{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"GISELLE LOPEZ","gend":1,"add":"15641 WHEATFIELD RD                                         ","city":"WOODBRIDGE                    ","state":"VA","zip":"22193-5745","dob":"1987-12-11","age":"","mstatus":"","insh":10044278,"cliId":"","pno":7035830656,"cno":"","email":"","ename":"","eno":"","pphy":"AKRAMI KHASRAGHI, FARDIN                                    ","ppno":"","pcpadd":"2200 Opitz Blvd Ste 235","pcpcity":"Woodbridge                    ","pcpstate":"VA","pcpzip":221913343,"pcpcounty":"","pcpid":"P9058188","pcpname":"WOODBRIDGE INTERNAL MEDICINE PC","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"NORTHERN\/ WINCHESTER","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"15641 WHEATFIELD RD                                         ","madd2":"                                                            ","madd3":"","mcity":"WOODBRIDGE                    ","mstate":"VA","mzip":"22193-5745","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["B07.0","B35.3","M21.6X1","L84","M21.6X2","B07.8","M20.5X2","M20.5X1","M21.759","K57.92","R10.32","R11.2","R30.0","R10.84","R10.31","R11.0","R62.50","L20.89","L60.3","R89.5","L60.1","L40.8","N89.8","Z91.19"],"date":["2021-03-31","2021-03-22","2020-02-24","2021-01-15","2020-02-24","2019-12-09","2019-12-09","2019-12-09","2020-01-08","2020-04-18","2020-04-18","2020-04-18","2020-04-18","2020-04-18","2020-04-18","2020-04-18","2020-04-18","2020-08-17","2021-03-22","2020-08-31","2020-11-30","2021-01-15","2021-03-16","2021-03-22"],"priorHcc":["","","","","","","","","","","","","","","","","","","","","","","",""]}},{"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":[["","16714076301","CALCIPOTRIEN","0.01%","60","Select","Select",""],["","63646001004","KETOCONAZOLE","2%","120","Select","Select",""],["","45802006405","TRIAMCINOLON","0.10%","454","Select","Select",""],["","65862039010","ONDANSETRON","4MG ODT","12","Select","Select",""],["","00591079501","DICYCLOMINE","20MG","30","Select","Select",""],["","16714076301","CALCIPOTRIEN ","CRE 0.00005","60","Select","Select",""],["","63646001004","KETOCONAZOLE ","SHA 0.02","120","Select","Select",""],["","45802006405","TRIAMCINOLON ","CRE 0.001","454","Select","Select",""],["","65862039010","ONDANSETRON ","TAB 4MG ODT","12","Select","Select",""],["","00591079501","DICYCLOMINE ","TAB 20MG","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","",""],["N\/A","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["No","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":""}]}]}