{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MARIA   E COUTS","gend":1,"add":"1015 PALEMTTO AVENUE NW","city":"ROANOKE","state":"VA","zip":"24017-2935","dob":"1966-02-25","age":"","mstatus":"","insh":10063199,"cliId":"","pno":5408180535,"cno":5408180535,"email":"","ename":"","eno":"","pphy":"PAGAN, ELVIS R","ppno":5402243870,"pcpadd":"615 McDowell Ave NW, ","pcpcity":"Roanoke","pcpstate":"VA","pcpzip":240161225,"pcpcounty":"","pcpid":"","pcpname":"","plan":"VPHP","program":"MEDICAID","lob":"MLTSS","region":"ROANOKE\/ ALLEGHANY","aligned":"","ano":5407932959,"add2":"APT A","add3":"","madd1":"1015 PALEMTTO AVENUE NW","madd2":"APT A","madd3":"","mcity":"ROANOKE","mstate":"VA","mzip":"24017-2935","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["I45.81","R94.31","R10.9","Z96.0","F31.31","Z79.899","Z51.81","F11.20","R07.9","F19.94","E11.40","E11.649","F33.2","E11.319","F14.20","R45.851","J43.9","B96.20","Z59.0","I10","N39.0","B19.20","F10.20","Z09","N13.9","F11.23","E78.2","B18.2","J44.9","Z76.0","Z11.1","Z78.9","Z91.89","R39.15","N89.8","R68.89","R19.7","J18.9","A41.9","G93.40","J96.01","J93.12","R65.21","J93.9","F19.10","R78.81","R52","E10.10","F17.200","E10.65","R51","R07.89","K21.9","Z86.73","F31.9","Z79.4","F17.210","F31.63","F31.30","F32.9","F31.62","E11.65","Z71.6","A64","E13.42","T40.1X1A","Y92.009","F10.10","I95.9","R11.0","E11.9","E78.00","R63.4","R91.8","Z03.89","K59.00","R74.8","F60.3","K52.9","F41.8","M25.532","F15.10","F12.20","F11.99","F11.21","E11.42","N39.46","Z01.818","F41.1","K74.00","R10.13","R14.0","N87.0","N30.01","R00.0","R45.850","N30.00","B19.9","B96.29","N20.1","Z18.89","F25.0","I48.91","Z48.03","Z72.0","R11.2","R53.83","R05","Z20.828","F31.12","R19.00","R22.32","M79.89","F19.90","Z11.9","F60.0","R44.2","R07.81","J18.1","F11.90","Z01.419","N92.6","N64.4","M25.551","G89.29","Z12.31","Z12.11","Z71.89","T50.904A","N13.1","N13.39","N10","D72.829","G93.49","F14.10","F11.10","Z98.890","R45.89","J95.811","E87.70","Z46.82","Z93.8","E83.42","J96.91","E11.11","R23.4","I49.8","S09.90XA","S00.03XA","F10.920","F19.20","F31.32","B35.1","Z11.52","R07.1","X58.XXXA","A41.59","N13.6","M54.9","F19.231","N28.89","E83.51","J47.9","R09.89","E10.11","J44.0","J15.4","F10.239","W10.8XXA","Y93.89","Y92.098","M54.5","F10.120","K86.89","I86.8","Z90.49","R87.610","E78.5","Z00.8","F41.9","K31.9","K29.00","D12.5","E10.9","Z79.82","K70.31","R06.00","R91.1","R87.810","N13.30","Z86.19","K75.9","R11.10","A40.3","G72.81","J13","J90","J96.02","Z23","E87.4","D69.6","E10.319","E83.39","E87.8","A59.9","N17.9","Z43.8","R06.02","W19.XXXA","M54.31","E08.40","R10.2","Z20.2","Z71.1","Z87.42","E10.40","E10.649","F25.9","Z91.14","I95.2","T42.6X5A","T40.495A","Z87.891","S29.8XXA","F05","R00.1","F15.90","I45.19","I51.7","R53.81","R41.0","J06.9","F20.9","B96.1","E55.9","F10.129","F33.9","F20.3","E11.21","M19.90","K58.9","G89.4","M54.6","R30.0","E13.65","R35.1","N32.81","Z71.51","K25.9","K63.5","K29.70","M79.7","G47.00","F19.19","D64.9","D72.828","I07.1","I33.0","R50.9","J44.1","F14.14","K86.1","G43.909","K58.0","F41.0","K58.1","M62.838","Z12.4","Z72.51","T40.2X1D","T40.2X1A","R31.9","M54.2","R63.0","R35.0","F14.90","U07.1","K70.30","N76.0"],"date":["2019-04-12","2020-01-14","2021-04-29","2019-08-19","2019-08-11","2021-02-04","2021-02-08","2021-04-30","2020-04-15","2021-01-08","2021-01-08","2021-01-08","2019-08-19","2019-08-12","2021-04-26","2021-01-08","2021-04-19","2019-08-13","2020-05-26","2021-03-15","2020-10-29","2021-03-15","