{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"SUE   E HUNDLEY","gend":1,"add":"70   STOKESLAND  AVENUE                                     ","city":"DANVILLE                      ","state":"VA","zip":"24541-5311","dob":"1963-01-28","age":"","mstatus":"","insh":10052232,"cliId":"","pno":4344212960,"cno":4344212960,"email":"","ename":"","eno":"","pphy":"WINFIELD II, ALBERT C","ppno":"","pcpadd":"441 Piney Forest Rd,Ste A","pcpcity":"DANVILLE                      ","pcpstate":"VA","pcpzip":245404154,"pcpcounty":"","pcpid":"P9443093","pcpname":"PROVIDENCE FAMILY AND SPORTS MEDICINE INC","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"WESTERN\/ CHARLOTTESVILLE","aligned":"","ano":"","add2":"APT 1C                                                      ","add3":"","madd1":"70   STOKESLAND  AVENUE                                     ","madd2":"APT 1C                                                      ","madd3":"","mcity":"DANVILLE                      ","mstate":"VA","mzip":"24541-5311","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F40.10","F41.1","F43.10","R10.9","G62.9","F34.1","F40.01","Z00.00","Z68.24","K59.00","J02.9","F41.9","F32.9","L25.9","L29.9","Z01.419","Z12.12","Z12.31","E55.9","E78.5","H69.81","E04.2","Z13.89","R52","Z00.01","E53.8","K58.9","K21.9","Z13.820","Z11.51","R14.0","K59.09","Z71.9"],"date":["2021-11-30","2021-11-30","2021-11-30","2019-09-16","2021-07-19","2021-07-19","2020-08-25","2019-09-16","2021-03-10","2021-03-10","2019-10-29","2020-03-02","2020-03-02","2019-11-11","2019-11-11","2021-06-28","2021-06-28","2021-06-28","2021-03-10","2021-03-10","2020-03-02","2020-03-02","2021-03-10","2021-07-19","2021-03-10","2021-03-10","2021-07-19","2021-10-12","2021-05-17","2021-06-28","2021-10-12","2021-10-12","2021-10-12"],"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":[["","69452015120","VITAMIN","50000UNT","8","Select","Select",""],["","10370010150","BUPROPN","150MG XL","30","Select","Select",""],["","00054327099","FLUTICASONE","50MCG","16","Select","Select",""],["","13668013701","ESCITALOPRAM","20MG","90","Select","Select",""],["","00093816601","QUETIAPINE","50MG","30","Select","Select",""],["","65862052305","GABAPENTIN","600MG","90","Select","Select",""],["","00456120330","LINZESS","72MCG","30","Select","Select",""],["","59651000305","OMEPRAZOLE","40MG","90","Select","Select",""],["","65862032904","ALENDRONATE","70MG","12","Select","Select",""],["","43547026910","ROPINIROLE","0.5MG","90","Select","Select",""],["","60505264907","TIZANIDINE","4MG","180","Select","Select",""],["","00093005805","TRAMADOL","50MG","30","Select","Select",""],["","70461032003","FLUCLVX","2020-21","0.5","Select","Select",""],["","33342032915","TRIAMCINOLON","0.10%","15","Select","Select",""],["","50428041670","ALLRGY","10-240MG","90","Select","Select",""],["","64380080438","RANITIDINE","300MG","30","Select","Select",""],["","65862085901","FAMOTIDINE","20MG","90","Select","Select",""],["","69452015120","VITAMIN ","CAP 50000UNT","8","Select","Select",""],["","10370010150","BUPROPN ","TAB 150MG XL","30","Select","Select",""],["","00054327099","FLUTICASONE ","SPR 50MCG","16","Select","Select",""],["","13668013701","ESCITALOPRAM ","TAB 20MG","90","Select","Select",""],["","00093816601","QUETIAPINE ","TAB 50MG","30","Select","Select",""],["","65862052305","GABAPENTIN ","TAB 600MG","90","Select","Select",""],["","00456120330","LINZESS ","CAP 72MCG","30","Select","Select",""],["","00093005805","TRAMADOL ","TAB 50MG","30","Select","Select",""],["","60505264907","TIZANIDINE ","CAP 4MG","42","Select","Select",""],["","59651000305","OMEPRAZOLE ","CAP 40MG","90","Select","Select",""],["","65862032904","ALENDRONATE ","TAB 70MG","12","Select","Select",""],["","43547026910","ROPINIROLE ","TAB 0.5MG","90","Select","Select",""],["","70461032003","FLUCLVX ","INJ 2020-21","0.5","Select","Select",""],["","33342032915","TRIAMCINOLON ","CRE 0.001","15","Select","Select",""],["","50428041670","ALLRGY ","TAB 10-240MG","90","Select","Select",""],["","64380080438","RANITIDINE ","TAB 300MG","30","Select","Select",""],["","65862085901","FAMOTIDINE ","TAB 20MG","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","",""],["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":""}]}]}