{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"ROT HTIDUJZEPOL SER","gend":1,"add":"MDNIW DLO 1321D TPA RIC LLI","city":"HARRISONBURG","state":"VA","zip":"22802-9998","dob":"1966-09-08","age":"","mstatus":"","insh":"9620210*76","cliId":"","pno":"82\/0457052-2","cno":"540\/282-2507","email":"","ename":"","eno":"","pphy":"WYRICK, KIMBERLEY F DO","ppno":"540\/433-3344","pcpadd":"1751 ERICKSON AVE","pcpcity":"HARRISONBURG","pcpstate":"VA","pcpzip":22801,"pcpcounty":"","pcpid":972968,"pcpname":"Rockingham Family Physicians, PC","plan":"OHP","program":"ACA","lob":"Individual","region":"CHARLOTTESVILLE WESTERN","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":["I10.","E78.5","E03.9","I83.813","E66.3","Z68.27","M79.89","L97.519","T25.331D","T30.0","T25.021A","M77.8","N90.7","R35.0","N89.8","R10.2","Z11.3","J45.909","Z87.19","E07.9","K21.9","E78.00","Z87.442","T25.331A","Z00.00","J01.00","Z20.828","Z12.31","Z12.11","X12.XXXA","R42.","R04.0","M26.601"],"date":["2021-09-16","2021-04-01","2021-04-01","2020-07-16","2020-06-04","2020-06-04","2020-09-24","2021-01-07","2021-01-07","2021-01-07","2020-12-24","2020-12-24","2020-03-19","2020-03-19","2020-03-19","2020-03-19","2020-03-19","2020-03-19","2020-03-19","2020-03-19","2021-04-01","2020-03-19","2020-03-19","2021-01-14","2021-04-01","2021-04-01","2021-05-06","2021-03-31","2021-07-07","2021-01-07","2021-10-28","2021-10-28","2021-10-28"],"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":[["","69238183007","LEVOTHYROXIN","25MCG","30","Select","Select",""],["","43547035411","LISINOPRIL","20MG","-30","Select","Select",""],["","65862042005","SMZ\/TMP","800-160","-20","Select","Select",""],["","00378395105","ATORVASTATIN","20MG","90","Select","Select",""],["","63304069301","CLINDAMYCIN","300MG","28","Select","Select",""],["","13811071910","NITROFURANTN","100MG","14","Select","Select",""],["","11917015492","PROBIOTIC","ADULT","30","Select","Select",""],["","69238183007","LEVOTHYROXIN ","25MCG","30","Select","Select",""],["","68180098103","LISINOPRIL ","20MG","30","Select","Select",""],["","13811071910","NITROFURANTN ","100MG","14","Select","Select",""],["","65862042005","SMZ\/TMP ","800-160","20","Select","Select",""],["","63304069301","CLINDAMYCIN ","300MG","-28","Select","Select",""],["","11917015492","PROBIOTIC ","ADULT","30","Select","Select",""],["","00378395105","ATORVASTATIN ","20MG","-90","Select","Select",""],["","70954005920","PREDNISONE","10MG","-20","Select","Select",""],["","57237000511","FLUCONAZOLE","150MG","1","Select","Select",""],["","57237000511","FLUCONAZOLE ","TAB 150MG","1","Select","Select",""],["","70954005920","PREDNISONE ","TAB 10MG","-20","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":""}]}]}