{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"SHERRY   S FAUNTLEROY","gend":1,"add":"10739 ROBERT E LEE DR                                       ","city":"SPOTSYLVANIA                  ","state":"VA","zip":"22551-4514","dob":"1958-06-13","age":"","mstatus":"","insh":10048821,"cliId":"","pno":5409723717,"cno":"","email":"","ename":"","eno":"","pphy":"GALDAMEZ, GLORIA E","ppno":"","pcpadd":"12101 Carol Ln","pcpcity":"Fredericksburg                ","pcpstate":"VA","pcpzip":224076101,"pcpcounty":"","pcpid":"","pcpname":"","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"CENTRAL","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"10739 ROBERT E LEE DR                                       ","madd2":"                                                            ","madd3":"","mcity":"SPOTSYLVANIA                  ","mstate":"VA","mzip":"22551-4514","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","1","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["N20.0","N28.1","K80.20","E11.9","I10","E78.2","E55.9","E78.1","E53.8","D51.8","M79.672","M76.829","M21.42","M21.41","D51.9","R39.81","E78.00","L22"],"date":["2019-01-09","2019-01-09","2019-03-21","2021-10-05","2021-10-05","2021-10-01","2021-10-01","2020-11-10","2020-07-14","2020-11-10","2020-09-16","2020-09-16","2020-09-16","2020-09-16","2021-04-02","2021-11-25","2021-10-05","2021-11-25"],"priorHcc":["","","","","","","","","","","","","","","",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":[["","00193731221","CONTOUR","NEXT","100","Select","Select",""],["","60505014101","GLIPIZIDE","5MG","180","Select","Select",""],["","68180052001","LISINOP\/HCTZ","20-25MG","90","Select","Select",""],["","70377000612","ROSUVASTATIN","5MG","90","Select","Select",""],["","70377000114","SIMVASTATIN","5MG","30","Select","Select",""],["","68382075810","METFORMIN","500MG","60","Select","Select",""],["","50428016516","CVS","5000UNIT","30","Select","Select",""],["","50428037624","VITAMIN","1000MCG","30","Select","Select",""],["","45802041926","AMMONIUM","12%","400","Select","Select",""],["","00193731221","CONTOUR ","TES NEXT","100","Select","Select",""],["","60505014101","GLIPIZIDE ","TAB 5MG","180","Select","Select",""],["","68180052001","LISINOP\/HCTZ ","TAB 20-25MG","90","Select","Select",""],["","70377000612","ROSUVASTATIN ","TAB 5MG","90","Select","Select",""],["","70377000114","SIMVASTATIN ","TAB 5MG","30","Select","Select",""],["","68382075810","METFORMIN ","TAB 500MG","60","Select","Select",""],["","50428016516","CVS ","CAP 5000UNIT","30","Select","Select",""],["","50428037624","VITAMIN ","TAB 1000MCG","30","Select","Select",""],["","45802041926","AMMONIUM ","LOT 0.12","400","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":""}]}]}