{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"TS ANNODNOSNEHPE","gend":1,"add":" KCIWRAW 0062301 TPA DVLB","city":"NEWPORT NEWS","state":"VA","zip":"23607-9998","dob":"1965-03-14","age":"","mstatus":"","insh":"1208110*05","cliId":"","pno":"43\/7577255-9","cno":"757\/349-5527","email":"","ename":"","eno":"","pphy":"ASPILI, CONCEPCION MD","ppno":"757\/874-8400","pcpadd":"4714 MARSHALL AVE","pcpcity":"NEWPORT NEWS","pcpstate":"VA","pcpzip":23607,"pcpcounty":"","pcpid":510019,"pcpname":"","plan":"OHP","program":"ACA","lob":"Individual","region":"TIDEWATER","aligned":"","ano":"757\/349-5527, ","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":["Z20.828","Z21.","I10.","E78.5","Z72.0","Z12.31","Z12.11","F12.90","R89.6","Z71.89"],"date":["2021-06-01","2021-08-31","2021-08-31","2021-08-31","2021-08-31","2021-08-31","2021-08-31","2021-08-31","2021-08-31","2021-08-31"],"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":[["","00054040713","RITONAVIR ","100MG","60","Select","Select",""],["","00378352091","FOSAMPRENAVI ","700MG","60","Select","Select",""],["","00093538256","ABACA\/LAMIVU ","600-300","-30","Select","Select",""],["","61958250101","BIKTARVY ","","30","Select","Select",""],["","67877019805","AMLODIPINE ","5MG","-30","Select","Select",""],["","00378352091","FOSAMPRENAVI","700MG","60","Select","Select",""],["","00054040713","RITONAVIR","100MG","60","Select","Select",""],["","00093538256","ABACA\/LAMIVU","600-300","30","Select","Select",""],["","61958250101","BIKTARVY","","30","Select","Select",""],["","67877019805","AMLODIPINE","5MG","-30","Select","Select",""],["","72205000490","ROSUVASTATIN","20MG","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","",""],["Yes","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":""}]}]}