2021-04-26","2020-02-04","2019-09-23","2020-03-04","2020-04-14","2021-05-12","2021-03-15","2020-02-28","2019-08-27","2020-10-27","2019-08-27","2019-09-23","2020-12-28","2021-02-25","2021-04-26","2021-04-19","2020-01-25","2020-01-25","2020-03-04","2020-01-25","2020-02-04","2020-01-21","2020-12-14","2020-01-25","2020-01-25","2020-08-13","2021-02-18","2021-05-11","2020-05-26","2021-02-01","2021-03-15","2021-03-15","2020-12-24","2021-04-29","2021-03-25","2021-04-26","2021-05-15","2020-07-24","2021-03-25","2020-08-24","2021-04-29","2020-08-24","2020-08-24","2020-09-28","2020-09-28","2020-09-28","2020-09-28","2021-04-29","2020-10-04","2021-03-15","2020-11-02","2021-04-19","2020-10-29","2021-04-08","2020-11-02","2021-04-26","2020-11-19","2020-12-07","2020-12-14","2021-01-12","2021-04-26","2021-01-12","2021-04-29","2021-04-29","2021-02-08","2021-03-10","2021-04-08","2021-05-12","2021-04-26","2021-04-29","2021-05-07","2019-04-12","2020-01-14","2020-05-13","2020-12-10","2019-08-16","2019-08-16","2019-08-23","2019-08-23","2021-01-07","2020-01-14","2020-01-22","2021-04-08","2020-05-13","2020-11-02","2021-04-27","2020-10-20","2021-04-22","2020-10-26","2020-10-26","2020-12-14","2020-11-02","2020-11-02","2021-01-07","2021-01-07","2021-04-08","2021-04-19","2021-04-22","2020-12-08","2019-02-07","2019-02-07","2020-08-13","2021-03-15","2020-12-17","2021-03-15","2019-02-07","2020-09-28","2019-06-28","2019-07-07","2019-07-08","2019-07-04","2019-07-05","2020-10-04","2019-07-07","2019-07-07","2019-12-26","2020-01-18","2020-01-18","2020-01-21","2020-01-19","2020-05-14","2020-02-21","2020-02-04","2020-02-04","2020-04-15","2020-05-26","2020-05-27","2020-05-27","2020-10-04","2020-12-11","2020-12-11","2021-02-10","2021-04-08","2021-04-08","2019-06-29","2019-06-29","2019-07-16","2019-06-29","2019-07-02","2019-12-06","2021-04-27","2020-02-18","2020-03-04","2020-03-04","2020-03-04","2020-03-04","2020-05-26","2020-05-26","2020-05-26","2020-07-27","2020-05-26","2020-10-29","2021-03-03","2021-03-03","2021-05-07","2021-01-08","2021-01-08","2021-04-29","2021-03-15","2021-03-15","2021-03-15","2021-03-15","2021-03-15","2021-03-26","2021-04-27","2021-04-19","2021-05-07","2019-08-13","2019-08-13","2019-08-13","2019-12-26","2020-01-12","2020-01-12","2020-01-12","2020-01-12","2020-01-12","2020-01-12","2020-01-12","2020-01-15","2020-01-12","2020-01-12","2020-01-12","2020-01-12","2020-01-14","2020-01-21","2021-01-19","2020-05-26","2020-09-18","2021-04-29","2020-09-18","2020-09-18","2020-12-28","2020-12-28","2021-01-08","2021-01-08","2021-01-08","2021-01-08","2021-01-08","2021-01-08","2021-01-08","2021-01-19","2021-04-08","2019-07-04","2019-07-06","2020-01-12","2020-01-12","2020-01-12","2020-01-12","2020-01-23","2020-02-10","2020-07-25","2020-05-14","2020-05-14","2020-05-26","2020-07-23","2020-07-23","2020-07-25","2020-07-25","2020-07-25","2020-07-25","2020-07-27","2020-12-08","2020-08-18","2021-02-05","2021-02-05","2021-05-12","2021-03-15","2021-03-15","2021-03-15","2019-04-12","2019-04-12","2019-04-12","2020-01-15","2020-01-15","2020-01-18","2020-01-18","2020-01-18","2020-02-21","2020-05-13","2020-05-13","2020-05-13","2020-05-13","2020-05-13","2020-07-27","2020-10-04","2020-12-08","2021-03-01","2019-04-13","2019-04-13","2019-06-28","2019-07-16","2019-07-16","2019-12-12","2020-10-04","2020-10-04","2021-02-16","2021-03-01"],"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":[["","99073013001","FREESTYLE    MIS LANCETS","MIS