{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"TERESA   C BROGGIN","gend":1,"add":"P O BOX 122                                                 ","city":"APPOMATTOX                    ","state":"VA","zip":"24522-0122","dob":"1968-01-24","age":"","mstatus":"","insh":10051720,"cliId":"","pno":4343527012,"cno":4346640401,"email":"","ename":"","eno":"","pphy":"BROSE, TEODORA G","ppno":"","pcpadd":"131 Jones St","pcpcity":"Appomattox                    ","pcpstate":"VA","pcpzip":245229830,"pcpcounty":"","pcpid":"P9307464","pcpname":"PRIVIA MEDICAL GROUP LLC","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"WESTERN\/ CHARLOTTESVILLE","aligned":"","ano":"","add2":"LOT 7                                                       ","add3":"","madd1":"Po Box 122                                                  ","madd2":"                                                            ","madd3":"","mcity":"Appomattox                    ","mstate":"VA","mzip":"24522-0122","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["M54.2","M25.512","E11.51","R11.0","I10","R73.9","F17.210","J45.909","J42","E03.9","R05","E11.9","J44.9","J02.9","J40","J98.01","R09.89","I51.7","R09.81","J96.00","E86.0","R11.2","R42","E78.5","E55.9","R73.09","F41.9","M51.26","M47.816","M47.817","R07.9","S29.9XXA","J20.9","Y04.0XXA","Y92.099","R07.89","E11.22","I13.0","I50.9","E66.01","G47.33","N18.9","G43.919","I51.9","F32.9","R45.851","E11.65","Z79.4","F60.3","Z79.899","Z91.041","F43.23","F29","T14.91XA","R45.0","R25.1","E16.1","E16.2","Z00.00","Z68.43","Z71.3","Z71.82","Z23","G43.909","M94.0","J06.9","R10.9","K21.9","Z79.1","F32.2","E11.42","J44.0","J96.11","R65.10","Z99.81","J44.1","Z88.5","Z88.1","Z72.0","L65.9","J30.2","R60.0","M54.41","G89.29","M79.651","M25.551","E11.40","M54.5","M79.606","M51.27","M48.07","M62.81","R27.0","R33.9","Z53.20","R29.898","R20.0","B37.3","S30.811A","L08.9","M51.36","M48.061","S70.01XA","M54.16","E87.6","R20.2","W19.XXXA","Y92.89","S79.911A","M54.89","M25.60","R53.1","Z88.8","G57.91","M79.604","M79.89","R60.9","M17.11","M25.561"],"date":["2019-01-17","2019-01-17","2020-03-10","2020-08-26","2021-09-22","2019-04-26","2021-09-22","2019-12-22","2019-01-22","2019-12-22","2020-02-29","2021-09-19","2021-07-26","2019-04-24","2019-01-31","2020-02-18","2019-01-31","2019-06-26","2019-02-24","2021-07-26","2019-04-24","2019-04-24","2019-08-24","2021-01-19","2020-10-26","2019-04-26","2019-12-22","2021-08-03","2021-08-03","2021-04-29","2020-02-29","2019-06-26","2019-06-26","2019-06-26","2019-06-26","2019-10-26","2019-08-24","2019-08-24","2019-08-24","2021-09-22","2021-08-14","2019-08-24","2019-08-26","2019-08-26","2019-10-26","2019-10-26","2021-10-08","2021-09-22","2019-12-22","2021-09-19","2020-02-29","2019-12-11","2019-10-26","2019-10-26","2019-11-14","2019-11-14","2019-11-14","2019-11-14","2019-11-25","2021-04-29","2019-11-25","2019-11-25","2019-11-25","2019-12-09","2019-12-22","2019-12-22","2020-02-29","2021-09-22","2019-12-22","2021-03-02","2021-04-19","2020-02-29","2020-03-01","2020-03-01","2021-01-19","2020-03-10","2020-02-29","2021-09-19","2021-04-30","2020-03-10","2020-08-26","2021-10-08","2021-04-09","2021-04-09","2021-04-09","2021-04-09","2021-04-19","2021-07-31","2021-04-28","2021-04-29","2021-08-03","2021-04-29","2021-04-30","2021-04-29","2021-04-29","2021-04-30","2021-08-14","2021-06-24","2021-06-24","2021-06-24","2021-07-31","2021-08-03","2021-08-14","2021-08-14","2021-08-14","2021-08-14","2021-08-14","2021-08-14","2021-08-14","2021-09-07","2021-09-07","2021-09-07","2021-09-22","2021-09-22","2021-10-08","2021-10-08","2021-10-08","2021-10-08","2021-10-08"],"priorHcc":["","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","",""]}},{"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":[["","00088221905","LANTUS","100\/ML","15","Select","Select",""],["","65162010250","GABAPENTIN","300MG","90","Select","Select",""],["","55111029236","SUMATRIPTAN","50MG","18","Select","Select",""],["","87701040750","GNP","1000UNIT","90","Select","Select",""],["","64380080806","IBUPROFEN","600MG","40","Select","Select",""],["","13668001105","CITALOPRAM","40MG","30","Select","Select",""],["","00597007541","SPIRIVA","HANDIHLR","30","Select","Select",""],["","68001036105","MONTELUKAST","10MG","90","Select","Select",""],["","50228010705","METFORMIN","1000MG","60","Select","Select",""],["","69315011710","FUROSEMIDE","40MG","30","Select","