{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"EULA F SIEVER","gend":1,"add":"181 ROCKINGHAM DR","city":"HARRISONBURG","state":"VA","zip":"22802-9998","dob":"1960-08-26","age":"","mstatus":"","insh":"11009898","cliId":"","pno":5404420589,"cno":"","email":"","ename":"","eno":"","pphy":"LONG, KEITH C","ppno":5404773808,"pcpadd":"1661 S Main St","pcpcity":"Harrisonburg","pcpstate":"VA","pcpzip":228012728,"pcpcounty":"","pcpid":"","pcpname":"MOUNT JACKSON MEDICAL CENTER","plan":"VPHP","program":"MEDICARE","lob":"DSNP","region":"CHARLOTTESVILLE WESTERN","aligned":"Y","ano":"","add2":"APT O","add3":"","madd1":"181 ROCKINGHAM DR","madd2":"APT O","madd3":"","mcity":"HARRISONBURG","mstate":"VA","mzip":"22802-9998","pcpfaxno":"(540) 713-4101","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"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":[]},{"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":[]}]},{"t":"Allergies \/ Medications","q":[{"a":[]},{"a":{"comment":"","sub":[["","00378180710","LEVOTHYROXIN ","88MCG","90.00","Select","Select",""],["","50111033401","METRONIDAZOL ","500MG","14.00","Select","Select",""],["","00093365840","BUPRENORPHIN ","15MCG\/HR","4.00","Select","Select",""],["","63402030230","LATUDA ","20MG","60.00","Select","Select",""],["","00093221001","SUCRALFATE ","1GM","120.00","Select","Select",""],["","70377002711","ATORVASTATIN ","10MG","90.00","Select","Select",""],["","00591252001","CHLORZOXAZON ","500MG","30.00","Select","Select",""],["","62175061743","PANTOPRAZOLE ","40MG","90.00","Select","Select",""],["","00603389121","HYDROCO\/APAP ","7.5-325","90.00","Select","Select",""],["","50111056001","TRAZODONE ","50MG","60.00","Select","Select",""],["","58160081912","SHINGRIX ","50\/0.5ML","1.00","Select","Select",""],["","47781040960","HYDROCODONE ","10MG ER","60.00","Select","Select",""],["","16729020201","BUSPIRONE ","10MG","60.00","Select","Select",""],["","00115165903","PROPRANOLOL ","10MG","180.00","Select","Select",""],["","00093206301","QUETIAPINE ","25MG","90.00","Select","Select",""],["","47781030301","NITROFURANTN ","100MG","14.00","Select","Select",""],["","65162052110","PROMETHAZINE ","25MG","180.00","Select","Select",""],["","31722070090","LOSARTAN ","25MG","90.00","Select","Select",""],["","43547026910","ROPINIROLE ","0.5MG","45.00","Select","Select",""],["","68382003516","VENLAFAXINE ","75MG ER","90.00","Select","Select",""],["","65862085901","FAMOTIDINE ","20MG","180.00","Select","Select",""],["","42858010201","OXYCOD\/APAP ","5-325MG","90.00","Select","Select",""],["","69097083412","SERTRALINE ","50MG","45.00","Select","Select",""],["","14539067401","HYDROXYZ ","25MG","45.00","Select","Select",""],["","69097094312","GABAPENTIN ","300MG","90.00","Select","Select",""],["","68180098103","LISINOPRIL ","20MG","90.00","Select","Select",""],["","00093220305","METOCLOPRAM ","10MG","120.00","Select","Select",""],["","59385002160","BELBUCA ","75MCG","60.00","Select","Select",""],["","59011075704","BUTRANS ","7.5\/HR","4.00","Select","Select",""],["","51672404801","CLOTRIM\/BETA ","DIPROP","30.00","Select","Select",""],["","64764024060","AMITIZA ","24MCG","180.00","Select","Select",""],["","59762500901","CLINDAMYCIN ","2% VAG","40.00","Select","Select",""],["","68180012202","CEPHALEXIN ","500MG","30.00","Select","Select",""],["","49281042050","FLUZONE ","2020-21","0.50","Select","Select",""],["","59746000103","METHYLPRED ","4MG","21.00","Select","Select",""],["","67877025130","TRIAMCINOLON ","0.10%","30.00","Select","Select",""],["","53489011905","DOXYCYCL ","100MG","14.00","Select","Select",""]]}},{"a":[]},{"a":[]},{"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":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Pain","q":[{"a":[]}]},{"t":"Vital Signs","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Exam Review","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Screenings Needed","q":[{"a":{"indx":["","1"],"comment":["",""]}},{"a":{"indx":["","1"],"comment":["",""]}},{"a":{"indx":["","1"],"comment":["",""]}},{"a":{"indx":["","1"],"comment":["",""]}},{"a":{"indx":["","1"],"comment":["",""]}},{"a":{"indx":["","1"],"comment":["",""]}},{"a":{"indx":["","1"],"comment":["",""]}},{"a":[]}]},{"t":"Mini-Cog","q":[{"a":[]},{"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":"","a13":""}]}]}