{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"   ALEGNAYELDUD L","gend":1,"add":"IDIREM 5361B TPA TS NA","city":"CHARLOTTESVILLE","state":"VA","zip":"22902-9998","dob":"1976-02-10","age":"","mstatus":"","insh":"6128710*45","cliId":"","pno":"92\/4342289-5","cno":"","email":"","ename":"","eno":"","pphy":"HEALD, EVAN B MD","ppno":"434\/924-1931","pcpadd":"1222 JEFFERSON PARK AVE","pcpcity":"CHARLOTTESVILLE","pcpstate":"VA","pcpzip":22903,"pcpcounty":"","pcpid":"","pcpname":"UNIVERSITY OF VIRGINIA PHYSICIANS GROUP","plan":"OHP","program":"MEDICAID","lob":"M4","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":["F14.20","Z20.828","K58.0","N15.9","Z90.49","Z72.0","K21.9","J06.9","Z20.822","Z01.419","N89.8","N81.10","F90.0","F41.1","R20.0","E87.6","B34.9","N39.0","F33.1","F90.2","G47.00","F33.41"],"date":["2021-11-08","2020-10-02","2021-04-15","2021-04-15","2021-04-15","2021-04-15","2021-04-15","2021-10-08","2021-10-08","2020-03-04","2020-03-04","2020-03-04","2021-04-21","2021-04-21","2021-01-07","2021-01-07","2021-01-07","2021-12-19","2020-01-31","2021-04-21","2020-01-31","2021-04-21"],"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":[["","","BUPROPN","TAB 150MG XL","","Select","Select",""],["","","MIRTAZAPINE","TAB 15MG","","Select","Select",""],["","00143312601","DICYCLOMINE","CAP 10MG","180","Select","Select",""],["","62175061743","PANTOPRAZOLE","TAB 40MG","90","Select","Select",""],["","80777027399","MODERNA","INJ COVID-19","0","Select","Select",""],["","50428660019","CVS","CHW 80MG","30","Select","Select",""],["","00536589488","NICOTINE","DIS 7MG\/24HR","28","Select","Select",""],["","57237000511","FLUCONAZOLE","TAB 150MG","1","Select","Select",""],["","58657045101","PHENAZOPYRID","TAB 200MG","6","Select","Select",""],["","55111012705","CIPROFLOXACN","TAB 500MG","20","Select","Select",""],["","43547030303","ARIPIPRAZOLE","TAB 5MG","30","Select","Select",""],["","60505283303","ATOMOXETINE","CAP 40MG","30","Select","Select",""],["","00245531911","KLOR-CON","TAB 20MEQ ER","6","Select","Select",""],["","00228306011","AMPHET\/DEXTR","CAP 20MG ER","30","Select","Select",""],["","","HYDROXYZ","TAB 25MG","","Select","Select",""],["","54092038701","ADDERALL","CAP 20MG","30","Select","Select",""],["","","SMZ\/TMP","TAB 800-160","","Select","Select",""],["","","CEPHALEXIN","CAP 500MG","","Select","Select",""],["","50111043303","TRAZODONE","TAB 50MG","60","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":""}]}]}