{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"NOLIZMARIE ARCE RIVERA","gend":1,"add":"PO BOX 102                                                  ","city":"ELKTON                        ","state":"VA","zip":"22827-0102","dob":"2000-01-25","age":"","mstatus":"","insh":10050838,"cliId":"","pno":5404358770,"cno":5404358770,"email":"","ename":"","eno":"","pphy":"PERKINS, JASON F                                            ","ppno":"","pcpadd":"13737 Spotswood Trl,B08","pcpcity":"Elkton                        ","pcpstate":"VA","pcpzip":228273200,"pcpcounty":"","pcpid":"P9058602","pcpname":"EAST ROCKINGHAM HEALTH CENTER","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"WESTERN\/ CHARLOTTESVILLE","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"PO BOX 102                                                  ","madd2":"                                                            ","madd3":"","mcity":"ELKTON                        ","mstate":"VA","mzip":"22827-0102","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["E05.90","E05.00","R63.5","E66.01","Z68.41","Z71.3","Z68.53","E66.3","Q90.9","Z00.00","Z23","Z13.21","K59.00","R11.0","R68.81","L02.93","E55.9"],"date":["2021-11-18","2019-03-26","2019-03-27","2021-11-18","2021-11-18","2019-09-09","2019-09-09","2019-10-10","2020-09-17","2019-10-28","2019-10-28","2020-05-08","2020-02-20","2020-02-20","2020-02-20","2020-02-20","2021-11-18"],"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":[["","23155007001","METHIMAZOLE","5MG","90","Select","Select",""],["","23155007001","METHIMAZOLE ","TAB 5MG","90","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","",""],["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":""}]}]}