{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"DUANE   M CLAY","gend":0,"add":"545 TERRILL DRIVE                                           ","city":"WIRTZ                         ","state":"VA","zip":"24184-4306","dob":"1999-05-07","age":"","mstatus":"","insh":10054512,"cliId":"","pno":5404201928,"cno":5407190399,"email":"","ename":"","eno":"","pphy":"HAYES, BRITTANY B                                           ","ppno":"","pcpadd":"390 S Main St Ste 201","pcpcity":"Rocky Mount                   ","pcpstate":"VA","pcpzip":241511767,"pcpcounty":"","pcpid":"P0117675","pcpname":"CARILION MEDICAL ASSOCIATES ROCKY MOUNT","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"ROANOKE\/ ALLEGHANY","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"545 TERRILL DRIVE                                           ","madd2":"                                                            ","madd3":"","mcity":"WIRTZ                         ","mstate":"VA","mzip":"24184-4306","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F41.1","F84.5","S86.892A","S86.891A","E66.9","Z68.37","R03.0","I10","F39","Z79.899","Z23"],"date":["2021-09-17","2019-02-05","2020-01-24","2020-01-24","2021-01-28","2021-01-28","2021-01-28","2021-09-17","2021-09-17","2021-04-26","2021-09-17"],"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":[["","65862052405","GABAPENTIN","800MG","60","Select","Select",""],["","68180098003","LISINOPRIL","10MG","30","Select","Select",""],["","65862052405","GABAPENTIN ","TAB 800MG","60","Select","Select",""],["","68180098003","LISINOPRIL ","TAB 10MG","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","",""],["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":""}]}]}