{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"HILLARIE RASNAKE","gend":1,"add":"HC 66 BOX 16 A                                              ","city":"RICHLANDS                     ","state":"VA","zip":"24641-9701","dob":"1984-02-18","age":"","mstatus":"","insh":10132556,"cliId":"","pno":2769630311,"cno":2769706807,"email":"","ename":"","eno":"","pphy":"PIRIZ, TOEYA                                                ","ppno":"","pcpadd":"1 Clinic Dr","pcpcity":"Richlands                     ","pcpstate":"VA","pcpzip":246411102,"pcpcounty":"","pcpid":"P0060216","pcpname":"CLINCH VALLEY PHYSICIANS ASSOCIATES LLC","plan":"VPHP","program":"MEDICAID","lob":"VPM4","region":"SOUTHWEST","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"HC 66 BOX 16 A                                              ","madd2":"                                                            ","madd3":"","mcity":"RICHLANDS                     ","mstate":"VA","mzip":"24641-9701","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F20.9","F25.0","H10.45","J45.901","J30.9","F17.200","F41.8","R10.2","Z12.4","N92.6","Z01.411","Z32.01","N85.2","D25.2","D25.1","F41.9","R63.8","E34.9","O09.521","O26.891","O34.11","D25.9","O34.81","N83.12","R03.0","Z36.89","O36.80X0","Z34.81","Z3A.08","Z3A.11","R11.0","Z3A.13","Z34.90","Z3A.00","O09.522","Z36.3","Z3A.19","I10","Z36.9","O99.613","K59.00","F31.9","F39","O99.419","I05.8","R56.9","G43.119","G44.40","E66.9","Z3A.36","O10.919","Z3A.32","O09.529","O99.213","K64.4","G43.909","O99.210","O26.899","R51","G43.109","Z79.899","O99.89","O09.513","O98.413","O99.343","Z3A.35","Z36.85","O36.8130","Z3A.39","O98.42","O60.14X0","O99.354","O10.92","O76","O99.62","K21.9","O99.52","J45.909","O99.824","O99.344","Z03.89","M54.17","R60.0","F40.01","F25.9","J02.0","J02.9","H60.11","H66.91","H92.01","L03.811","F17.210","Z88.6","Z91.030","J06.9","R05","F32.9","M06.9","Z11.59","M54.41","M54.5","M54.9","B18.2","F99","Z87.891","E66.01","Z68.41","M47.816","M48.061","M51.36","R65.10","Z20.822","R50.9","M48.062","M54.16","R42","M62.830","M25.551","M06.4","R76.0","M79.641","M79.642","R10.9","M51.26","R09.89","R06.2","J40","Z79.51","R06.02","R07.9","B19.20","K62.5","G62.9","J20.9","J44.9","R91.8","R05.3","D86.9","Z01.810","D12.8","K62.1","K64.0","K63.89","F32.A"],"date":["2020-05-28","2021-09-20","2019-07-29","2021-09-12","2019-09-23","2019-10-23","2020-05-20","2019-10-23","2019-10-15","2019-10-15","2019-10-15","2019-10-15","2019-10-15","2019-10-15","2019-10-15","2021-11-18","2019-10-15","2019-10-23","2019-12-12","2019-10-23","2019-11-13","2019-11-13","2019-10-23","2019-10-23","2019-10-23","2019-10-23","2019-11-13","2019-12-12","2019-11-13","2019-12-02","2019-12-12","2019-12-12","2020-05-22","2020-05-20","2020-01-27","2020-01-27","2020-01-27","2021-12-01","2020-05-22","2020-03-13","2020-03-13","2020-05-28","2020-05-28","2020-03-10","2020-03-10","2021-05-24","2020-07-20","2020-04-17","2020-05-22","2020-05-01","2020-05-01","2020-05-01","2020-05-27","2020-05-27","2020-05-13","2021-05-24","2020-05-13","2020-05-20","2020-05-20","2020-05-20","2021-11-18","2020-05-20","2020-05-20","2020-05-20","2020-05-20","2020-05-20","2020-05-22","2020-05-27","2020-05-27","2020-05-28","2020-05-28","2020-05-28","2020-05-28","2020-05-28","2020-05-28","2020-05-28","2020-05-28","2021-11-16","2020-05-28","2020-05-28","2020-05-28","2020-08-25","2020-07-20","2