LANCETS","100","Select","Select",""],["","12496120803","SUBOXONE ","MIS 8-2MG","8","Select","Select",""],["","00378827052","ALBUTEROL ","NEB 0.00083","375","Select","Select",""],["","69097083512","SERTRALINE ","TAB 100MG","30","Select","Select",""],["","00093005401","BUSPIRONE ","TAB 10MG","42","Select","Select",""],["","65862052305","GABAPENTIN ","TAB 600MG","90","Select","Select",""],["","59779043951","CVS ","TAB 81MG EC","30","Select","Select",""],["","68462039610","OMEPRAZOLE ","CAP 20MG","90","Select","Select",""],["","45802086803","POLYETH ","POW 3350 NF","510","Select","Select",""],["","70000052901","GAS ","CAP 125MG","120","Select","Select",""],["","68180051303","LISINOPRIL ","TAB 5MG","30","Select","Select",""],["","72626270101","SOFOS\/VELPAT ","TAB 400-100","28","Select","Select",""],["","45802075930","PROMETHAZINE ","SUP 25MG","12","Select","Select",""],["","00228212750","CLONIDINE ","TAB 0.1MG","60","Select","Select",""],["","69097084507","CYCLOBENZAPR ","TAB 5MG","90","Select","Select",""],["","59779048493","PAIN ","TAB 500MG","120","Select","Select",""],["","00054327099","FLUTICASONE ","SPR 50MCG","16","Select","Select",""],["","68382075810","METFORMIN ","TAB 500MG","60","Select","Select",""],["","00169368712","LEVEMIR ","INJ ","10","Select","Select",""],["","70377002811","ATORVASTATIN ","TAB 20MG","30","Select","Select",""],["","43547040510","METHOCARBAM ","TAB 500MG","90","Select","Select",""],["","59779027408","ASPIRIN ","CHW 81MG","30","Select","Select",""],["","00069047103","CHANTIX ","PAK 0.5& 1MG","53","Select","Select",""],["","65862039010","ONDANSETRON ","TAB 4MG ODT","10","Select","Select",""],["","00169750111","NOVOLOG ","INJ 100\/ML","10","Select","Select",""],["","00536116361","MUCUS ","TAB 600MG ER","60","Select","Select",""],["","10006070029","MELATONIN ","TAB 3MG","90","Select","Select",""],["","08290328438","INSULIN ","MIS 0.3\/31G","100","Select","Select",""],["","68180071160","CEFDINIR ","CAP 300MG","20","Select","Select",""],["","43598081112","CETIRIZINE ","TAB 10MG","90","Select","Select",""],["","67877032105","IBUPROFEN ","TAB 800MG","120","Select","Select",""],["","99073012101","FREESTYLE    TES","TES ","100","Select","Select",""],["","99073070805","FREESTYLE    MIS LITE","MIS LITE","1","Select","Select",""],["","65862022701","LAMOTRIGINE ","TAB 25MG","14","Select","Select",""],["","57664050083","MIRTAZAPINE ","TAB 30MG","30","Select","Select",""],["","00406802003","BUPREN\/NALOX ","SUB 8-2MG","6","Select","Select",""],["","00054001825","PREDNISONE ","TAB 20MG","15","Select","Select",""],["","65162036111","FOLIC ","TAB 1MG","30","Select","Select",""],["","29300014901","QUETIAPINE ","TAB 100MG","14","Select","Select",""],["","65862053820","LEVOFLOXACIN ","TAB 750MG","6","Select","Select",""],["","55111053401","DIVALPROEX ","TAB 500MG ER","60","Select","Select",""],["","13668013601","ESCITALOPRAM ","TAB 10MG","30","Select","Select",""],["","50111033401","METRONIDAZOL ","TAB 500MG","14","Select","Select",""],["","00172572860","FAMOTIDINE ","TAB 20MG","180","Select","Select",""],["","00093031401","KETOROLAC ","TAB 10MG","20","Select","Select",""],["","66993068130","OLANZAPINE ","TAB 5MG","30","Select","Select",""],["","99073070827","FREESTYLE    TES LITE","TES LITE","100","Select","Select",""],["","47781030301","NITROFURANTN ","CAP 100MG","10","Select","Select",""],["","65862042005","SMZ\/TMP ","TAB 800-160","20","Select","Select",""],["","00088222033","LANTUS ","INJ 100\/ML","10","Select","Select",""],["","31604001281","VITAMIN ","TAB 100MG","30","Select","Select",""],["","00597007541","SPIRIVA ","CAP HANDIHLR","30","Select","Select",""],["","00173087310","INCRUSE ","INH 62.5MCG","30","Select","Select",""],["","45802008902","NICOTINE ","LOZ 2MG MINT","81","Select","Select",""],["","63824000832","MUCINEX ","TAB 600MG ER","60","Select","Select",""],["","00536466010","THEREMS ","TAB ","90","Select","Select",""],["","57896010201","ACETAMINOPHE ","TAB 325MG","100","Select","Select",""],["","50428232902","ANTI-DIARRHE ","TAB 2MG","48","Select","Select",""],["","68462018135","CLOTRIMAZOLE ","CRE 0.01","30","Select","Select",""],["","48582080220","BIOTENE ","LIQ DRY MTH","237","Select","Select",""],["","68180012202","CEPHALEXIN ","CAP 500MG","28","Select","Select",""],["","00904673059","ACETAMIN ","TAB 500MG","100","Select","Select",""],["","00173086910","ANORO ","AER 62.5-25","60","Select","Select",""],["","45802048678","DOCUSATE ","CAP 100MG","30","Select","Select",""],["","57896079101","SIMETHICONE ","CHW 80MG","30","Select","Select",""],["","00002771559","BASAGLAR ","INJ 100UNIT","3","Select","Select",""],["","33674015692","ALIVE ","TAB WOMENS","30","Select","Select",""],["","72140000021","EUCERIN ","CRE ","120","Select","Select",""],["","68180016113","AZITHROMYCIN ","TAB 500MG","3","Select","Select",""],["","65862041901","SMZ-TMP ","TAB 400-80MG","6","Select","Select",""],["","50428707932","STOOL ","TAB 8.6-50MG","90","Select","Select",""],["","00143122701","DICYCLOMINE ","TAB 20MG","21","Select","Select",""],["","00536124701","SENEXON-S ","TAB 8.6-50MG","30","Select","Select",""],["","80681005000","DAILY-VITE ","TAB ","30","Select","Select",""],["","51991074890","DULOXETINE ","CAP 60MG","30","Select","Select",""],["","57896010101","NON-ASPIRIN ","TAB 325MG","30","Select","Select",""],["","69547035302","NARCAN ","SPR ","2","Select","Select",""],["","16729008110","NALTREXONE ","TAB 50MG","30","Select","Select",""],["","50428043715","MAGNESIUM ","TAB 500MG","60","Select","Select",""],["","72140003147","AQUAPHOR ","OIN ","396","Select","Select",""],["","00143980350","DOXYCYCL ","CAP 100MG","20","Select","Select",""],["","43598075201","BUPROPION ","TAB 150MG SR","30","Select","Select",""],["","63402030430","LATUDA ","TAB 40MG","30","Select","Select",""],["","50428166363","BISACODYL ","TAB 5MG EC","4","Select","Select",""],["","50428085942","PREP ","PAD ","100","Select","Select",""],["","00603020922","MAG ","TAB 400MG","30","Select","Select",""],["","45802049383","AMMONIUM ","CRE 0.12","140","Select","Select",""],["","08290320109","BD  PEN NEEDL","MIS 31GX8MM","120","Select","Select",""],["","51991029201","OXCARBAZEPIN ","TAB 150MG","28","Select","Select",""],["","69842048490","ACETAMINOPHN ","TAB 500MG","120","Select","Select",""],["","65162083366","DICLOFENAC ","GEL 0.01","100","Select","Select",""],["","00093005805","TRAMADOL ","TAB 50MG","30","Select","Select",""],["","00093310905","AMOXICILLIN ","CAP 500MG","12","Select","Select",""],["","33332031901","AFLURIA ","INJ 2019-20","0.5","Select","Select",""],["","50383077932","LACTULOSE ","10GM\/15","1,892.00","Select","Select",""],["","51672125901","CLOBETASOL ","0.05%","30","Select","Select",""],["","56151161051","TRUEPLUS ","GLUCOSE","50","Select","Select",""],["","70000020702","ALLERGY ","25MG","120","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":[[["Yes","Select","","","","","Select","",""],["Yes","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":""}]}]}