{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"AMY SANCHEZ","gend":1,"add":"982 N BRADDOCK STREET","city":"WINCHESTER  ","state":"VA","zip":"22601-9998","dob":"1990-01-01","age":"","mstatus":"","insh":11018470,"cliId":"7PD6G67NK49","pno":5402446838,"cno":"","email":"","ename":"","eno":"","pphy":"PANCIO, BROOKE M  ","ppno":5406782800,"pcpadd":"104 Selma Dr","pcpcity":"Winchester  ","pcpstate":"VA","pcpzip":226013834,"pcpcounty":"","pcpid":"P9059049","pcpname":"SELMA MEDICAL ASSOCIATES","plan":"VPHP","program":"MEDICARE","lob":"DSNP","region":"NORTHERN & WINCHESTER","aligned":"N","ano":"","add2":"","add3":"","madd1":"982 N BRADDOCK STREET","madd2":"","madd3":"","mcity":"WINCHESTER  ","mstate":"VA","mzip":"22601-9998","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["O99.211","E66.9","Z3A.08","E66.09","O99.341","O35.5XX0","Z82.79","Z3A.12","T78.1XXA","R10.13","A05.9","Z34.90","R06.02","R55","N76.0","O23.592","B96.89","O26.892","R10.30","Z3A.18","O20.9","J02.9","J35.8","R19.8","B37.0","F17.210","Z33.1","E87.6","R07.9","R00.2","R11.0","M79.606","R79.89","R07.0","O99.212","O99.332","Z3A.19"],"date":["2021-09-09","2021-08-13","2021-08-13","2021-10-28","2021-09-09","2021-10-28","2021-10-28","2021-09-09","2021-09-25","2021-09-25","2021-09-25","2021-10-04","2021-10-06","2021-10-26","2021-10-13","2021-10-13","2021-10-13","2021-10-13","2021-10-13","2021-10-13","2021-10-13","2021-10-29","2021-10-29","2021-10-29","2021-10-29","2021-10-29","2021-10-29","2021-11-16","2021-11-16","2021-11-16","2021-11-04","2021-11-16","2021-11-16","2021-11-16","2021-10-28","2021-10-28","2021-10-28"],"priorHcc":["","","",null,"",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":[["","65862085901","FAMOTIDINE","20MG","180","Select","Select",""],["","39328010610","PRENATAL","27-1MG","90","Select","Select",""],["","50111033401","METRONIDAZOL","500MG","14","Select","Select",""],["","65862085901","FAMOTIDINE ","TAB 20MG","60","Select","Select",""],["","70710113908","FLUCONAZOLE ","TAB 150MG","1","Select","Select",""],["","68462018135","CLOTRIMAZOLE ","CRE 0.01","60","Select","Select",""],["","00121086816","NYSTATIN ","SUS 100000","360","Select","Select",""],["","39328010610","PRENATAL ","TAB 27-1MG","90","Select","Select",""],["","50111033401","METRONIDAZOL ","TAB 500MG","14","Select","Select",""],["","00093310905","AMOXICILLIN ","CAP 500MG","30","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":""}]}]}