{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"KARIVART ","gend":0,"add":"RCLLIH 6RIC TSE","city":"HAMPTON","state":"VA","zip":"23666-9998","dob":"1958-05-10","age":"","mstatus":"","insh":"1430210*07","cliId":"","pno":"83\/7572129-7","cno":"757\/387-9212","email":"","ename":"","eno":"","pphy":"PASCUAL, REYMOND MD","ppno":"757\/826-2102","pcpadd":"2100 HARTFORD RD","pcpcity":"HAMPTON","pcpstate":"VA","pcpzip":23666,"pcpcounty":"","pcpid":182173,"pcpname":"TPMG PENINSULA MEDICAL ASSOCIATES","plan":"OHP","program":"ACA","lob":"Individual","region":"TIDEWATER","aligned":"","ano":"757\/387-9212","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":["E05.90","E11.9","E88.81","E11.59","E11.69","E05.00","I10.","E78.5","E89.0","Z79.84","Z12.5","E78.2","Z91.14","I15.2"],"date":["2021-11-01","2021-11-01","2021-11-01","2021-11-01","2021-11-01","2021-11-01","2021-09-28","2021-11-01","2021-06-22","2021-05-11","2021-11-01","2021-02-02","2021-02-08","2021-11-01"],"priorHcc":[null,null,null,null,null,null,null,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":[["","64679092603","ENALAPRIL","20MG","30","Select","Select",""],["","51991081801","PROPRANOLOL","80MG ER","30","Select","Select",""],["","00093727398","PIOGLITAZONE","45MG","30","Select","Select",""],["","64980028101","GLIPIZIDE","10MG","-60","Select","Select",""],["","70377002811","ATORVASTATIN","20MG","30","Select","Select",""],["","68382076010","METFORMIN","1000MG","60","Select","Select",""],["","80777027399","MODERNA","COVID-19","0","Select","Select",""],["","00378180510","LEVOTHYROXIN","75MCG","30","Select","Select",""],["","51991081801","PROPRANOLOL ","80MG ER","30","Select","Select",""],["","64679092603","ENALAPRIL ","20MG","30","Select","Select",""],["","68382076010","METFORMIN ","1000MG","60","Select","Select",""],["","70377002811","ATORVASTATIN ","20MG","30","Select","Select",""],["","64980028001","GLIPIZIDE ","5MG","60","Select","Select",""],["","00093727398","PIOGLITAZONE ","45MG","90","Select","Select",""],["","80777027399","MODERNA ","COVID-19","0","Select","Select",""],["","00378180510","LEVOTHYROXIN ","75MCG","90","Select","Select",""],["","49884064001","METHIMAZOLE","5MG","30","Select","Select",""],["","56151146004","TRUE","GLUCOSE","50","Select","Select",""],["","49884064001","METHIMAZOLE ","TAB 5MG","30","Select","Select",""],["","56151146004","TRUE ","TES GLUCOSE","50","Select","Select",""],["","53885024510","ONETOUCH ","TES ULTRA","100","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","",""],["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":""}]}]}