{"version":"0.4","data":[{"t":"Demographics","q":[{"name":" CARL EVANS","gend":0,"add":"P O BOX 741","city":"BLUEFIELD","state":"VA","zip":"24605-0741","dob":"1965-01-10","age":"","mstatus":"","insh":10059566,"cliId":"","pno":"2764330240, 2764330240","cno":2763221551,"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":"SOUTHWEST","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"311 Circle Dr","madd2":"                                                            ","madd3":"","mcity":"Bluefield","mstate":"VA","mzip":"24605-1303","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["S22.41XA","G61.0","D72.1","J90","J43.2","F32.9","J94.8","F17.210","I72.4","M84.48XA","R07.9","R09.02","R06.02","J96.01","S22.41XK","J44.9","J93.9","Z93.8","R91.8","Z79.01","R26.89","F17.200","Z71.6","Z99.3","J43.9","G62.9","J20.9","S22.41XG","Z43.8","J42","X58.XXXA","Z85.118","Z79.899","J86.9","S99.922A","L08.9","I87.2","R05","R73.9","J91.8","R06.00","S90.935A","M79.672","N52.9","Z87.81","J98.19","J98.4","R68.89","Z01.89","M62.81","R26.81","G65.0","R94.31","R10.11","R10.811","R07.89","R07.1","R00.0","G89.29","J98.11","S91.105A","J95.812","T81.82XA","M84.48XS","F12.90","M54.9","R53.81","Z72.89","Z79.891"],"date":["2019-06-11","2020-01-29","2019-06-11","2019-12-02","2019-06-11","2019-06-11","2019-11-21","2019-12-02","2019-06-11","2019-06-12","2019-06-11","2019-11-22","2019-11-16","2019-11-18","2019-11-18","2020-01-29","2019-11-25","2019-11-25","2019-11-25","2020-01-29","2019-08-21","2019-06-07","2019-06-11","2019-06-11","2019-11-16","2020-01-29","2019-11-14","2019-11-18","2019-11-26","2020-02-12","2019-06-07","2019-06-07","2019-11-15","2019-11-17","2020-01-29","2020-01-29","2020-01-29","2020-02-12","2019-02-25","2019-11-15","2019-11-15","2020-02-02","2020-02-02","2019-04-12","2019-11-15","2019-11-22","2019-11-23","2019-11-26","2019-06-12","2019-12-02","2019-08-21","2019-12-02","2019-11-21","2019-06-10","2019-06-10","2019-06-11","2019-06-11","2019-11-21","2019-11-25","2019-11-26","2020-02-02","2019-11-15","2019-11-15","2019-11-15","2019-11-15","2019-11-15","2019-11-15","2019-11-15","2019-11-15"],"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":[["","51991074710","DULOXETINE ","CAP 30MG","30","Select","Select",""],["","00093171901","WARFARIN ","TAB 7.5MG","30","Select","Select",""],["","00536589453","NICOTINE ","DIS 7MG\/24HR","14","Select","Select",""],["","69452015120","VITAMIN ","CAP 50000UNT","4","Select","Select",""],["","66993001968","ALBUTEROL ","AER HFA","18","Select","Select",""],["","00597007541","SPIRIVA ","CAP HANDIHLR","30","Select","Select",""],["","57664037718","TRAMADOL ","TAB 50MG","30","Select","Select",""],["","53746019005","NAPROXEN ","TAB 500MG","30","Select","Select",""],["","42806000501","OXYCODONE ","TAB 5MG","20","Select","Select",""],["","65862018601","CLINDAMYCIN ","CAP 300MG","56","Select","Select",""],["","53746011005","HYDROCO\/APAP ","TAB 10-325MG","20","Select","Select",""],["","00186037020","SYMBICORT ","AER 160-4.5","10.2","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":""}]}]}