{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"CLARK A ROCHE","gend":0,"add":"6006 RED FOX DR","city":"SPOTSYLVANIA","state":"VA","zip":"22551-9998","dob":"1980-02-16","age":"","mstatus":"","insh":11017587,"cliId":"7X59C22HD16","pno":5405825411,"cno":5408504323,"email":"","ename":"","eno":"","pphy":"ANSARI, NATHER B  ","ppno":5407859900,"pcpadd":"1075 GARRISONVILLE RD,Ste 115","pcpcity":"STAFFORD ","pcpstate":"VA","pcpzip":225568600,"pcpcounty":"","pcpid":"P0125879","pcpname":"SENIOR AND ADULT CARE LLC","plan":"VPHP","program":"MEDICARE","lob":"DSNP","region":"CENTRAL","aligned":"Y","ano":"","add2":"6006   RED FOX DRIVE","add3":"","madd1":"6006 RED FOX DR","madd2":"6006   RED FOX DRIVE","madd3":"","mcity":"SPOTSYLVANIA","mstate":"VA","mzip":"22551-9998","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F31.9","Z04.6","Z03.818","Z00.8","F84.5","Z20.822","F42.9","Z82.49","F70","F84.0","F63.81","F43.10","F42.2","Z23","F39","R45.6","Z86.59"],"date":["2021-03-11","2021-10-09","2021-03-10","2021-03-11","2021-10-09","2021-03-11","2021-03-10","2021-03-10","2021-03-11","2021-03-11","2021-03-11","2021-03-11","2021-03-11","2021-05-19","2021-10-09","2021-10-09","2021-10-09"],"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":[["","70710113101","CHLORPROMAZ","TAB 50MG","","Select","Select",""],["","27241000506","RISPERIDONE","TAB 3MG","","Select","Select",""],["","43547040710","CLONAZEPAM","TAB 1MG","","Select","Select",""],["","71093011205","GABAPENTIN","TAB 800MG","","Select","Select",""],["","62559016001","FLUVOXAMINE","TAB 100MG","","Select","Select",""],["","69315090501","LORAZEPAM","TAB 1MG","","Select","Select",""],["","51672401206","CLOMIPRAMINE","CAP 50MG","","Select","Select",""],["","185061505","HYDROXYZ PAM","CAP 50MG","","Select","Select",""],["","70710113101","CHLORPROMAZ ","TAB 50MG","30","Select","Select",""],["","69315090501","LORAZEPAM ","TAB 1MG","90","Select","Select",""],["","43547040710","CLONAZEPAM ","TAB 1MG","60","Select","Select",""],["","27241000506","RISPERIDONE ","TAB 3MG","60","Select","Select",""],["","71093011205","GABAPENTIN ","TAB 800MG","90","Select","Select",""],["","62559016001","FLUVOXAMINE ","TAB 100MG","60","Select","Select",""],["","185061505","HYDROXYZ ","CAP 50MG","4","Select","Select",""],["","51672401206","CLOMIPRAMINE ","CAP 50MG","4","Select","Select",""],["","00185061505","HYDROXYZ","50MG","4","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","",""],["No","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":""}]}]}