{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"THERESA FOX","gend":1,"add":"2064 HAWKSBILL RD                                           ","city":"MCGAHEYSVILLE                 ","state":"VA","zip":"22840-2135","dob":"1967-05-17","age":"","mstatus":"","insh":10051897,"cliId":"","pno":4433705393,"cno":5402141250,"email":"","ename":"","eno":"","pphy":"BUCKWALTER, VICTOR LEE                                      ","ppno":"","pcpadd":"1151 Keezletown Rd Ste 101","pcpcity":"Weyers Cave                   ","pcpstate":"VA","pcpzip":244862337,"pcpcounty":"","pcpid":"P0117820","pcpname":"CARILION FAMILY MEDICINE WEYERS CAVE","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"WESTERN\/ CHARLOTTESVILLE","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"2064 HAWKSBILL RD                                           ","madd2":"                                                            ","madd3":"","mcity":"MCGAHEYSVILLE                 ","mstate":"VA","mzip":"22840-2135","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["G89.4","Q79.6","M79.7","F41.1","R52","M54.16","F11.90","F32.9","Z72.0","Q79.60","M25.50","R03.0","F41.8","M51.36","N60.19","Z76.89","S80.00XA","M25.561","M25.562","W19.XXXA","Y92.480","J44.9","Z85.41","K58.9","Z88.1","Z88.5","Z91.030","Z91.018","S80.01XA","S80.02XA","S89.91XA","S89.92XA","M23.322","M22.42","M23.331","M94.261","S83.241A","S83.242A","R60.0","R63.4","M94.262","G43.009","M23.203","Z80.41","Z91.89","J45.20","M50.30","M23.204","M25.552","Z13.220","F51.04"],"date":["2019-02-22","2019-09-12","2021-10-21","2019-09-12","2019-02-22","2019-02-22","2019-02-22","2019-09-12","2019-09-12","2021-10-21","2021-10-21","2019-12-20","2021-10-21","2021-10-21","2019-12-20","2019-12-20","2020-02-17","2020-06-16","2020-06-16","2020-02-17","2020-02-17","2020-02-17","2020-02-17","2020-02-17","2020-02-17","2020-02-17","2020-02-17","2020-02-17","2020-03-11","2020-02-17","2020-02-17","2020-02-17","2020-03-11","2020-03-11","2020-03-11","2020-06-16","2020-06-16","2020-06-16","2020-03-11","2020-04-01","2020-06-16","2021-10-21","2020-10-07","2020-10-07","2021-10-21","2021-10-21","2020-10-07","2020-10-07","2021-10-21","2021-04-21","2021-10-21"],"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":[["","00832105515","BACLOFEN","20MG","45","Select","Select",""],["","55111029336","SUMATRIPTAN","100MG","9","Select","Select",""],["","43598029690","PREGABALIN","200MG","90","Select","Select",""],["","57237000830","MIRTAZAPINE","15MG","30","Select","Select",""],["","31722070530","VALACYCLOVIR","1GM","20","Select","Select",""],["","00172392570","DIAZEPAM","2MG","90","Select","Select",""],["","00832105515","BACLOFEN ","TAB 20MG","90","Select","Select",""],["","55111029336","SUMATRIPTAN ","TAB 100MG","9","Select","Select",""],["","43598029690","PREGABALIN ","CAP 200MG","90","Select","Select",""],["","57237000830","MIRTAZAPINE ","TAB 15MG","30","Select","Select",""],["","31722070530","VALACYCLOVIR ","TAB 1GM","20","Select","Select",""],["","00172392570","DIAZEPAM ","TAB 2MG","90","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","",""],["No","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":""}]}]}