{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"PHILLIP DIX","gend":0,"add":"18500   GOSPEL TEMPLE ROAD                                  ","city":"MELFA                         ","state":"VA","zip":"23410-3132","dob":"1966-06-12","age":"","mstatus":"","insh":10047259,"cliId":"","pno":7577104379,"cno":7577104379,"email":"","ename":"","eno":"","pphy":"SNYDER, JOHN W                                              ","ppno":"","pcpadd":"9524 Hospital Ave,STE 114","pcpcity":"Nassawadox                    ","pcpstate":"VA","pcpzip":23413,"pcpcounty":"","pcpid":"P0125432","pcpname":"RIVERSIDE EASTERN SHORE PHYSICIANS AND SURGEONS","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"TIDEWATER","aligned":"","ano":"","add2":"PO BOX 626                                                  ","add3":"","madd1":"18500   GOSPEL TEMPLE ROAD                                  ","madd2":"                                                            ","madd3":"","mcity":"MELFA                         ","mstate":"VA","mzip":"23410-3132","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","1","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["B35.3","I73.9","B35.1","L85.1","R68.89","F25.1","N52.01","R10.9","E09.9","E78.5","Z11.3","R29.818","E53.8","L84","R19.00","G47.30","Z79.899","N52.9","G47.31","G47.33","R06.83","R06.81","E11.9","R39.11","Z12.5","Z71.3","R06.02","K59.01","K59.00","R10.31","Z79.82","M79.671","M19.071","J30.2","R05","M41.9","I10","Z23","R51","R73.02","R35.1","R73.03","K21.9","N40.1","M25.562","R19.7","R10.84","K52.9","K64.4","K92.1","R19.4","K64.8","K31.9","R42","R10.13","K31.89","Q39.9","Z53.8","Z92.29","R00.0","E56.9","E11.51","N30.00","E61.1","R51.9","K63.89","K44.9","Z46.82","J98.11","Z03.89","K56.609","K59.89","D49.9","J90","R11.2","Z98.890","Z48.89","Z45.2","J98.4","R14.0","Z04.3","Z04.9","K56.7","K91.89"],"date":["2019-07-22","2021-08-06","2021-08-06","2021-08-06","2021-02-19","2021-10-25","2021-03-11","2019-07-30","2021-10-25","2021-07-15","2019-02-12","2019-03-04","2021-03-11","2019-03-11","2019-04-08","2019-04-17","2021-04-19","2020-09-28","2021-04-19","2021-11-03","2019-05-28","2019-05-28","2021-11-03","2019-06-03","2020-09-28","2020-02-14","2019-06-24","2021-10-25","2021-10-30","2019-07-18","2021-04-19","2019-07-22","2019-07-22","2019-07-30","2019-07-30","2019-07-30","2021-03-11","2021-04-23","2020-07-06","2020-09-28","2020-09-28","2020-11-11","2021-11-03","2021-10-25","2020-11-11","2021-01-12","2021-02-26","2021-04-19","2021-02-26","2021-02-26","2021-04-19","2021-04-19","2021-04-19","2021-04-19","2021-04-19","2021-10-29","2021-04-19","2021-04-19","2021-04-23","2021-07-15","2021-07-15","2021-08-06","2021-10-25","2021-10-25","2021-10-25","2021-10-30","2021-10-29","2021-11-18","2021-11-18","2021-10-29","2021-11-30","2021-11-01","2021-11-03","2021-11-04","2021-11-04","2021-11-30","2021-11-15","2021-11-08","2021-11-08","2021-11-16","2021-11-11","2021-11-13","2021-11-18","2021-11-30"],"priorHcc":["","","","","","","","","","","","","","","","","","","",null,"","",null,"","","","","","","","","","","","","","","","","","","",null,"","","","","","","","","","","","","","","","","","","","","","","","",null,null,"",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":[["","60505024801","MIRTAZAPINE","30MG","30","Select","Select",""],["","68382011714","RISPERIDONE","4MG","60","Select","Select",""],["","49348004214","PAIN","500MG","120","Select","Select",""],["","68645056354","IBUPROFEN","800MG","90","Select","Select",""],["","00904053080","TAB-A-VITE","","30","Select","Select",""],["","70677004101","SM","8.6MG","180","Select","Select",""],["","49483048112","ASPIRIN","81MG