{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"CHARLES CUSTER","gend":0,"add":"19300 WILLOW BREEZE LN                                      ","city":"BROADWAY                      ","state":"VA","zip":"22815-2022","dob":"1966-02-05","age":"","mstatus":"","insh":10051678,"cliId":"","pno":5402097155,"cno":"","email":"","ename":"","eno":"","pphy":"LONG, KEITH C                                               ","ppno":"","pcpadd":"1661 S Main St,Ste 120","pcpcity":"Harrisonburg                  ","pcpstate":"VA","pcpzip":228012728,"pcpcounty":"","pcpid":"P9059084","pcpname":"SRMH TIMBER WAY HEALTH CENTER","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"WESTERN\/ CHARLOTTESVILLE","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"19300 WILLOW BREEZE LN                                      ","madd2":"                                                            ","madd3":"","mcity":"BROADWAY                      ","mstate":"VA","mzip":"22815-2022","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["E11.9","Z79.4","J44.9","F17.200","Z12.11","R03.0","J06.9","R09.89","F17.210","R07.9","K43.9","K76.0","L02.215","L03.116","L02.214","Z87.438","L03.315","Z68.42","N17.9","G47.33","E66.01","E86.0","Z82.49","J43.1","E11.65","Z23","Z00.00"],"date":["2021-04-06","2021-04-06","2021-04-06","2021-04-06","2019-02-21","2021-04-06","2019-03-21","2019-03-21","2019-03-24","2019-03-21","2019-03-24","2019-03-24","2019-03-27","2019-04-03","2019-03-24","2019-10-28","2019-03-24","2019-03-24","2019-03-24","2021-11-12","2019-03-24","2019-03-24","2019-03-24","2019-03-27","2019-07-25","2020-12-03","2020-05-26"],"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":[["","00169643810","LEVEMIR","FLEXTOUC","30","Select","Select",""],["","08496310401","EASY","31GX1\/4\"","100","Select","Select",""],["","56151210201","PEN NEEDLES","31GX6MM","100","Select","Select",""],["","08470359001","UNIFINE","31GX6MM","60","Select","Select",""],["","23155010410","METFORMIN","1000MG","60","Select","Select",""],["","00169643810","LEVEMIR ","INJ FLEXTOUC","30","Select","Select",""],["","08496310401","EASY ","MIS 31GX1\/4\"","100","Select","Select",""],["","67877056305","METFORMIN ","TAB 1000MG","60","Select","Select",""],["","56151210201","PEN  NEEDLES  ","MIS 31GX6MM","100","Select","Select",""],["","08470359001","UNIFINE ","MIS 31GX6MM","60","Select","Select",""],["","59267100001","PFIZER ","INJ COVID-19","0.3","Select","Select",""],["","70461032103","FLUCLVX ","INJ 2021-22","0.5","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":""}]}]}