{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MARJORIE D PENDLETON","gend":1,"add":"762PROSPECT AVENUE APT C","city":"CHARLOTTESVILLE","state":"VA","zip":"22903-9998","dob":"1954-12-16","age":"","mstatus":"","insh":11017417,"cliId":"8VH2MP7CR08","pno":4342490877,"cno":4342490877,"email":"","ename":"","eno":"","pphy":"BEVINS, LAUREN E  ","ppno":8002239173,"pcpadd":"Lee Street & 11th Street SW","pcpcity":"Charlottesville","pcpstate":"VA","pcpzip":229080001,"pcpcounty":"","pcpid":"P9059131","pcpname":"UVA HOSPITAL","plan":"VPHP","program":"MEDICARE","lob":"DSNP","region":"CHARLOTTESVILLE WESTERN","aligned":"Y","ano":"","add2":"APT C","add3":"","madd1":"762PROSPECT AVENUE APT C","madd2":"APT C","madd3":"","mcity":"CHARLOTTESVILLE","mstate":"VA","mzip":"22903-9998","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","1","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["G89.29","J18.9","Z12.39","J43.2","C34.90","D50.9","C34.92","Z08","Z85.118","Z90.2","I10","J45.20","M81.0","K59.03","D64.9","B02.29","K21.9","M75.101","M75.21","E83.42","Z87.891","E44.1","R11.0","R06.02","Z74.3","R05","J42","J43.9","R53.83","R63.4","G47.00","F32.89","F43.21"],"date":["2021-07-16","2021-07-16","2021-02-16","2021-09-17","2021-07-16","2021-05-05","2021-07-16","2021-05-05","2021-09-17","2021-05-05","2021-10-13","2021-07-16","2021-07-16","2021-07-16","2021-09-22","2021-07-16","2021-07-16","2021-07-16","2021-07-16","2021-07-16","2021-09-17","2021-09-22","2021-07-16","2021-09-10","2021-09-10","2021-09-14","2021-09-17","2021-09-17","2021-09-22","2021-09-22","2021-09-22","2021-09-22","2021-09-22"],"priorHcc":["","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","",""]}},{"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":[["","172409680","BACLOFEN","TAB 10MG","","Select","Select",""],["","29300022010","MONTELUKAST","TAB 10MG","","Select","Select",""],["","603188016","LIDOCAINE","PAD 0.05","","Select","Select",""],["","172409680","BACLOFEN ","TAB 10MG","90","Select","Select",""],["","29300022010","MONTELUKAST ","TAB 10MG","90","Select","Select",""],["","67877022305","GABAPENTIN ","300MG","270","Select","Select",""],["","603188016","LIDOCAINE ","5%","90","Select","Select",""],["","55111015810","OMEPRAZOLE ","20MG","180","Select","Select",""],["","65862069705","VENLAFAXINE ","150MG ER","90","Select","Select",""],["","67877022305","GABAPENTIN","300MG","270","Select","Select",""],["","67877056860","DRONABINOL","2.5MG","60","Select","Select",""],["","00069046956","CHANTIX","1MG","56","Select","Select",""],["","65862069705","VENLAFAXINE","150MG ER","90","Select","Select",""],["","10702001801","OXYCODONE","5MG","30","Select","Select",""],["","65162083366","DICLOFENAC","0.01","300","Select","Select",""],["","68180051303","LISINOPRIL","5MG","90","Select","Select",""],["","00310737220","BUDES\/FORMOT","80-4.5","30.6","Select","Select",""],["","55111015810","OMEPRAZOLE","20MG","180","Select","Select",""],["","65162052110","PROMETHAZINE","25MG","30","Select","Select",""],["","69097052444","DICLOFENAC ","GEL 0.01","300","Select","Select",""],["","10702001801","OXYCODONE ","TAB 5MG","30","Select","Select",""],["","65162052110","PROMETHAZINE ","TAB 25MG","30","Select","Select",""],["","68180051303","LISINOPRIL ","TAB 5MG","90","Select","Select",""],["","00310737220","BUDES\/FORMOT ","AER 80-4.5","30.6","Select","Select",""],["","67877056860","DRONABINOL ","CAP 2.5MG","60","Select","Select",""],["","00069046956","CHANTIX ","TAB 1MG","56","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","",false,""],["No","Select","",false,""],["No","Select","",false,""],["Yes","Select","",false,""],["No","Select","",false,""],["No","Select","",false,""],["N\/A","Select","",false,""]]]},{"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":""}]}]}