{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"REGULO NAVARRETE ESPINAL","gend":0,"add":"13115 MELVILLE LANE  ","city":"FAIRFAX  ","state":"VA","zip":"22033-9998","dob":"1952-09-02","age":"","mstatus":"","insh":11018524,"cliId":"6WC3PU3CM89","pno":5714147150,"cno":5714147150,"email":"","ename":"","eno":"","pphy":"GOVIL, KANIKA  ","ppno":7039566757,"pcpadd":"14133 Robert Paris Ct","pcpcity":"CHANTILLY","pcpstate":"VA","pcpzip":201514203,"pcpcounty":"","pcpid":"P0124230","pcpname":"CHANTILLY FAMILY MEDICINE LLC","plan":"VPHP","program":"MEDICARE","lob":"DSNP","region":"NORTHERN & WINCHESTER","aligned":"Y","ano":"","add2":"","add3":"","madd1":"13115 MELVILLE LANE  ","madd2":"","madd3":"","mcity":"FAIRFAX  ","mstate":"VA","mzip":"22033-9998","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["E11.21","E78.2","E11.3413","E11.3411","E11.3412","H35.372","H25.13"],"date":["2021-09-14","2021-09-14","2021-11-16","2021-11-16","2021-11-16","2021-11-16","2021-11-16"],"priorHcc":["","",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":[["","58160082311","SHINGRIX","50\/0.5ML","1","Select","Select",""],["","13668018190","ROSUVASTATIN","20MG","90","Select","Select",""],["","42571013725","KETOROLAC","0.50%","10","Select","Select",""],["","69238115409","EZETIMIBE","10MG","90","Select","Select",""],["","68382075810","METFORMIN","500MG","180","Select","Select",""],["","58160082311","SHINGRIX ","INJ 50\/0.5ML","1","Select","Select",""],["","53885000810","ONETOUCH ","MIS PLUS 33G","100","Select","Select",""],["","68382075810","METFORMIN ","TAB 500MG","180","Select","Select",""],["","69238115409","EZETIMIBE ","TAB 10MG","90","Select","Select",""],["","13668018190","ROSUVASTATIN ","TAB 20MG","90","Select","Select",""],["","42571013725","KETOROLAC ","SOL 0.005","10","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","",""],["Yes","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":""}]}]}