EC","30","Select","Select",""],["","16714089803","LORATADINE","10MG","30","Select","Select",""],["","00904672040","ACETAMIN","500MG","120","Select","Select",""],["","00781148610","AMITRIPTYLIN","10MG","90","Select","Select",""],["","68180044801","QUETIAPINE","200MG","60","Select","Select",""],["","00904674880","BISACODYL","5MG EC","90","Select","Select",""],["","00781286810","OMEPRAZOLE","20MG","90","Select","Select",""],["","68382013201","TAMSULOSIN","0.4MG","90","Select","Select",""],["","57896045101","GERI-KOT","8.6MG","30","Select","Select",""],["","00067611730","ALLERGY","10MG","30","Select","Select",""],["","49035007860","EQ","SOFTENER","60","Select","Select",""],["","00904645760","DOK","100MG","60","Select","Select",""],["","65162019011","NAPROXEN","500MG","60","Select","Select",""],["","58765000005","CALCIUM\/D","600-200","180","Select","Select",""],["","74312006470","VITAMIN","COMPLEX","90","Select","Select",""],["","00904770418","ASPIR-LOW","81MG EC","30","Select","Select",""],["","49035032712","GENTLE","5MG EC","30","Select","Select",""],["","45802086803","POLYETH","3350 NF","510","Select","Select",""],["","00904404360","FISH","1000MG","90","Select","Select",""],["","00536478701","B","","90","Select","Select",""],["","70677003401","STOOL","100MG","60","Select","Select",""],["","65862078430","ESOMEPRA","40MG DR","30","Select","Select",""],["","45802014167","CICLOPIROX","8%","6.6","Select","Select",""],["","60505024801","MIRTAZAPINE ","TAB 30MG","30","Select","Select",""],["","68382011714","RISPERIDONE ","TAB 4MG","60","Select","Select",""],["","49348004214","PAIN ","TAB 500MG","120","Select","Select",""],["","68645056354","IBUPROFEN ","TAB 800MG","90","Select","Select",""],["","00904053080","TAB-A-VITE ","TAB ","30","Select","Select",""],["","70677004101","SM ","TAB 8.6MG","180","Select","Select",""],["","49483048112","ASPIRIN ","TAB 81MG EC","30","Select","Select",""],["","16714089803","LORATADINE ","TAB 10MG","30","Select","Select",""],["","00904672040","ACETAMIN ","TAB 500MG","120","Select","Select",""],["","00781148610","AMITRIPTYLIN ","TAB 10MG","90","Select","Select",""],["","68180044801","QUETIAPINE ","TAB 200MG","60","Select","Select",""],["","00904674880","BISACODYL ","TAB 5MG EC","90","Select","Select",""],["","00781286810","OMEPRAZOLE ","CAP 20MG","90","Select","Select",""],["","68382013201","TAMSULOSIN ","CAP 0.4MG","90","Select","Select",""],["","57896045101","GERI-KOT ","TAB 8.6MG","30","Select","Select",""],["","00067611730","ALLERGY ","TAB 10MG","30","Select","Select",""],["","49035007860","EQ ","CAP SOFTENER","60","Select","Select",""],["","00904645760","DOK ","CAP 100MG","60","Select","Select",""],["","65162019011","NAPROXEN ","TAB 500MG","60","Select","Select",""],["","58765000005","CALCIUM\/D ","TAB 600-200","180","Select","Select",""],["","74312006470","VITAMIN ","TAB COMPLEX","90","Select","Select",""],["","00904770418","ASPIR-LOW ","TAB 81MG EC","30","Select","Select",""],["","49035032712","GENTLE ","TAB 5MG EC","30","Select","Select",""],["","45802086803","POLYETH ","POW 3350 NF","510","Select","Select",""],["","00904404360","FISH ","CAP 1000MG","90","Select","Select",""],["","00536478701","B ","CAP ","90","Select","Select",""],["","70677003401","STOOL ","CAP 100MG","60","Select","Select",""],["","65862078430","ESOMEPRA ","CAP 40MG DR","30","Select","Select",""],["","45802014167","CICLOPIROX ","SOL 0.08","6.6","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","",""],["N\/A","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["Yes","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":""}]}]}