{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"DOMINIQUE FORBES","gend":1,"add":"479 BEECHWOOD DRIVE ","city":"LYNCHBURG ","state":"VA","zip":"24502-3198","dob":"2000-10-13","age":"","mstatus":"","insh":10120853,"cliId":"","pno":4344267937,"cno":"","email":"","ename":"","eno":"","pphy":"SULLIVAN, STEPHANIE J ","ppno":"","pcpadd":"1212 McConville Rd, ","pcpcity":"Lynchburg ","pcpstate":"VA","pcpzip":245024536,"pcpcounty":"","pcpid":"","pcpname":"F READ HOPKINS PEDIATRICS","plan":"VPHP","program":"MEDICAID","lob":"VPM4","region":"WESTERN\/ CHARLOTTESVILLE","aligned":"","ano":"","add2":"479 BEECHWOOD DR","add3":"","madd1":"479 BEECHWOOD DRIVE ","madd2":"479 BEECHWOOD DR","madd3":"","mcity":"LYNCHBURG ","mstate":"VA","mzip":"24502-3198","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","1","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["M54.9","N39.0","R39.89","R30.0","R10.9","N94.6","N30.10","N32.81","N92.0","R10.2","R35.0","R39.15","M62.81","N39.46","Z00.00","J45.20","Z11.1","R31.9","Z11.3","N73.9","R93.89","F43.10","F33.1","F43.21","R11.10","Z32.02","R10.30","R63.4","Z23","Z20.828","N92.5","R33.9"],"date":["2019-03-01","2019-07-08","2019-03-01","2021-07-12","2019-10-20","2021-04-21","2019-07-08","2019-03-01","2019-08-21","2019-10-20","2019-10-15","2019-10-15","2019-06-05","2019-06-05","2019-08-22","2019-08-22","2019-08-22","2019-10-15","2019-10-15","2019-10-20","2019-10-20","2019-11-06","2021-10-07","2020-02-05","2020-01-13","2020-03-24","2020-07-24","2020-07-24","2020-07-24","2021-01-18","2021-07-12","2021-04-21"],"priorHcc":["","","","","","","","","","","","","","","","","","","","","","",null,"","","","","","","","",""]}},{"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":[["","16729020201","BUSPIRONE","10MG","90","Select","Select",""],["","13668013701","ESCITALOPRAM","20MG","30","Select","Select",""],["","50111043301","TRAZODONE","50MG","30","Select","Select",""],["","47781030301","NITROFURANTN","100MG","14","Select","Select",""],["","00093317431","ALBUTEROL","E","8.5","Select","Select",""],["","00456120130","LINZESS","145MCG","30","Select","Select",""],["","50458009801","ELMIRON","100MG","90","Select","Select",""],["","65862007701","CIPROFLOXACN","500MG","10","Select","Select",""],["","65862042005","SMZ\/TMP","800-160","14","Select","Select",""],["","65862051601","NAPROXEN","550MG","30","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","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["No","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":""}]}]}