{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"ELIZABETH   L CUBBAGE","gend":1,"add":"960 BRADY ROAD                                              ","city":"STANLEY                       ","state":"VA","zip":"22851-4211","dob":"2001-03-27","age":"","mstatus":"","insh":10106141,"cliId":"","pno":5402449584,"cno":5402449584,"email":"","ename":"","eno":"","pphy":"JAMES G DALE                                                ","ppno":5407432887,"pcpadd":"250 Memorial Dr","pcpcity":"Luray                         ","pcpstate":"VA","pcpzip":228351000,"pcpcounty":"","pcpid":"P0060063","pcpname":"VALLEY INTERNAL MEDICINE","ano":"","add2":"                                                            ","add3":"","madd1":"960 BRADY ROAD                                              ","madd2":"                                                            ","madd3":"","mcity":"STANLEY                       ","mstate":"VA","mzip":"22851-4211","pcpfaxno":"","plan":"VPHP","program":"MEDICAID","lob":"VPM4","region":"NORTHERN\/ WINCHESTER","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["M25.561","M67.51","M22.2X1","M23.200","M22.41","M65.861","E10.9","Z79.4","Z79.1","Z79.3","S83.281D","M25.551","R42","R11.0","Z09","J02.9","H40.011","H52.13","E11.65","Z77.21","O20.8","Z3A.00","O20.9","O99.89","R10.9","O24.911","Z3A.01","Z71.9","O26.841","O20.0","R10.2","E11.9","Z3A.11","R10.32","O24.919","O26.892","M54.9","Z3A.19","O35.8XX1","O24.012","Z3A.21","O26.842","E10.65","O21.9","R10.31","Z3A.22","R10.30","N13.30","O24.112","O09.92","Z23","O99.891","M53.3","Z3A.23","R53.83"],"date":["2019-02-11","2019-02-11","2019-02-11","2019-02-11","2019-02-11","2019-02-11","2020-06-09","2020-10-27","2019-02-11","2019-02-11","2019-02-11","2019-02-12","2019-02-12","2019-02-12","2019-03-22","2019-05-19","2019-12-12","2019-12-12","2020-06-09","2020-06-09","2020-07-30","2020-06-23","2020-07-30","2020-06-23","2020-06-23","2020-07-30","2020-07-08","2020-09-21","2020-08-05","2020-07-30","2020-07-30","2020-10-27","2020-08-05","2020-10-18","2020-08-05","2020-10-27","2020-10-01","2020-10-01","2020-10-07","2020-10-18","2020-10-16","2020-10-16","2020-10-18","2020-10-18","2020-10-18","2020-10-22","2020-10-18","2020-10-19","2020-10-27","2020-10-22","2020-10-22","2020-10-27","2020-10-27","2020-10-27","2021-06-28"],"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":[["","00591352530","LIDOCAINE","5%","30","Select","Select",""],["","57599000101","FREESTYLE KIT SENSOR","SENSOR","6","Select","Select",""],["","00002143380","TRULICITY","0.75\/0.5","2","Select","Select",""],["","68645058259","METFORMIN","500MG","60","Select","Select",""],["","57599000200","FREESTYLE MIS READER","READER","1","Select","Select",""],["","00002751001","HUMALOG","100\/ML","10","Select","Select",""],["","08290320119","BD PEN NEEDL","31GX5MM","100","Select","Select",""],["","65162019050","NAPROXEN","500MG","20","Select","Select",""],["","45802048678","DOCUSATE","100MG","20","Select","Select",""],["","00088222033","LANTUS","100\/ML","10","Select","Select",""],["","00591352530","LIDOCAINE ","PAD 0.05","30","Select","Select",""],["","57599000101","FREESTYLE    KIT SENSOR","KIT SENSOR","6","Select","Select",""],["","00002143380","TRULICITY ","INJ 0.75\/0.5","2","Select","Select",""],["","68645058259","METFORMIN ","TAB 500MG","60","Select","Select",""],["","57599000200","FREESTYLE    MIS READER","MIS READER","1","Select","Select",""],["","00002751001","HUMALOG ","INJ 100\/ML","10","Select","Select",""],["","08290320119","BD  PEN NEEDL","MIS 31GX5MM","100","Select","Select",""],["","65162019050","NAPROXEN ","TAB 500MG","20","Select","Select",""],["","45802048678","DOCUSATE ","CAP 100MG","20","Select","Select",""],["","00088222033","LANTUS ","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","",""],["N\/A","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":""}]}]}