{"version":"0.4","data":[{"t":"Demographics","q":[{"name":" LEAHCIMENAL R  ","gend":0,"add":"OM 1234NL YLL","city":"CHARLOTTESVILLE","state":"VA","zip":"22902-9998","dob":"1966-12-26","age":"","mstatus":"","insh":"7799110*41","cliId":"","pno":"59\/4347683-3","cno":"434\/953-3867","email":"","ename":"","eno":"","pphy":"BISHOP, RAYMOND MD","ppno":"434\/591-5056","pcpadd":"138 HERITAGE DR STE A","pcpcity":"PALMYRA","pcpstate":"VA","pcpzip":22963,"pcpcounty":"","pcpid":210191,"pcpname":"","plan":"OHP","program":"ACA","lob":"Individual","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"434\/960-0316","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":["I48.0","I87.2","M79.604","M79.605","I80.03","I10.","E78.2","Z12.5","M76.60","Z00.00","I82.462"],"date":["2021-03-08","2020-08-26","2020-08-26","2020-08-26","2020-08-26","2020-06-29","2020-06-29","2020-06-29","2020-05-28","2021-06-03","2020-08-26"],"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":[["","00378001801","METOPROL","25MG","180","Select","Select",""],["","68180051703","LISINOPRIL","40MG","30","Select","Select",""],["","16729000617","SIMVASTATIN","40MG","30","Select","Select",""],["","33332042010","AFLURIA","2020-21","0","Select","Select",""],["","00003089421","ELIQUIS","5MG","-180","Select","Select",""],["","13668018830","SILDENAFIL","100MG","10","Select","Select",""],["","00378001801","METOPROL ","25MG","60","Select","Select",""],["","16729000617","SIMVASTATIN ","40MG","30","Select","Select",""],["","68180051703","LISINOPRIL ","40MG","30","Select","Select",""],["","00003089421","ELIQUIS ","5MG","180","Select","Select",""],["","13668018830","SILDENAFIL ","100MG","10","Select","Select",""],["","33332042010","AFLURIA ","2020-21","0","Select","Select",""],["","49281042150","FLUZONE","2021-22","0","Select","Select",""],["","49281042150","FLUZONE ","INJ 2021-22","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","",""],["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":""}]}]}