{"version":"0.4","data":[{"t":"Demographics","q":[{"name":" TEVIN D GRASTY","gend":0,"add":"1000 LAWLESS CREEK ROAD","city":"BLAIRS","state":"VA","zip":"24527-2258","dob":"1992-09-09","age":"","mstatus":"","insh":10052602,"cliId":"","pno":"4347704031, 4344831274","cno":4344328488,"email":"","ename":"","eno":"","pphy":"UNKNOWN PROVIDER QNXT PCP","ppno":"               ","pcpadd":"UNKNOWN STREET, ","pcpcity":"RICHMOND","pcpstate":"VA","pcpzip":232190000,"pcpcounty":"","pcpid":"","pcpname":"","plan":"VPHP - VIRGINIA PREMIER","program":"MEDICAID","lob":"MLTSS","region":"WESTERN","aligned":"","ano":"","add2":"LOT 9","add3":"","madd1":"1000 LAWLESS CREEK ROAD","madd2":"LOT 9","madd3":"","mcity":"BLAIRS","mstate":"VA","mzip":"24527-2258","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F33.1","S31.109A","S32.058B","S32.19XB","W34.00XA","Z79.899","R11.2","R11.0","R19.7","E87.6","Z72.0","Z98.890","R26.9","M54.5","M62.81","R29.898","W34.00XD","S34.3XXD","F33.2","K52.9","K56.609","R10.84","K92.1","K62.5","K59.09","K29.00","F32.89","R45.851","F32.9","S32.058A","S32.19XA","R33.9","R05","R03.0","R00.0","R73.9","F17.200","F12.10","F10.10","R74.0","R10.9","M51.9","M79.605","M54.89","Z87.891","R10.11","R11.10","M79.2","R29.818","R20.0","R53.1","N31.9","F11.20","N39.0","I10","R09.89","G89.29","M54.42","M54.41","S70.02XA","M79.604","R21","L29.8","F17.210","Z88.8","Z20.822","D13.1","R41.82","F12.20","S31.609A","S32.059A","S32.301A","R15.9","S39.91XA","M54.9","F43.0","S34.125D","S34.104D","X58.XXXD","K59.2","E44.0","Z76.0","N47.5","N48.89","A64","N47.8","S34.139A","R11.11","K56.7","Z20.2","K29.70","R61","S34.103D","X58.XXXA","N31.2","E55.9","R52","F10.20","S32.058D","S32.19XD","F11.23","S31.030A","S32.10XB","S32.059B","X95.9XXA","Y92.9","X93.XXXA","G82.20","S32.301B","T14.8XXA","G89.21","S32.058S","S32.19XS","M25.552","T14.90XA","W34.00XS","Z74.09","K56.600","M79.10","R63.0","S34.105A","G89.11","G83.4","X93.XXXD","G82.22","S32.019D","S32.10XD","Z72.89","F06.4","F43.29","M54.16","K59.00","G47.00","K64.9","K21.9"],"date":["2019-09-03","2019-09-11","2019-09-11","2019-09-11","2019-12-03","2021-02-28","2021-02-28","2021-02-09","2019-12-17","2019-12-17","2021-02-28","2019-12-17","2020-04-06","2020-04-06","2020-04-06","2020-04-06","2020-12-18","2021-02-25","2020-09-01","2020-06-10","2020-11-07","2021-02-09","2021-02-25","2021-02-26","2021-02-26","2021-02-28","2020-01-02","2019-07-16","2021-01-29","2020-01-29","2019-09-12","2019-10-21","2019-09-24","2019-09-24","2020-02-20","2019-09-24","2019-12-17","2019-09-24","2019-09-24","2019-09-24","2021-02-28","2020-02-19","2020-02-19","2020-02-20","2020-11-28","2020-07-23","2020-07-23","2020-12-18","2019-09-12","2019-09-12","2019-09-30","2019-10-24","2019-11-26","2019-11-26","2019-11-26","2019-12-12","2020-03-11","2020-01-29","2020-01-17","2020-01-17","2020-03-11","2020-12-08","2020-12-08","2021-02-28","2021-02-28","2021-01-29","2021-02-03","2019-07-16","2019-07-17","2019-09-11","2019-09-13","2019-09-13","2019-09-11","2019-09-11","2019-10-14","2019-12-03","2019-10-02","2019-10-02","2019-10-02","2019-10-02","2019-10-02","2019-10-14","2019-11-12","2020-06-03","2020-05-01","2020-06-03","2020-06-03","2020-07-23","2020-11-07","2020-11-28","2021-02-03","2021-02-28","2019-09-25","2019-09-24","2019-09-30","2019-09-30","2021-01-31","2019-07-16","2019-11-04","2019-11-04","2019-11-26","2019-09-11","2019-09-11","2019-09-11","2019-09-11","2019-09-11","2019-09-11","2019-09-11","2019-09-11","2019-09-12","2019-11-18","2019-11-18","2019-11-18","2020-01-17","2020-01-17","2020-05-12","2020-05-12","2020-11-07","2021-01-31","2021-01-31","2019-09-13","2019-09-13","2019-09-17","2019-09-17","2019-09-17","2019-09-17","2019-09-17","2019-09-17","2019-09-17","2019-09-19","2019-11-04","2019-12-12","2020-01-02","2020-01-02","2020-01-02"],"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":[["","00591352530","LIDOCAINE ","PAD 0.05","30","Select","Select",""],["","65862056090","PANTOPRAZOLE ","TAB 40MG","30","Select","Select",""],["","65862001205","SERTRALINE ","TAB 50MG","30","Select","Select",""],["","00472034356","HYDROCORT ","CRE 0.01","28","Select","Select",""],["","27808003502","HYDROCO\/APAP ","TAB 5-325MG","10","Select","Select",""],["","69097052444","DICLOFENAC ","GEL 0.01","200","Select","Select",""],["","52817033200","CYCLOBENZAPR ","TAB 10MG","90","Select","Select",""],["","00904671960","ACETAMINOPHE ","TAB 325MG","120","Select","Select",""],["","68462012705","GABAPENTIN ","TAB 800MG","90","Select","Select",""],["","00363010412","PAIN ","TAB 325MG","120","Select","Select",""],["","65162074510","PROMETHAZINE ","TAB 12.5MG","15","Select","Select",""],["","65862085901","FAMOTIDINE ","TAB 20MG","20","Select","Select",""],["","11917011818","D3 ","CAP 2000UNIT","30","Select","Select",""],["","55111018015","TIZANIDINE ","TAB 4MG","90","Select","Select",""],["","00378064110","PREDNISONE ","TAB 10MG","20","Select","Select",""],["","70710122600","AMITRIPTYLIN ","TAB 25MG","30","Select","Select",""],["","68382013201","TAMSULOSIN ","CAP 0.4MG","30","Select","Select",""],["","11917017096","VITAMIN ","CAP 2000UNIT","30","Select","Select",""],["","65862039010","ONDANSETRON ","TAB 4MG ODT","12","Select","Select",""],["","00904645760","DOK ","CAP 100MG","60","Select","Select",""],["","00093078710","ATENOLOL ","TAB 25MG","30","Select","Select",""],["","45802006435","TRIAMCINOLON ","CRE 0.001","15","Select","Select",""],["","00527133001","BACLOFEN ","TAB 10MG","90","Select","Select",""],["","50111043302","TRAZODONE ","TAB 50MG","30","Select","Select",""],["","00591079501","DICYCLOMINE ","TAB 20MG","20","Select","Select",""],["","65862019201","FLUOXETINE ","CAP 10MG","30","Select","Select",""],["","00363000260","EASY-LAX ","TAB 8.6-50MG","40","Select","Select",""],["","27241009903","DULOXETINE ","CAP 60MG","30","Select","Select",""],["","00406055201","OXYCODONE ","TAB 5MG","90","Select","Select",""],["","45802086803","POLYETH ","POW 3350 NF","510","Select","Select",""],["","69547035302","NARCAN ","SPR ","2","Select","Select",""],["","68462018147","CLOTRIMAZOLE ","CRE 0.01","45","Select","Select",""],["","00574705012","BISACODYL ","SUP 10MG","30","Select","Select",""],["","68382079201","ACYCLOVIR ","TAB 800MG","50","Select","Select",""],["","50428672550","ANTI-DIARRHE ","TAB 2MG","12","Select","Select",""],["","51224012230","AZITHROMYCIN ","TAB 500MG","2","Select","Select",""],["","45802048678","DOCUSATE ","CAP 100MG","14","Select","Select",""],["","64380080438","RANITIDINE ","TAB 300MG","30","Select","Select",""],["","65162062711","TRAMADOL ","TAB 50MG","40","Select","Select",""],["","68180012202","CEPHALEXIN ","CAP 500MG","40","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","",""],["No","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":""}]}]}