{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"ERIC TILLERY","gend":0,"add":"8657 HOWERTON RD","city":"CENTER CROSS","state":"VA","zip":"22437-9998","dob":"1961-12-01","age":"","mstatus":"","insh":"11014659","cliId":"","pno":8044430390,"cno":"","email":"","ename":"","eno":"","pphy":"KLECAN, ANN MARIE","ppno":4346541950,"pcpadd":"901 Preston Ave Ste 300","pcpcity":"Charlottesville","pcpstate":"VA","pcpzip":229034491,"pcpcounty":"","pcpid":"","pcpname":"SENTARA MARTHA JEFFERSON FAMILY MEDICINE","plan":"VPHP","program":"MEDICARE","lob":"DSNP","region":"CENTRAL","aligned":"Y","ano":"","add2":"","add3":"","madd1":"PO BOX 164","madd2":"","madd3":"","mcity":"CENTER CROSS","mstate":"VA","mzip":"22437-9998","pcpfaxno":"","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":[["","72305005030","EUTHYROX ","50MCG","30.00","Select","Select",""],["","68645055254","LISINOPRIL ","10MG","90.00","Select","Select",""],["","00185061501","HYDROXYZ ","50MG","180.00","Select","Select",""],["","72205000490","ROSUVASTATIN ","20MG","30.00","Select","Select",""],["","00456112030","VIIBRYD ","20MG","90.00","Select","Select",""],["","00093505898","ATORVASTATIN ","40MG","90.00","Select","Select",""],["","62037059705","CARTIA ","120\/24HR","30.00","Select","Select",""],["","45802008801","ALBUTEROL ","HFA","17.00","Select","Select",""],["","67877022310","GABAPENTIN ","300MG","270.00","Select","Select",""],["","68180044801","QUETIAPINE ","200MG","90.00","Select","Select",""],["","10702000709","CYCLOBENZAPR ","10MG","90.00","Select","Select",""],["","68382080701","TRAZODONE ","150MG","90.00","Select","Select",""],["","65862085999","FAMOTIDINE ","20MG","30.00","Select","Select",""],["","50742061610","METOPROL ","50MG ER","90.00","Select","Select",""],["","00143992801","CIPROFLOXACN ","500MG","2.00","Select","Select",""],["","59310057922","PROAIR ","","8.50","Select","Select",""],["","68462063945","NITROGLYCERN ","0.4MG","25.00","Select","Select",""],["","29300011716","TOPIRAMATE ","100MG","60.00","Select","Select",""],["","47781030301","NITROFURANTN ","100MG","20.00","Select","Select",""],["","00310737020","BUDES\/FORMOT ","160-4.5","10.20","Select","Select",""],["","00003376474","ELIQUIS ","5MG","74.00","Select","Select",""],["","70010075401","METHOCARBAM ","500MG","40.00","Select","Select",""],["","67877021905","CEPHALEXIN ","500MG","20.00","Select","Select",""],["","55111029209","SUMATRIPTAN ","50MG","9.00","Select","Select",""],["","68645059090","CLOPIDOGREL ","75MG","90.00","Select","Select",""],["","00093005405","BUSPIRONE ","10MG","90.00","Select","Select",""],["","13668010401","ISOSORB ","30MG ER","30.00","Select","Select",""],["","58160082311","SHINGRIX ","50\/0.5ML","1.00","Select","Select",""],["","42858000101","OXYCODONE ","5MG","8.00","Select","Select",""],["","65162083366","DICLOFENAC ","1%","100.00","Select","Select",""],["","65162019011","NAPROXEN ","500MG","20.00","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":""}]}]}