{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"RICKY L MONGOLD","gend":0,"add":"15446 LONE PINE DR.  ","city":"TIMBERVILLE ","state":"VA","zip":"22853-9998","dob":"1965-09-29","age":"","mstatus":"","insh":11008178,"cliId":"6EA4QX2UG83","pno":5408961650,"cno":5408961650,"email":"","ename":"","eno":"","pphy":"ALLEYNE, LISA  ","ppno":5402483413,"pcpadd":"1371 LEE HIGHWAY","pcpcity":"VERONA","pcpstate":"VA","pcpzip":244820000,"pcpcounty":"","pcpid":"P0117769","pcpname":"CARILION FAMILY MEDICINE FORT DEFIANCE","plan":"VPHP","program":"MEDICARE","lob":"DSNP","region":"CHARLOTTESVILLE WESTERN","aligned":"Y","ano":"","add2":"","add3":"","madd1":"PO BOX 185  ","madd2":"","madd3":"","mcity":"TIMBERVILLE ","mstate":"VA","mzip":"22853-9998","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Current Conditions \/ Suspect Codes","q":[{"a":{"diag":["F31.2","Z79.899","I10","R53.81","R53.83","R73.09","F20.9","Z83.3","E78.5","Z00.00","F20.0","R41.3","E66.3","K59.00","K50.10","L72.3","K50.90","F42.9","Z79.82","Z82.49","Z81.8","Z82.3","Z82.61","Z80.41","H50.15","H52.4","M43.6","G43.809","R94.01","F42.2","F84.0","F60.9","G43.C0","R51.9","R42","R55","I95.9","N17.9","E66.9","Z68.27","D50.9","K63.89","R10.9","I95.89","E86.1","R79.89","F03.90","Z23","Z12.11","F01.50","R93.89","E78.00","F31.61","I95.0"],"date":["2021-10-25","2021-11-22","2021-09-17","2020-07-08","2020-07-08","2021-09-17","2020-01-14","2021-09-17","2021-09-17","2021-03-04","2021-09-17","2021-04-21","2021-09-17","2021-09-17","2020-05-26","2020-08-19","2021-09-17","2021-07-01","2021-05-03","2021-05-03","2020-08-19","2020-08-19","2020-08-19","2020-08-19","2020-10-05","2020-10-05","2021-04-21","2021-04-21","2020-10-28","2021-03-01","2021-03-01","2021-03-01","2021-04-08","2021-05-03","2021-05-03","2021-05-04","2021-05-03","2021-05-04","2021-05-03","2021-05-03","2021-05-03","2021-05-04","2021-05-04","2021-05-05","2021-05-04","2021-09-17","2021-08-25","2021-09-17","2021-09-17","2021-07-01","2021-07-01","2021-07-01","2021-07-01","2021-05-03"],"priorHcc":[null,null,"","","","","","","","","","","","","","","",null,"","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","",null,null,null,null,null]}},{"a":[]}]},{"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":{"indx":["","",""],"comment":["","",""],"sub":[]}},{"a":{"indx":["","",""],"comment":["","",""],"sub":[]}}]},{"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":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Allergies \/ Medications","q":[{"a":[]},{"a":{"comment":"","sub":[["","69315013801","BENZTROPINE","TAB 2MG","","Select","Select",""],["","57664034713","CLOZAPINE","TAB 100MG","","Select","Select",""],["","53489051701","TRAZODONE","TAB 150MG","","Select","Select",""],["","59746071190","CLOMIPRAMINE","CAP 50MG","","Select","Select",""],["","456241060","SAPHRIS","SUB 10MG","","Select","Select",""],["","71093011105","GABAPENTIN","TAB 600MG","","Select","Select",""],["","591024101","LORAZEPAM","TAB 1MG","","Select","Select",""],["","67877051305","ATORVASTATIN","TAB 40MG","","Select","Select",""],["","43975035003","PALIPERIDONE","TAB ER 3MG","","Select","Select",""],["","43547035311","LISINOPRIL","TAB 10MG","","Select","Select",""],["","228202950","ALPRAZOLAM","TAB 0.5MG","","Select","Select",""],["","10572010101","PEG-3350","SOL ELECTROL","","Select","Select",""],["","33332041910","AFLURIA QUAD","INJ 2019-20","","Select","Select",""],["","33342007007","OLANZAPINE","TAB 10MG","","Select","Select",""],["","61874011530","VRAYLAR","CAP 1.5MG","","Select","Select",""],["","49281063315","FLUZONE QUAD","INJ 2020-21","","Select","Select",""],["","67877051305","ATORVASTATIN ","TAB 40MG","90","Select","Select",""],["","456241060","SAPHRIS ","SUB 10MG","60","Select","Select",""],["","69315013801","BENZTROPINE ","TAB 2MG","60","Select","Select",""],["","71093011105","GABAPENTIN ","TAB 600MG","90","Select","Select",""],["","591024101","LORAZEPAM ","TAB 1MG","120","Select","Select",""],["","406880701","CLOMIPRAMINE ","CAP 50MG","180","Select","Select",""],["","53489051701","TRAZODONE ","TAB 150MG","60","Select","Select",""],["","57664034713","CLOZAPINE ","TAB 100MG","90","Select","Select",""],["","43975035003","PALIPERIDONE ","TAB ER 3MG","30","Select","Select",""],["","43547035311","LISINOPRIL ","TAB 10MG","90","Select","Select",""],["","228202950","ALPRAZOLAM ","TAB 0.5MG","120","Select","Select",""],["","10572010101","PEG-3350 ","SOL ELECTROL","4,000.00","Select","Select",""],["","49281063315","FLUZONE ","INJ 2020-21","0.5","Select","Select",""],["","33332041910","AFLURIA ","INJ 2019-20","0.5","Select","Select",""],["","33342006807","OLANZAPINE ","TAB 5MG","30","Select","Select",""],["","61874011530","VRAYLAR ","CAP 1.5MG","30","Select","Select",""],["","49281063315","FLUZONE","2020-21","0.5","Select","Select",""],["","33332041910","AFLURIA","2019-20","0.5","Select","Select",""]]}},{"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":[]}]},{"t":"Pain","q":[{"a":[]}]},{"t":"Vital Signs","q":[{"a":[]},{"a":[]}]},{"t":"Exam Review","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Screenings Needed","q":[[["No","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""]]]},{"t":"Mini-Cog","q":[{"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":""}]}]}