{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"NOMSEDGNIK D","gend":0,"add":" NITRAM 502403 TPA EVA","city":"DANVILLE","state":"VA","zip":"24541-9998","dob":"1983-08-28","age":"","mstatus":"","insh":"60300210*24","cliId":"","pno":"02\/4340780-3","cno":"","email":"","ename":"","eno":"","pphy":"WINFIELD, ALBERT C MD","ppno":"434\/791-4110","pcpadd":"173 EXECUTIVE DRIVE","pcpcity":"DANVILLE","pcpstate":"VA","pcpzip":24541,"pcpcounty":"","pcpid":"","pcpname":"PROVIDENCE FAMILY SPORTS MEDICINE INC","plan":"OHP","program":"MEDICAID","lob":"OHCC","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":["G47.33","G25.81","G47.34","I10.","F17.200","E66.3","Z68.41","Z71.3","Z91.81","J41.0","M54.5","M79.604","M79.673","Z79.899","Z68.39","Z13.89","M79.605","Z68.37"],"date":["2021-09-22","2020-02-26","2020-02-26","2021-02-26","2020-06-03","2020-06-03","2020-06-03","2020-06-03","2021-02-26","2019-02-21","2019-07-16","2019-07-16","2019-03-12","2019-03-12","2019-03-12","2019-03-12","2019-07-16","2019-07-16"],"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":[["","71800080630","FOLIKA-CI","TAB ","90","Select","Select",""],["","24470092360","CHLORZOXAZON","TAB 250MG","120","Select","Select",""],["","21922000909","DICLOFENAC","GEL 0.01","300","Select","Select",""],["","00173071920","FLOVENT","AER 110MCG","12","Select","Select",""],["","00378632577","VALSART\/HCTZ","TAB 320-25MG","90","Select","Select",""],["","52565000950","LIDOCAINE","SOL 0.04","300","Select","Select",""],["","16729018201","HYDROCHLOROT","TAB 12.5MG","30","Select","Select",""],["","68462030201","INDOMETHACIN","CAP 50MG","60","Select","Select",""],["","62332003231","ROPINIROLE","TAB 1MG","30","Select","Select",""],["","67877019905","AMLODIPINE","TAB 10MG","90","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":""}]}]}