{"version":"0.4","data":[{"t":"Demographics","q":[{"name":" EIRAMNOTLEF","gend":1,"add":"RAW 3101RD DLEIF","city":"PORTSMOUTH","state":"VA","zip":"23701-9998","dob":"1963-04-22","age":"","mstatus":"","insh":"27200210*40","cliId":"","pno":"84\/7574331-5","cno":"","email":"","ename":"","eno":"","pphy":"MISTRY, ZARINE MD","ppno":"757\/261-5910","pcpadd":"850 KEMPSVILLE RD SUITE 200A","pcpcity":"NORFOLK","pcpstate":"VA","pcpzip":23502,"pcpcounty":"","pcpid":"","pcpname":"SMG - Sentara Internal Medicine Physicians - Kempsville","plan":"OHP","program":"MEDICAID","lob":"OHCC","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":["Z20.828","J98.01","B34.9","J45.20","I10.","K21.9","Z12.11","J01.00","R68.89","U07.1","R68.83","Z79.899","Z12.31","M25.512","R10.84","R11.0","R19.7"],"date":["2020-09-02","2020-09-02","2020-09-02","2021-11-01","2021-11-01","2021-11-01","2021-11-01","2020-08-16","2020-08-16","2020-08-19","2020-08-19","2020-08-19","2021-09-30","2019-10-08","2019-11-13","2019-11-13","2019-11-13"],"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":{"indx":[false,false],"comment":["",""],"score":["",""]}},{"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":[["","00173068220","VENTOLIN","AER ","18","Select","Select",""],["","68180052002","LISINOP\/HCTZ","TAB 20-25MG","30","Select","Select",""],["","62175011843","OMEPRAZOLE","CAP 20MG","90","Select","Select",""],["","64380080707","IBUPROFEN","TAB 800MG","21","Select","Select",""],["","68180051303","LISINOPRIL","TAB 5MG","30","Select","Select",""],["","65862001705","AMOXICILLIN","CAP 500MG","28","Select","Select",""],["","00406012405","HYDROCO\/APAP","TAB 7.5-325","8","Select","Select",""],["","","ALBUTEROL","AER HFA","","Select","Select",""],["","","FLUTICASONE","SPR 50MCG","","Select","Select",""],["","","ALLERGY","TAB 10MG","","Select","Select",""],["","","RA","TAB 30MG","","Select","Select",""],["","","PREDNISONE","TAB 20MG","","Select","Select",""],["","50111033402","METRONIDAZOL","TAB 500MG","14","Select","Select",""],["","00093031101","LOPERAMIDE","CAP 2MG","20","Select","Select",""],["","00093314705","CEPHALEXIN","CAP 500MG","10","Select","Select",""],["","00527058601","DICYCLOMINE","CAP 10MG","20","Select","Select",""],["","65862039010","ONDANSETRON","TAB 4MG ODT","12","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":""}]}]}