{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"M SEMAJ YDENNEK ","gend":0,"add":"AW 1031DR SRET","city":"CHESAPEAKE","state":"VA","zip":"23322-9998","dob":"1973-05-01","age":"","mstatus":"","insh":"0628110*17","cliId":"","pno":"29\/5045851-2","cno":"405\/922-1585, 757\/793-4354","email":"","ename":"","eno":"","pphy":"LOOMIS, ANNA MD","ppno":"757\/410-4488","pcpadd":"1024 S BATTLEFIELD BLVD","pcpcity":"CHESAPEAKE","pcpstate":"VA","pcpzip":"23322-9998","pcpcounty":"","pcpid":120527,"pcpname":"Hanbury Family Medicine","plan":"OHP - OPTIMA","program":"ACA","lob":"Small Group","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":["H65.02","E55.9","Z13.29","E78.5","I25.2","I10.","R73.9","I25.118","I25.110","I25.82","Z79.02","Z79.82","Z79.899","F17.290","R06.09","R74.8","Z87.891","Z68.41","I25.10","Z00.00"],"date":["2020-06-30","2021-04-26","2020-12-21","2021-04-26","2021-04-26","2021-05-11","2021-04-26","2021-04-26","2020-08-26","2020-08-26","2020-08-26","2020-08-26","2020-08-26","2020-08-26","2020-08-26","2021-05-26","2020-08-26","2021-04-26","2021-05-11","2020-12-21"],"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":[["","68645056854","ATORVASTATIN","40MG","90","Select","Select",""],["","29300022019","MONTELUKAST","10MG","30","Select","Select",""],["","49035056317","ASPIRIN","81MG EC","30","Select","Select",""],["","68462031960","RANOLAZINE","500MG ER","120","Select","Select",""],["","57237010099","METOPROL","25MG","180","Select","Select",""],["","55111019690","CLOPIDOGREL","75MG","90","Select","Select",""],["","31722059690","FENOFIBRATE","145MG","30","Select","Select",""],["","13668010401","ISOSORB","30MG ER","90","Select","Select",""],["","68462034690","LEVOCETIRIZI","5MG","30","Select","Select",""],["","43598043611","NITROGLYCERN","0.4MG","25","Select","Select",""],["","00054327099","FLUTICASONE","50MCG","16","Select","Select",""],["","00143924920","AMOX\/K","875-125","20","Select","Select",""],["","49035056311","","","30","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","",""],["N\/A","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["N\/A","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":""}]}]}