{"version":"0.4","data":[{"t":"Demographics","q":[{"name":" SIRHCEROOM","gend":0,"add":"ERIUGCM 25731 TPA LP ","city":"NEWPORT NEWS","state":"VA","zip":"23601-9998","dob":"1960-05-01","age":"","mstatus":"","insh":"6520210*97","cliId":"","pno":"7875755129","cno":"","email":"","ename":"","eno":"","pphy":"AMENYEFIA, OYE A NP","ppno":7578731317,"pcpadd":"500 J CLYDE MORRIS BLVD SUITE 500","pcpcity":"NEWPORT NEWS","pcpstate":"VA","pcpzip":"23601-9998","pcpcounty":"","pcpid":"","pcpname":"RIVERSIDE PHYSICIAN SERVICES INC","plan":"OHP","program":"ACA","lob":"Individual","region":"TIDEWATER","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":["N20.0","N20.1","N13.30","R10.9","Z87.442","Z20.828","R05.","I48.91","I10.","F17.210","Z79.01","Z79.899","Z82.49","Z88.1","Z88.2","M54.9","K40.20","E05.90","Z12.5","Z13.220","I48.20","N20.2","K31.89","K86.89","Z00.00","M25.369","Z12.11","N13.2","E66.9","F17.200","Z68.32","Z01.810","F17.209","T78.40XA","Z01.818","F10.10","Z91.19","M16.0"],"date":["2023-06-08","2022-02-16","2022-02-16","2022-09-27","2023-06-08","2021-08-30","2021-08-30","2022-09-27","2023-05-19","2022-09-27","2022-09-27","2022-09-27","2022-09-27","2022-09-27","2022-09-27","2022-09-27","2023-04-25","2023-05-19","2023-05-19","2023-05-19","2023-05-19","2022-02-15","2022-02-15","2022-02-15","2022-06-14","2022-06-14","2022-07-13","2022-02-15","2022-02-15","2022-02-15","2022-02-15","2022-02-16","2022-03-24","2022-03-24","2022-03-16","2022-06-14","2022-06-14","2022-06-14"],"priorHcc":["","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","",""]}}]},{"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":[]},{"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":[]}]},{"t":"Allergies \/ Medications","q":[{"a":[]},{"a":{"comment":"","sub":[["","68382053701","POTASSIUM CITRATE ER","10 MEQ","120","Select","Select",""],["","00228278111","PROPRANOLOL HCL ER","160 MG","30","Select","Select",""],["","75826011410","PHENAZOPYRID TAB","100MG","10","Select","Select",""],["","00228278111","PROPRANOLOL CAP","160MG ER","30","Select","Select",""],["","53746010901","HYDROCO\/APAP TAB","5-325MG","10","Select","Select",""],["","69618004410","DOCUSATE SOD CAP","100MG","60","Select","Select",""],["","42858000101","OXYCODONE TAB","5MG","3","Select","Select",""],["","68645051554","AMLODIPINE BESYLATE","5 MG","30","Select","Select",""],["","16714057601","ALLOPURINOL","100 MG","30","Select","Select",""]]}},{"a":[]},{"a":[]},{"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":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Pain","q":[{"a":[]}]},{"t":"Vital Signs","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Exam Review","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Screenings Needed","q":[{"a":{"indx":["","1"],"comment":["",""],"sub":[]}},{"a":{"indx":["","1"],"comment":["",""],"sub":[]}},{"a":{"indx":["","1"],"comment":["",""],"sub":[]}},{"a":{"indx":["","1"],"comment":["",""],"sub":[]}},{"a":{"indx":["","1"],"comment":["",""],"sub":[]}},{"a":{"indx":["","1"],"comment":["",""],"sub":[]}},{"a":{"indx":["","1"],"comment":["",""],"sub":[]}},{"a":[]}]},{"t":"Mini-Cog","q":[{"a":[]},{"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":"","a13":""}]}]}