{"version":"0.4","data":[{"t":"Demographics","q":[{"name":" RICHARD S CLAYTON","gend":0,"add":"478 MAPLE STREET","city":"ABINGDON","state":"VA","zip":"24210-9998","dob":"1956-08-08","age":"","mstatus":"","insh":10058657,"cliId":"","pno":"2765919012, 2765919012","cno":"","email":"","ename":"","eno":"","pphy":"CLARITY, GREGORY E","ppno":"               ","pcpadd":"208 Medical Park Blvd, ","pcpcity":"Bristol","pcpstate":"TN","pcpzip":376207343,"pcpcounty":"","pcpid":"","pcpname":"","plan":"VPHP - VIRGINIA PREMIER","program":"MEDICAID","lob":"MLTSS","region":"SOUTHWEST","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"478 MAPLE STREET","madd2":"                                                            ","madd3":"","mcity":"ABINGDON","mstate":"VA","mzip":"24210-9998","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["H25.811","J20.9","J39.8","Z93.0","J38.6","F32.9","M54.5","F90.0","M25.551","M76.31","M25.851","M25.859","M16.51","M87.851","M16.11","F41.9","F33.1","I10","K21.9","F33.0","Z68.33","S25.01XS","Z68.34","M87.051","S32.481S","M21.371","H25.813","Z96.1","J06.9","J44.9","I20.9","H25.812","H26.491"],"date":["2019-05-15","2019-10-10","2019-11-06","2021-05-19","2019-11-06","2020-02-03","2020-02-03","2020-02-03","2021-03-19","2021-03-01","2021-03-01","2021-03-01","2021-05-19","2021-04-16","2021-05-19","2019-12-17","2021-05-03","2021-03-19","2020-12-08","2021-02-15","2021-03-19","2021-01-04","2021-02-15","2021-05-19","2021-05-19","2021-02-15","2019-02-22","2020-11-03","2019-10-10","2019-10-29","2019-10-10","2019-04-04","2019-06-27"],"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":[["","00172572880","FAMOTIDINE ","TAB 20MG","60","Select","Select",""],["","00065924007","DUREZOL ","EMU 0.0005","5","Select","Select",""],["","00527133010","BACLOFEN ","TAB 10MG","60","Select","Select",""],["","47335022090","KETOROLAC ","SOL 0.005","5","Select","Select",""],["","70436005922","BUPROPION ","TAB 150MG SR","60","Select","Select",""],["","65862019299","FLUOXETINE ","CAP 10MG","30","Select","Select",""],["","68382003510","VENLAFAXINE ","CAP 75MG ER","30","Select","Select",""],["","64679096105","AZITHROMYCIN ","TAB 250MG","6","Select","Select",""],["","68180042201","MOXIFLOXACIN ","SOL HCL 0.5%","3","Select","Select",""],["","65162025350","RANITIDINE ","TAB 150MG","60","Select","Select",""],["","00378623105","CITALOPRAM ","TAB 10MG","30","Select","Select",""],["","69097012605","AMLODIPINE ","TAB 2.5MG","30","Select","Select",""],["","59267100002","PFIZER ","INJ COVID-19","0.3","Select","Select",""],["","24208072002","DEXAMETH ","SOL 0.1% OP","10","Select","Select",""],["","68180051902","LISINOP\/HCTZ ","TAB 20-12.5","90","Select","Select",""],["","65162019011","NAPROXEN ","TAB 500MG","60","Select","Select",""],["","60758090810","POLYMYXIN ","SOL TRIMETHP","10","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":""}]}]}