Select",""],["","60432060816","PROMETHAZINE","6.25\/5ML","120","Select","Select",""],["","00904404360","FISH","1000MG","60","Select","Select",""],["","30768015605","VITAMIN","1000UNIT","30","Select","Select",""],["","00487950125","ALBUTEROL","0.08%","225","Select","Select",""],["","57237007630","ONDANSETRON","8MG","30","Select","Select",""],["","68180051901","LISINOP\/HCTZ","20-12.5","90","Select","Select",""],["","68382080501","TRAZODONE","50MG","30","Select","Select",""],["","60505257908","ATORVASTATIN","20MG","90","Select","Select",""],["","59746017310","PREDNISONE","10MG","15","Select","Select",""],["","65862064290","AZITHROMYCIN","500MG","5","Select","Select",""],["","60432060616","PROMETH\/COD","6.25-10","120","Select","Select",""],["","59746000103","METHYLPRED","4MG","21","Select","Select",""],["","68001028103","DICLOFENAC","75MG DR","60","Select","Select",""],["","52800048316","LUBRIDERM","SENSITIV","473","Select","Select",""],["","00168001631","HYDROCORT","0.50%","28.35","Select","Select",""],["","00406048501","APAP\/CODEINE","300-60MG","40","Select","Select",""],["","00904679480","ASPIRIN","81MG","90","Select","Select",""],["","31604002677","D3","1000UNIT","90","Select","Select",""],["","50428067309","CVS","1000UNIT","30","Select","Select",""],["","65862053750","LEVOFLOXACIN","500MG","5","Select","Select",""],["","65862042001","SMZ\/TMP","800-160","20","Select","Select",""],["","68001025404","FLUCONAZOLE","200MG","6","Select","Select",""],["","00472022041","CLOTRIMAZOLE","1%","90","Select","Select",""],["","43547039910","CYCLOBENZAPR","5MG","30","Select","Select",""],["","68382005105","MELOXICAM","15MG","30","Select","Select",""],["","00378034501","DIAZEPAM","5MG","2","Select","Select",""],["","00088221905","LANTUS ","INJ 100\/ML","15","Select","Select",""],["","65162010250","GABAPENTIN ","CAP 300MG","90","Select","Select",""],["","55111029236","SUMATRIPTAN ","TAB 50MG","18","Select","Select",""],["","87701040750","GNP ","TAB 1000UNIT","90","Select","Select",""],["","64380080806","IBUPROFEN ","TAB 600MG","40","Select","Select",""],["","13668001105","CITALOPRAM ","TAB 40MG","30","Select","Select",""],["","00597007541","SPIRIVA ","CAP HANDIHLR","30","Select","Select",""],["","68001036105","MONTELUKAST ","TAB 10MG","90","Select","Select",""],["","50228010705","METFORMIN ","TAB 1000MG","60","Select","Select",""],["","69315011710","FUROSEMIDE ","TAB 40MG","30","Select","Select",""],["","60432060816","PROMETHAZINE ","SYP 6.25\/5ML","120","Select","Select",""],["","00904404360","FISH ","CAP 1000MG","60","Select","Select",""],["","30768015605","VITAMIN ","CAP 1000UNIT","30","Select","Select",""],["","00487950125","ALBUTEROL ","NEB 0.00083","225","Select","Select",""],["","57237007630","ONDANSETRON ","TAB 8MG","30","Select","Select",""],["","68180051901","LISINOP\/HCTZ ","TAB 20-12.5","90","Select","Select",""],["","68382080501","TRAZODONE ","TAB 50MG","30","Select","Select",""],["","60505257908","ATORVASTATIN ","TAB 20MG","90","Select","Select",""],["","59746017310","PREDNISONE ","TAB 10MG","15","Select","Select",""],["","65862064290","AZITHROMYCIN ","TAB 500MG","5","Select","Select",""],["","60432060616","PROMETH\/COD ","SOL 6.25-10","120","Select","Select",""],["","59746000103","METHYLPRED ","TAB 4MG","21","Select","Select",""],["","68001028103","DICLOFENAC ","TAB 75MG DR","60","Select","Select",""],["","52800048316","LUBRIDERM ","LOT SENSITIV","473","Select","Select",""],["","00168001631","HYDROCORT ","OIN 0.005","28.35","Select","Select",""],["","00406048501","APAP\/CODEINE ","TAB 300-60MG","40","Select","Select",""],["","00904679480","ASPIRIN ","CHW 81MG","90","Select","Select",""],["","31604002677","D3 ","CAP 1000UNIT","90","Select","Select",""],["","50428067309","CVS ","CAP 1000UNIT","30","Select","Select",""],["","65862053750","LEVOFLOXACIN ","TAB 500MG","5","Select","Select",""],["","94046000174","PEN  NEEDLES  ","MIS 31GX5MM","100","Select","Select",""],["","65862042001","SMZ\/TMP ","TAB 800-160","20","Select","Select",""],["","68001025404","FLUCONAZOLE ","TAB 200MG","6","Select","Select",""],["","00472022041","CLOTRIMAZOLE ","CRE 0.01","90","Select","Select",""],["","43547039910","CYCLOBENZAPR ","TAB 5MG","30","Select","Select",""],["","68382005105","MELOXICAM ","TAB 15MG","30","Select","Select",""],["","00378034501","DIAZEPAM ","TAB 5MG","2","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":""}]}]}