{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"DORIS   V BURFORD","gend":1,"add":"109 POTTS LANE                                              ","city":"MONROE                        ","state":"VA","zip":"24574-2134","dob":"1948-01-15","age":"","mstatus":"","insh":10051612,"cliId":"","pno":4349294569,"cno":4349294569,"email":"","ename":"","eno":"","pphy":"GUANZON, VERNA                                              ","ppno":"","pcpadd":"131 Jones St","pcpcity":"Appomattox                    ","pcpstate":"VA","pcpzip":245229830,"pcpcounty":"","pcpid":"P9307466","pcpname":"PRIVIA MEDICAL GROUP LLC","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"WESTERN\/ CHARLOTTESVILLE","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"109 POTTS LANE                                              ","madd2":"                                                            ","madd3":"","mcity":"MONROE                        ","mstate":"VA","mzip":"24574-2134","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","1","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["N39.41","L60.0","L60.2","B35.1","M79.674","M79.675","E11.9","E03.9","E78.00","I10","R60.0","H25.13","E78.2","E55.9","Z28.21","R63.4","H26.9","L60.8","G56.02","Z12.11","K59.09","R26.81","N64.89","R92.8","N60.11","R19.5","Z71.9","R12","R68.89","E11.65","N64.9","Z23","L72.3","R85.89","Z13.31"],"date":["2021-11-02","2021-10-13","2021-10-13","2021-10-13","2021-10-13","2021-10-13","2021-02-03","2021-10-19","2019-06-10","2021-10-19","2019-06-10","2019-10-25","2021-09-14","2021-09-14","2021-10-19","2021-10-19","2019-12-16","2021-10-13","2020-06-16","2020-06-16","2020-06-16","2020-06-26","2021-03-24","2021-03-24","2020-09-01","2020-11-03","2020-11-03","2021-02-17","2021-02-03","2021-09-14","2021-03-24","2021-04-12","2021-07-14","2021-09-14","2021-10-19"],"priorHcc":[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":[["","45802065078","LORATADINE","10MG","30","Select","Select",""],["","24208046570","ADULT","OCUVITE","30","Select","Select",""],["","68180072103","AMLODIPINE","10MG","30","Select","Select",""],["","69452015120","VITAMIN","50000UNT","5","Select","Select",""],["","53746051101","SPIRONOLACT","25MG","30","Select","Select",""],["","00378021610","FUROSEMIDE","40MG","30","Select","Select",""],["","69097015807","MELOXICAM","7.5MG","30","Select","Select",""],["","70377002911","ATORVASTATIN","40MG","30","Select","Select",""],["","55111032001","GLIMEPIRIDE","1MG","30","Select","Select",""],["","65862085901","FAMOTIDINE","20MG","60","Select","Select",""],["","31722070290","LOSARTAN","100MG","30","Select","Select",""],["","67877056110","METFORMIN","500MG","60","Select","Select",""],["","45802048678","DOCUSATE","100MG","60","Select","Select",""],["","00378181377","LEVOTHYROXIN","125MCG","30","Select","Select",""],["","50742061510","METOPROL","25MG ER","30","Select","Select",""],["","80777027399","MODERNA","COVID-19","0.5","Select","Select",""],["","50428606624","STOOL","100MG","60","Select","Select",""],["","59779061239","ALLERGY","10MG","30","Select","Select",""],["","45802065078","LORATADINE ","TAB 10MG","30","Select","Select",""],["","24208046570","ADULT ","CAP OCUVITE","30","Select","Select",""],["","68180072103","AMLODIPINE ","TAB 10MG","30","Select","Select",""],["","69452015120","VITAMIN ","CAP 50000UNT","5","Select","Select",""],["","53746051101","SPIRONOLACT ","TAB 25MG","30","Select","Select",""],["","00378021610","FUROSEMIDE ","TAB 40MG","30","Select","Select",""],["","69097015807","MELOXICAM ","TAB 7.5MG","30","Select","Select",""],["","70377002911","ATORVASTATIN ","TAB 40MG","30","Select","Select",""],["","55111032001","GLIMEPIRIDE ","TAB 1MG","30","Select","Select",""],["","65862085901","FAMOTIDINE ","TAB 20MG","60","Select","Select",""],["","31722070290","LOSARTAN ","TAB 100MG","30","Select","Select",""],["","00378181377","LEVOTHYROXIN ","TAB 125MCG","30","Select","Select",""],["","68382075810","METFORMIN ","TAB 500MG","60","Select","Select",""],["","45802048678","DOCUSATE ","CAP 100MG","60","Select","Select",""],["","50742061510","METOPROL ","TAB 25MG ER","30","Select","Select",""],["","80777027399","MODERNA ","INJ COVID-19","0.5","Select","Select",""],["","50428606624","STOOL ","CAP 100MG","60","Select","Select",""],["","59779061239","ALLERGY ","TAB 10MG","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":[[["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":""}]}]}