{"version":"0.4","data":[{"t":"Demographics","q":[{"name":" CANDELARIA  CHAVEZ","gend":1,"add":"8545 WILLOW GLEN COURT","city":"MANASSAS","state":"VA","zip":"20110-4651","dob":"1962-02-02","age":"","mstatus":"","insh":10070485,"cliId":"","pno":"5714942616, 5714942616","cno":"","email":"","ename":"","eno":"","pphy":"GUPTA, ARUN K","ppno":"               ","pcpadd":"9306 Forest Point Cir, ","pcpcity":"Manassas","pcpstate":"VA","pcpzip":201104700,"pcpcounty":"","pcpid":"","pcpname":"","plan":"VPHP - VIRGINIA PREMIER","program":"MEDICAID","lob":"MLTSS","region":"NORTHERN","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"8545 WILLOW GLEN COURT","madd2":"                                                            ","madd3":"","mcity":"MANASSAS","mstate":"VA","mzip":"20110-4651","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["N18.6","N25.81","Z99.2","Z23","D63.1","J84.9","D50.9","M05.10","B44.1","M05.9","M32.14","M81.0","E55.9","R70.0","Z20.822","J96.01","E10.22","E11.65","E11.21","I13.0","Z68.29","Z01.31","Z01.30","M35.8","S82.002A","R91.8","E78.00","R53.82","I25.9","Z13.1","E87.8","Z79.899","I87.1","T82.858A","I16.9","Z68.23","E78.5","E03.9","R06.00","I10","E78.2","Z49.01","M10.9","Z13.89","M19.071","M79.671","R17","J81.1","N18.9","U07.1","R10.13","S73.101A","M79.604","Z79.4","I13.11","R76.11","N25.0","M81.8","M25.842","M25.841","M85.842","M85.841","D64.9","Z20.828","R94.31","E11.22","R06.02","I12.0"],"date":["2021-05-22","2021-04-01","2021-04-06","2020-10-01","2021-04-01","2020-10-16","2021-02-02","2020-07-20","2020-01-20","2020-10-16","2020-10-16","2021-02-26","2021-02-26","2020-10-16","2021-04-22","2021-05-22","2019-06-25","2020-09-15","2020-09-01","2020-09-15","2020-09-15","2020-09-15","2020-09-15","2020-10-16","2021-02-20","2021-05-18","2019-06-19","2019-06-19","2019-09-10","2020-12-15","2019-08-01","2019-08-01","2020-01-29","2020-01-29","2020-07-09","2020-06-23","2020-07-09","2020-07-09","2021-04-06","2020-09-15","2020-09-15","2019-02-22","2019-06-19","2019-07-03","2019-07-15","2019-07-15","2019-08-01","2021-04-06","2021-05-22","2021-05-22","2019-04-10","2019-04-10","2019-04-10","2019-04-10","2019-04-10","2021-03-01","2021-04-01","2019-05-31","2020-04-03","2020-04-03","2020-04-03","2020-04-03","2021-04-06","2021-04-06","2021-04-06","2021-05-20","2021-04-06","2021-04-06"],"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":[["","13811052501","TRIPHROCAPS ","CAP ","30","Select","Select",""],["","72205002790","ROSUVASTATIN ","TAB 5MG","90","Select","Select",""],["","68382009405","CARVEDILOL ","TAB 12.5MG","60","Select","Select",""],["","64380073706","VITAMIN ","CAP 50000UNT","12","Select","Select",""],["","00088221905","LANTUS ","INJ 100\/ML","15","Select","Select",""],["","50383066730","LIDO\/PRILOCN ","CRE 2.5-2.5%","30","Select","Select",""],["","16714004211","ALLOPURINOL ","TAB 300MG","15","Select","Select",""],["","11534016503","FOLIC ","TAB 1MG","30","Select","Select",""],["","68645055254","LISINOPRIL ","TAB 10MG","30","Select","Select",""],["","68645051554","AMLODIPINE ","TAB 5MG","30","Select","Select",""],["","00781208102","CALC ","CAP 667MG","180","Select","Select",""],["","69097084507","CYCLOBENZAPR ","TAB 5MG","45","Select","Select",""],["","68645014059","FAMOTIDINE ","TAB 20MG","60","Select","Select",""],["","00093505998","ATORVASTATIN ","TAB 20MG","90","Select","Select",""],["","50111032701","HYDRALAZINE ","TAB 25MG","120","Select","Select",""],["","13107005999","APAP\/CODEINE ","TAB 300-30MG","15","Select","Select",""],["","00002751001","HUMALOG ","INJ 100\/ML","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":[[["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":""}]}]}