{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"KENDALL   S EPPS","gend":0,"add":"PO BOX 682                                                  ","city":"BLACKSOTNE                    ","state":"VA","zip":"23824-0682","dob":"1986-03-12","age":"","mstatus":"","insh":10048671,"cliId":"","pno":4342941246,"cno":4342941246,"email":"","ename":"","eno":"","pphy":"ESQUIVEL, MARISSA W                                         ","ppno":"","pcpadd":"213 N Main St,2116 W Laburnum Ave Ste 100","pcpcity":"Blackstone                    ","pcpstate":"VA","pcpzip":238241425,"pcpcounty":"","pcpid":"P0149935","pcpname":"BLACKSTONE FAMILY PRACTICE CENTER","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"CENTRAL","aligned":"","ano":"","add2":"P. O. BOX 403, BLACKSTONE, VA 23824                         ","add3":"","madd1":"PO BOX 682                                                  ","madd2":"P. O. BOX 403, BLACKSTONE, VA 23824                         ","madd3":"","mcity":"BLACKSOTNE                    ","mstate":"VA","mzip":"23824-0682","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","1","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z20.2","F17.210","F32.9","F41.9","G47.09","Z11.3","M54.5","M41.9","M54.9","R59.9","Z20.822","Z71.1","Z11.59","Z20.828","R40.20","F10.10","F43.9","F10.929"],"date":["2019-07-09","2021-05-04","2020-07-06","2019-07-17","2020-07-06","2019-07-17","2020-02-12","2020-02-12","2020-02-12","2020-07-06","2021-05-04","2021-05-04","2021-05-04","2021-05-04","2021-10-30","2021-10-30","2021-10-30","2021-10-30"],"priorHcc":["","","","","","","","","","","","","","",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":[["","68382080510","TRAZODONE","50MG","30","Select","Select",""],["","13668001005","CITALOPRAM","20MG","30","Select","Select",""],["","70010075405","METHOCARBAM","500MG","42","Select","Select",""],["","00093031401","KETOROLAC","10MG","5","Select","Select",""],["","00591352530","LIDOCAINE","5%","30","Select","Select",""],["","43598081115","CETIRIZINE","10MG","30","Select","Select",""],["","42571016242","AMOX\/K","875-125","14","Select","Select",""],["","52817033200","CYCLOBENZAPR","10MG","90","Select","Select",""],["","66993001968","ALBUTEROL","HFA","18","Select","Select",""],["","68382080510","TRAZODONE ","TAB 50MG","30","Select","Select",""],["","13668001005","CITALOPRAM ","TAB 20MG","30","Select","Select",""],["","70010075405","METHOCARBAM ","TAB 500MG","42","Select","Select",""],["","00093031401","KETOROLAC ","TAB 10MG","5","Select","Select",""],["","00591352530","LIDOCAINE ","PAD 0.05","30","Select","Select",""],["","43598081115","CETIRIZINE ","TAB 10MG","30","Select","Select",""],["","42571016242","AMOX\/K ","TAB 875-125","14","Select","Select",""],["","52817033200","CYCLOBENZAPR ","TAB 10MG","90","Select","Select",""],["","66993001968","ALBUTEROL ","AER HFA","18","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":""}]}]}