{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MILDRED   J KIMBLE","gend":1,"add":"PO BOX 495                                                  ","city":"HARRISONBURG                  ","state":"VA","zip":"22803-0495","dob":"1961-08-02","age":"","mstatus":"","insh":10053107,"cliId":"","pno":5402710889,"cno":5402710889,"email":"","ename":"","eno":"","pphy":"PENCE, ROBERT P                                             ","ppno":"","pcpadd":"15 Killdeer Ln","pcpcity":"Dayton                        ","pcpstate":"VA","pcpzip":228219745,"pcpcounty":"","pcpid":"P0117891","pcpname":"CARILION FAMILY MEDICINE DAYTON","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"WESTERN\/ CHARLOTTESVILLE","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"PO BOX 495                                                  ","madd2":"                                                            ","madd3":"","mcity":"HARRISONBURG                  ","mstate":"VA","mzip":"22803-0495","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["M25.562","M17.12","N20.0","R03.0","E66.01","M17.11","R26.2","M25.662","R26.89","M17.0","E83.52","E78.00","Z01.810","Z01.818","Z68.41","M21.162","E21.0","I10","E78.5","Z23","Z79.899","Z87.442","Z82.49","M21.161","Z47.1","Z96.652","M79.89","G89.29","M25.861","R26.9","R21","Z12.31"],"date":["2020-10-30","2020-04-24","2020-03-16","2019-03-26","2019-10-23","2019-10-01","2020-01-24","2019-10-01","2020-10-30","2019-10-23","2019-10-14","2019-10-23","2019-10-14","2019-10-14","2019-10-23","2019-10-23","2019-10-23","2019-10-23","2019-10-23","2019-10-23","2019-10-23","2019-10-23","2019-10-23","2019-10-23","2020-04-24","2021-10-27","2019-11-07","2019-12-06","2020-01-24","2020-04-24","2021-01-06","2021-01-08"],"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":[["","65162019050","NAPROXEN","500MG","60","Select","Select",""],["","50428030894","MELATONIN","10MG","30","Select","Select",""],["","33342032915","TRIAMCINOLON","0.10%","45","Select","Select",""],["","49281042050","FLUZONE","2020-21","0.5","Select","Select",""],["","65162083366","DICLOFENAC","1%","100","Select","Select",""],["","45802025735","MOMETASONE","0.10%","30","Select","Select",""],["","65162019050","NAPROXEN ","TAB 500MG","60","Select","Select",""],["","50428030894","MELATONIN ","CAP 10MG","30","Select","Select",""],["","33342032915","TRIAMCINOLON ","CRE 0.001","45","Select","Select",""],["","49281042050","FLUZONE ","INJ 2020-21","0.5","Select","Select",""],["","65162083366","DICLOFENAC ","GEL 0.01","100","Select","Select",""],["","45802025735","MOMETASONE ","CRE 0.001","30","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":""}]}]}