{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"JORDAN   D COTHRAN","gend":1,"add":"235   ROCKY  LANE                                           ","city":"DANVILLE                      ","state":"VA","zip":"24540-1671","dob":"1992-09-13","age":"","mstatus":"","insh":10051544,"cliId":"","pno":4347093077,"cno":4347093077,"email":"","ename":"","eno":"","pphy":"ADDIS, DANIEL M                                             ","ppno":"","pcpadd":"219 Parker Rd,2116 W Laburnum Ave Ste 100","pcpcity":"Danville                      ","pcpstate":"VA","pcpzip":245404034,"pcpcounty":"","pcpid":"P0060036","pcpname":"PIEDMONT FAMILY AND OCCUPATIONAL MEDICINE","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"WESTERN\/ CHARLOTTESVILLE","aligned":"","ano":"","add2":"APT I                                                       ","add3":"","madd1":"235   ROCKY  LANE                                           ","madd2":"APT I                                                       ","madd3":"","mcity":"DANVILLE                      ","mstate":"VA","mzip":"24540-1671","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F31.32","R35.0","N94.4","N94.3","N92.6","Z01.419","Z11.8","Z11.4","Z11.59","F31.9","I25.10","E78.5","R06.2","I10","R06.02","Z79.899","R06.00","H57.9","H04.203","B02.9","J06.9","N91.5","J98.8","Z00.00","F29","K21.9","F64.1","Z23","J45.909","R42","S93.401A","R21","I87.2","J30.2","R07.9","D72.829","N63.42","T14.8XXA","W54.0XXA","R30.0","R63.1","K29.00","R11.0","F41.1","R80.9","R06.89","H61.20","J32.9","F41.9","G47.00","H61.23","J01.90","R00.0","N18.9","E66.9","F31.12","F31.81","H61.21","Z13.89"],"date":["2021-01-31","2019-01-15","2019-01-15","2019-01-15","2019-01-15","2021-02-09","2019-01-15","2019-01-15","2019-01-15","2021-11-03","2021-08-09","2021-08-09","2021-07-27","2021-08-09","2021-07-15","2021-10-28","2021-08-09","2019-02-04","2019-02-04","2019-03-26","2019-03-26","2019-03-29","2019-05-28","2019-06-14","2020-07-07","2021-08-09","2021-01-31","2020-06-22","2021-07-27","2021-07-27","2019-12-31","2020-02-07","2020-07-22","2021-04-06","2020-02-24","2021-07-14","2020-03-06","2020-06-22","2020-06-22","2021-03-11","2021-01-18","2021-01-18","2021-01-18","2021-11-03","2021-02-08","2021-04-01","2021-07-15","2021-07-15","2021-07-15","2021-07-15","2021-07-15","2021-07-27","2021-07-27","2021-07-27","2021-07-27","2021-08-23","2021-11-29","2021-10-06","2021-10-07"],"priorHcc":["","","","","","","","","",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":[["","60505083001","MOMETASONE","50MCG","17","Select","Select",""],["","65162044210","MECLIZINE","25MG","28","Select","Select",""],["","43547040610","CLONAZEPAM","0.5MG","28","Select","Select",""],["","68382000905","LAMOTRIGINE","150MG","56","Select","Select",""],["","43547034406","RISPERIDONE","4MG","28","Select","Select",""],["","80681004002","MELATONIN","5MG","84","Select","Select",""],["","62756079813","DIVALPROEX","500MG DR","84","Select","Select",""],["","50111045001","TRAZODONE","150MG","28","Select","Select",""],["","69097017353","IPRATROPIUM\/","ALBUTER","180","Select","Select",""],["","13668008105","MONTELUKAST","10MG","28","Select","Select",""],["","45802057178","FEXOFENADINE","180MG","28","Select","Select",""],["","59310057922","PROAIR","","8.5","Select","Select",""],["","00093221005","SUCRALFATE","1GM","112","Select","Select",""],["","65862056099","PANTOPRAZOLE","40MG","28","Select","Select",""],["","31722055190","LEVOCETIRIZI","5MG","28","Select","Select",""],["","69097015907","MELOXICAM","15MG","28","Select","Select",""],["","00378728590","LEVONOR\/ETHI","ESTRADIO","91","Select","Select",""],["","80777027399","MODERNA","COVID-19","0.5","Select","Select",""],["","64380080438","RANITIDINE","300MG","28","Select","Select",""],["","00093317431","ALBUTEROL","E","8.5","Select","Select",""],["","00781808926","AZITHROMYCIN","250MG","6","Select","Select",""],["","59651021430","AZELASTINE","0.10%","30","Select","Select",""],["","58160084252","BOOSTRIX","","0.5","Select","Select",""],["","62559043130","HYDROCORTISO","2.50%","30","Select","Select",""],["","65862018730","ONDANSETRON","4MG","20","Select","Select",""],["","53746027201","SMZ\/TMP","800-160","10","Select","Select",""],["","00168008031","HYDROCORT","2.50%","30","Select","Select",""],["","60505083001","MOMETASONE ","SPR 50MCG","17","Select","Select",""],["","65162044210","MECLIZINE ","TAB 25MG","28","Select","Select",""],["","43547040610","CLONAZEPAM ","TAB 0.5MG","28","Select","Select",""],["","68382000905","LAMOTRIGINE ","TAB 150MG","56","Select","Select",""],["","43547034406","RISPERIDONE ","TAB 4MG","28","Select","Select",""],["","80681004002","MELATONIN ","TAB 5MG","84","Select","Select",""],["","62756079813","DIVALPROEX ","TAB 500MG DR","84","Select","Select",""],["","50111045001","TRAZODONE ","TAB 150MG","28","Select","Select",""],["","69097017353","IPRATROPIUM\/ ","SOL ALBUTER","180","Select","Select",""],["","13668008105","MONTELUKAST ","TAB 10MG","28","Select","Select",""],["","45802057178","FEXOFENADINE ","TAB 180MG","28","Select","Select",""],["","59310057922","PROAIR ","AER ","8.5","Select","Select",""],["","00093221005","SUCRALFATE ","TAB 1GM","112","Select","Select",""],["","65862056099","PANTOPRAZOLE ","TAB 40MG","28","Select","Select",""],["","31722055190","LEVOCETIRIZI ","TAB 5MG","28","Select","Select",""],["","69097015907","MELOXICAM ","TAB 15MG","28","Select","Select",""],["","00378728590","LEVONOR\/ETHI ","TAB ESTRADIO","91","Select","Select",""],["","80777027399","MODERNA ","INJ COVID-19","0.5","Select","Select",""],["","00904662735","EAR ","DRO 0.065","15","Select","Select",""],["","64380080438","RANITIDINE ","TAB 300MG","28","Select","Select",""],["","00093317431","ALBUTEROL ","FAT E","8.5","Select","Select",""],["","00781808926","AZITHROMYCIN ","TAB 250MG","6","Select","Select",""],["","59651021430","AZELASTINE ","SPR 0.001","30","Select","Select",""],["","58160084252","BOOSTRIX ","INJ ","0.5","Select","Select",""],["","62559043130","HYDROCORTISO ","CRE 0.025","30","Select","Select",""],["","65862018730","ONDANSETRON ","TAB 4MG","20","Select","Select",""],["","53746027201","SMZ\/TMP ","TAB 800-160","10","Select","Select",""],["","00168008031","HYDROCORT ","CRE 0.025","30","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":""}]}]}