{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"S EIHPOSDOOWREH","gend":1,"add":"SERP 6031RD DLUOWT","city":"CLARKSVILLE","state":"VA","zip":"23927-9998","dob":"2001-08-13","age":"","mstatus":"","insh":"6570110*08","cliId":"","pno":"34\/7575654-4","cno":"757\/434-4565","email":"","ename":"","eno":"","pphy":"SUSLICK, RANDALL H MD","ppno":"434\/372-5141","pcpadd":"946 N MAIN ST","pcpcity":"CHASE CITY","pcpstate":"VA","pcpzip":23924,"pcpcounty":"","pcpid":"","pcpname":"","plan":"OHP","program":"MEDICAID","lob":"M4","region":"CENTRAL","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R05.9","Z20.822","J45.909","Z79.51","Z79.899","N39.0","R10.31","J98.2","I31.9","J45.30","Z20.828","K21.9","R05.","J45.21"],"date":["2022-01-25","2022-01-25","2022-01-25","2022-01-25","2022-09-07","2022-09-07","2022-09-07","2020-08-28","2020-08-26","2020-08-26","2020-08-26","2020-01-06","2020-08-28","2020-01-06"],"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":[["","00378730853","NORETH\/ETHIN","CHW FE","28","Select","Select",""],["","59267100001","PFIZER","INJ COVID-19","0","Select","Select",""],["","70700016406","LEVONORGESTR","TAB 1.5MG","8","Select","Select",""],["","49483060450","IBUPROFEN","TAB 800MG","20","Select","Select",""],["","43386035701","HYDROCO\/APAP","TAB 7.5-325","8","Select","Select",""],["","00093310905","AMOXICILLIN","CAP 500MG","21","Select","Select",""],["","00116200116","CHLORHEX","SOL 0.0012","473","Select","Select",""],["","68180090313","KAITLIB","CHW ","28","Select","Select",""],["","67877054360","CEFDINIR","CAP 300MG","14","Select","Select",""],["","65862039010","ONDANSETRON","TAB 4MG ODT","10","Select","Select",""],["","65862042005","SMZ\/TMP","TAB 800-160","10","Select","Select",""],["","52544006431","LAYOLIS","CHW ","84","Select","Select",""],["","13668008190","MONTELUKAST","TAB 10MG","30","Select","Select",""],["","31722071390","PANTOPRAZOLE","TAB 40MG","60","Select","Select",""],["","60505612902","BUDESONIDE","SUS 32MCG","8","Select","Select",""],["","45802057178","FEXOFENADINE","TAB 180MG","30","Select","Select",""],["","00186037020","SYMBICORT","AER 160-4.5","10","Select","Select",""],["","61783000012","FC2","MIS CONDOM","12","Select","Select",""],["","00172409680","BACLOFEN","TAB 10MG","45","Select","Select",""],["","60505082901","FLUTICASONE","SPR 50MCG","16","Select","Select",""],["","00173088210","BREO","INH 200-25","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":""}]}]}