","ASPIRIN ","325MG","90","Select","Select",""],["","62756045788","CARB\/LEVO ","50-200MG","270","Select","Select",""],["","60505257908","ATORVASTATIN ","20MG","90","Select","Select",""],["","55111015901","OMEPRAZOLE ","40MG","30","Select","Select",""],["","65162083366","DICLOFENAC ","1%","300","Select","Select",""],["","60505257908","","20MG","90","Select","Select",""],["","69097015815","MELOXICAM","7.5MG","90","Select","Select",""],["","68180035302","SERTRALINE","100MG","180","Select","Select",""],["","62756045788","CARB\/LEVO","50-200MG","270","Select","Select",""],["","75834002001","VITAMIN","50000UNT","13","Select","Select",""],["","00536105429","ASPIRIN","325MG","90","Select","Select",""],["","55111015901","OMEPRAZOLE","40MG","30","Select","Select",""],["","60505257908","ATORVASTATIN","20MG","90","Select","Select",""],["","70461012103","FLUAD","2021-22","0","Select","Select",""],["","65862039010","ONDANSETRON","4MG ODT","3","Select","Select",""],["","64380076921","PEG-3350\/KCL","\/SODIUM","-4000","Select","Select",""],["","65162083366","DICLOFENAC","1%","300","Select","Select",""],["","65862039010","ONDANSETRON ","TAB 4MG ODT","-3","Select","Select",""],["","64380076921","PEG-3350\/KCL ","SOL \/SODIUM","4000","Select","Select",""],["","70461012103","FLUAD ","INJ 2021-22","0","Select","Select",""],["","59267100002","PFIZER ","INJ COVID-19","0","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","",""],["No","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":""}]}]}