{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"DINAH BENSON","gend":1,"add":"105 PAPA BEAR LANE                                          ","city":"MADISON HEIGHTS               ","state":"VA","zip":"24572-2512","dob":"1960-01-05","age":"","mstatus":"","insh":10051210,"cliId":"","pno":4345280138,"cno":4345280138,"email":"","ename":"","eno":"","pphy":"BOLUSA-SABUGO, AHGNES U                                     ","ppno":"","pcpadd":"320 Federal St,Ste C","pcpcity":"Lynchburg                     ","pcpstate":"VA","pcpzip":245042306,"pcpcounty":"","pcpid":"P0124712","pcpname":"AMHERST COUNTY COMMUNITY HEALTH CENTER","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"WESTERN\/ CHARLOTTESVILLE","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"105 PAPA BEAR LANE                                          ","madd2":"                                                            ","madd3":"","mcity":"MADISON HEIGHTS               ","mstate":"VA","mzip":"24572-2512","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z12.31","M17.12","M25.562","G89.29","M54.5","Z72.0","I10","R25.2","M15.0","F33.1","F41.0","M25.552","M51.36","M54.41","M54.42","J01.40","J30.2","M43.22","Z79.891","M54.16","M50.323","Z98.1","M54.2","R20.0","M25.512","M50.30","R10.31","M19.012","M75.42","M67.922","M48.02","M50.23","M47.813","R31.21","Z86.79","R09.89","Z87.19","J30.9","J34.2","J34.89","N28.1","K57.90","R10.13","K31.84","K27.9","K57.92","K58.9","R68.89","G47.33","N94.10","N95.9","Z01.419","Z12.4","R87.618","Z11.3","Z11.51","J01.90","B37.3","K21.9","D69.2","M47.812","M47.26","M47.816","M79.602","M79.601","M54.12","R53.1","Z01.812","R42","I65.09","I65.23","I77.1","J36","J06.9","Z23","M25.561","N30.00","K59.01","R15.2","R15.9","K58.1","R10.33","R10.30","R14.0","Z86.010","Z71.9","K59.00","B35.4","Z91.81","B37.0","G47.30","F41.9","Z68.31","K62.89","K64.4","K64.8","K57.30","M51.16","M51.17","M47.27","M25.659","M62.81","M54.50","S14.109A","S34.109A","S49.91XA","S19.9XXA","M79.671"],"date":["2019-01-15","2019-11-26","2021-11-01","2021-11-01","2021-08-18","2021-11-01","2021-08-11","2020-03-23","2021-11-10","2021-08-11","2021-11-10","2019-03-08","2021-11-10","2019-05-14","2019-05-14","2019-03-20","2021-05-11","2021-11-19","2021-03-10","2021-08-31","2019-07-24","2020-01-21","2021-11-01","2019-07-24","2019-07-30","2021-11-10","2019-07-30","2019-08-02","2019-07-30","2019-08-02","2019-08-13","2019-08-13","2019-08-13","2019-08-27","2019-09-12","2019-09-13","2019-10-04","2019-10-10","2019-11-07","2019-11-07","2019-10-18","2019-10-18","2019-10-23","2020-11-30","2019-10-23","2019-10-23","2019-10-23","2019-11-07","2019-11-07","2019-11-12","2020-12-10","2020-12-10","2019-11-12","2019-11-12","2019-11-12","2019-11-12","2019-12-06","2019-12-06","2021-08-11","2019-12-17","2020-01-21","2021-05-25","2020-01-21","2020-01-21","2020-01-21","2020-01-21","2020-01-21","2020-01-21","2020-01-30","2020-01-30","2020-02-21","2020-02-21","2020-03-03","2020-03-03","2020-10-21","2021-07-23","2020-07-02","2021-08-11","2020-10-21","2021-05-11","2021-04-05","2020-12-01","2021-04-05","2021-04-05","2021-03-26","2021-04-05","2021-05-11","2020-12-10","2021-01-22","2021-02-02","2021-03-26","2021-03-26","2021-03-26","2021-03-26","2021-03-26","2021-03-26","2021-03-26","2021-05-25","2021-05-25","2021-12-02","2021-12-02","2021-12-02","2021-11-01","2021-10-19","2021-10-20","2021-10-20","2021-10-20","2021-11-16"],"priorHcc":["","",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":[["","68645052254","SERTRALINE","50MG","30","Select","Select",""],["","42571014401","CELECOXIB","200MG","60","Select","Select",""],["","29300013005","HYDROCHLOROT","12.5MG","30","Select","Select",""],["","16729013716","CLONAZEPAM","1MG","60","Select","Select",""],["","10702005601","OXYCODONE","10MG","120","Select","Select",""],["","00781286810","OMEPRAZOLE","20MG DR","60","Select","Select",""],["","29300022019","MONTELUKAST","10MG","30","Select","Select",""],["","16571040250","CETIRIZINE","10MG","30","Select","Select",""],["","57664050658","METOPROL","25MG","60","Select","Select",""],["","00046110711","PREMPRO","","28","Select","Select",""],["","49035030603","EQ","","510","Select","Select",""],["","59726019003","BISACODYL","MG","2","Select","Select",""],["","00591565810","CYCLOBENZAPR","10MG","90","Select","Select",""],["","00116200116","CHLORHEX","0.12%","946","Select","Select",""],["","00527512170","NYSTATIN","100000","160","Select","Select",""],["","00904645780","DOK","100MG","60","Select","Select",""],["","00456120130","LINZESS","145MCG","90","Select","Select",""],["","68462029817","CLOTRIM\/BETA","DIPROP","15","Select","Select",""],["","00143924920","AMOX\/K","875-125","20","Select","Select",""],["","68180012202","CEPHALEXIN","500MG","14","Select","Select",""],["","00781261305","AMOXICILLIN","500MG","20","Select","Select",""],["","68645052254","SERTRALINE ","TAB 50MG","30","Select","Select",""],["","42571014401","CELECOXIB ","CAP 200MG","60","Select","Select",""],["","29300013005","HYDROCHLOROT ","CAP 12.5MG","30","Select","Select",""],["","16729013716","CLONAZEPAM ","TAB 1MG","60","Select","Select",""],["","29300022019","MONTELUKAST ","TAB 10MG","30","Select","Select",""],["","16571040250","CETIRIZINE ","TAB 10MG","30","Select","Select",""],["","10702005601","OXYCODONE ","TAB 10MG","120","Select","Select",""],["","57664050658","METOPROL ","TAB 25MG","60","Select","Select",""],["","00781286810","OMEPRAZOLE ","CAP 20MG DR","60","Select","Select",""],["","00046110711","PREMPRO ","TAB ","28","Select","Select",""],["","49035030603","EQ ","POW ","510","Select","Select",""],["","59726019003","BISACODYL ","5 MG","2","Select","Select",""],["","00093342210","CYCLOBENZAPR ","TAB 10MG","90","Select","Select",""],["","00116200116","CHLORHEX ","SOL 0.0012","946","Select","Select",""],["","00527512170","NYSTATIN ","SUS 100000","160","Select","Select",""],["","00904645780","DOK ","CAP 100MG","60","Select","Select",""],["","00456120130","LINZESS ","CAP 145MCG","90","Select","Select",""],["","68462029817","CLOTRIM\/BETA ","CRE DIPROP","15","Select","Select",""],["","00143924920","AMOX\/K ","TAB 875-125","20","Select","Select",""],["","68180012202","CEPHALEXIN ","CAP 500MG","14","Select","Select",""],["","00781261305","AMOXICILLIN ","CAP 500MG","20","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","",""],["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":""}]}]}