{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"L LEUMASRS NAGO","gend":0,"add":" ELO 908TC ENWOT","city":"VIRGINIA BEACH","state":"VA","zip":"23452-9998","dob":"1959-07-29","age":"","mstatus":"","insh":"9200210*79","cliId":"","pno":"46\/7572748-6","cno":"757\/646-8472","email":"","ename":"","eno":"","pphy":"WELLS, VIRGINIA MD","ppno":"757\/222-0300","pcpadd":"2900 SABRE ST STE 300","pcpcity":"VIRGINIA BEACH","pcpstate":"VA","pcpzip":23452,"pcpcounty":"","pcpid":190887,"pcpname":"","plan":"OHP","program":"ACA","lob":"Individual","region":"TIDEWATER","aligned":"","ano":"757\/961-8302","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":["Z00.01","I10.","E78.2","K21.9","K59.01","D50.8","E55.9","R53.83","Z96.642","M70.62","M25.561","Z96.651","Z47.1","L23.9","J45.20","Z00.00","R74.01","R05.","J30.1","D51.8","R07.89","E88.81","I49.1","R07.9","R06.02","I65.21","R09.89","Z88.0","Z82.49","Z91.048","J45.901","J20.9","J98.11","Z91.09","R49.0","R79.1","Z12.11","D51.9","M54.41","R31.21","Z79.899","Z88.8","M25.551"],"date":["2021-02-02","2021-08-19","2021-08-19","2021-10-10","2021-02-02","2021-08-19","2021-08-19","2021-08-19","2021-11-05","2020-12-11","2020-01-03","2021-11-05","2021-11-05","2020-09-06","2020-09-06","2021-02-02","2021-02-02","2021-06-23","2021-06-23","2021-02-12","2021-05-21","2021-05-21","2021-01-28","2021-06-23","2021-06-23","2021-02-10","2021-06-23","2021-10-10","2021-01-28","2021-01-28","2021-06-23","2021-06-23","2021-06-23","2021-06-23","2021-06-23","2021-06-23","2021-05-23","2021-08-19","2021-10-10","2021-10-10","2021-10-10","2021-10-10","2021-11-05"],"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":[["","00093506110","HYDROXYZ","25MG","-28","Select","Select",""],["","42858010201","OXYCOD\/APAP","5-325MG","20","Select","Select",""],["","59746017506","PREDNISONE","20MG","21","Select","Select",""],["","00143962125","CYANOCOBALAM","1000MCG","4","Select","Select",""],["","64380073706","VITAMIN","50000UNT","12","Select","Select",""],["","72205000390","ROSUVASTATIN","10MG","30","Select","Select",""],["","65162046650","IBUPROFEN","800MG","20","Select","Select",""],["","67877025115","TRIAMCINOLON","0.10%","15","Select","Select",""],["","66993001968","ALBUTEROL","HFA","18","Select","Select",""],["","33342006310","VALSARTAN","80MG","30","Select","Select",""],["","63304069205","CLINDAMYCIN","150MG","30","Select","Select",""],["","00173068220","VENTOLIN","","18","Select","Select",""],["","31722070290","LOSARTAN","100MG","30","Select","Select",""],["","67877025115","TRIAMCINOLON ","0.10%","15","Select","Select",""],["","59746017506","PREDNISONE ","20MG","-21","Select","Select",""],["","42858010201","OXYCOD\/APAP ","5-325MG","20","Select","Select",""],["","63304069205","CLINDAMYCIN ","150MG","30","Select","Select",""],["","68645056354","IBUPROFEN ","800MG","20","Select","Select",""],["","66993001968","ALBUTEROL ","HFA","18","Select","Select",""],["","00093506110","HYDROXYZ ","25MG","28","Select","Select",""],["","00173068220","VENTOLIN ","","18","Select","Select",""],["","27808015601","ROSUVASTATIN ","10MG","30","Select","Select",""],["","00143962125","CYANOCOBALAM ","1000MCG","10","Select","Select",""],["","33342006310","VALSARTAN ","80MG","30","Select","Select",""],["","31722070290","LOSARTAN ","100MG","30","Select","Select",""],["","64380073706","VITAMIN ","50000UNT","12","Select","Select",""],["","65162079108","LIDOCAINE","5%","30","Select","Select",""],["","70010077001","METHOCARBAM","750MG","12","Select","Select",""],["","70010077001","METHOCARBAM ","TAB 750MG","12","Select","Select",""],["","72888001405","CYCLOBENZAPR ","TAB 10MG","14","Select","Select",""],["","16571020110","DICLOFENAC ","TAB 75MG DR","30","Select","Select",""],["","65162079108","LIDOCAINE ","PAD 0.05","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":""}]}]}