{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"LARRY M WINTERS","gend":0,"add":"843 Hill Station Alley Rd  ","city":"Gate City","state":"VA","zip":"24251-4687","dob":"1990-08-23","age":"","mstatus":"","insh":11018374,"cliId":"8EC0W24HF14","pno":2764520005,"cno":2765946514,"email":"","ename":"","eno":"","pphy":"HAGER, SHELTON ","ppno":4233926200,"pcpadd":"105 W STONE DRIVE,SUITE 3A","pcpcity":"KINGSPORT","pcpstate":"TN","pcpzip":376603365,"pcpcounty":"","pcpid":"P9058735","pcpname":"HOLSTON MEDICAL GROUP PC","plan":"VPHP","program":"MEDICARE","lob":"DSNP","region":"SOUTHWEST","aligned":"Y","ano":"","add2":"","add3":"","madd1":"843 Hill Station Alley Rd  ","madd2":"","madd3":"","mcity":"Gate City","mstate":"VA","mzip":"24251-4687","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["D64.9","R60.0","E78.5","R25.2","E10.3513","H43.13","H35.373","E10.8","E10.65","Z79.4","E10.22","I12.9","I10","N18.30","E87.5","K21.9","Z23","G47.00","F33.9","L02.214","R11.0","L03.314"],"date":["2021-11-16","2021-08-23","2021-08-23","2021-09-27","2021-07-14","2021-07-14","2021-07-14","2021-11-26","2021-11-26","2021-11-26","2021-11-17","2021-11-17","2021-09-27","2021-11-17","2021-11-17","2021-09-27","2021-09-27","2021-11-16","2021-11-16","2021-11-16","2021-11-16","2021-11-17"],"priorHcc":[null,"","","","","","",null,null,null,null,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":[]},{"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":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Allergies \/ Medications","q":[{"a":[]},{"a":{"comment":"","sub":[["","43598029490","PREGABALIN ","100MG","120","Select","Select",""],["","00002751001","HUMALOG ","100\/ML","50","Select","Select",""],["","50742061610","METOPROL ","50MG ER","90","Select","Select",""],["","70377000415","SIMVASTATIN ","40MG","90","Select","Select",""],["","70377000415","SIMVASTATIN","40MG","90","Select","Select",""],["","43598029490","PREGABALIN","100MG","120","Select","Select",""],["","00002751001","HUMALOG","100\/ML","50","Select","Select",""],["","50742061610","METOPROL","50MG ER","90","Select","Select",""],["","60758011905","PREDNISOLONE","1% OP","15","Select","Select",""],["","24208031510","POLYMYXIN","TRIMETHP","10","Select","Select",""],["","62175061743","PANTOPRAZOLE","40MG","90","Select","Select",""],["","68180098003","LISINOPRIL","10MG","90","Select","Select",""],["","60505025203","TIZANIDINE","4MG","90","Select","Select",""],["","31722053101","TORSEMIDE","20MG","270","Select","Select",""],["","50111056001","TRAZODONE","50MG","270","Select","Select",""],["","60758011905","PREDNISOLONE ","SUS 1% OP","15","Select","Select",""],["","24208031510","POLYMYXIN ","SOL TRIMETHP","10","Select","Select",""],["","60505025203","TIZANIDINE ","TAB 4MG","90","Select","Select",""],["","68180098003","LISINOPRIL ","TAB 10MG","90","Select","Select",""],["","31722053101","TORSEMIDE ","TAB 20MG","270","Select","Select",""],["","50111056001","TRAZODONE ","TAB 50MG","270","Select","Select",""],["","62175061743","PANTOPRAZOLE ","TAB 40MG","90","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":[[["Yes","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["Yes","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":""}]}]}