020-09-01","2021-05-25","2020-09-18","2020-09-18","2020-12-25","2020-12-25","2020-12-25","2020-12-25","2021-11-18","2021-11-18","2021-09-12","2021-02-17","2021-09-12","2021-07-28","2021-09-22","2021-05-11","2021-12-01","2021-08-18","2021-05-25","2021-05-25","2021-05-24","2021-05-24","2021-05-24","2021-05-24","2021-08-18","2021-05-24","2021-08-18","2021-05-25","2021-09-12","2021-05-24","2021-05-25","2021-05-25","2021-05-25","2021-12-01","2021-07-12","2021-08-09","2021-08-09","2021-08-09","2021-08-09","2021-08-09","2021-09-22","2021-09-12","2021-11-16","2021-09-12","2021-09-12","2021-09-12","2021-09-12","2021-11-18","2021-11-18","2021-12-01","2021-09-12","2021-10-28","2021-10-28","2021-11-16","2021-11-16","2021-11-16","2021-11-18","2021-11-18","2021-11-18","2021-11-18","2021-11-18"],"priorHcc":["","","","","","","","","","","","","","","",null,"","","","","","","","","","","","","","","","","","","","","",null,"","","","","","","","","","","","","","","","","","","","","","",null,"","","","","","","","","","","","","","","","",null,"","","","","","","","","","","","","",null,null,"","","","","","",null,"","","","","","","","","","","","","","","","",null,"","","","","","","","",null,"","","","",null,null,null,"",null,null,null,null,null,null,null,null,null,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":[["","00173068220","VENTOLIN","","18","Select","Select",""],["","49483060750","GABAPENTIN","400MG","90","Select","Select",""],["","00054455025","METHOTREXATE","2.5MG","14","Select","Select",""],["","00168001431","HYDROCORT","0.50%","30","Select","Select",""],["","27808003702","HYDROCO\/APAP","10-325MG","10","Select","Select",""],["","31722053405","METHOCARBAM","750MG","120","Select","Select",""],["","67877026410","DULOXETINE","30MG","30","Select","Select",""],["","65862001305","SERTRALINE","100MG","30","Select","Select",""],["","64980016905","HYDROXYZ","25MG","28","Select","Select",""],["","65862066230","ARIPIPRAZOLE","5MG","30","Select","Select",""],["","00904531346","PRENATAL","27-0.8MG","30","Select","Select",""],["","68180012202","CEPHALEXIN","500MG","40","Select","Select",""],["","59267100002","PFIZER","COVID-19","0.3","Select","Select",""],["","51293084610","FOLIC","1MG","30","Select","Select",""],["","55111015810","OMEPRAZOLE","20MG","30","Select","Select",""],["","66993001968","ALBUTEROL","HFA","18","Select","Select",""],["","65862064163","AZITHROMYCIN","250MG","6","Select","Select",""],["","00054418425","DEXAMETHASON","4MG","10","Select","Select",""],["","00487980125","IPRATROPIUM","0.02%INH","62.5","Select","Select",""],["","00527169505","BUT\/APAP\/CAF","","60","Select","Select",""],["","70461031903","FLUCLVX","2019-20","0.5","Select","Select",""],["","00054472831","PREDNISONE","5MG","30","Select","Select",""],["","63402030430","LATUDA","40MG","30","Select","Select",""],["","67877057305","BENZONATATE","100MG","30","Select","Select",""],["","00378561505","LEVETIRACETA","500MG","60","Select","Select",""],["","69097012212","TOPIRAMATE","25MG","60","Select","Select",""],["","00093747243","RIZATRIPTAN","10MG","9","Select","Select",""],["","59746011506","PROCHLORPER","10MG","6","Select","Select",""],["","43547035211","LISINOPRIL","5MG","30","Select","Select",""],["","65862019399","FLUOXETINE","20MG","30","Select","Select",""],["","60432060416","PROMETHAZINE","DM","200","Select","Select",""],["","53489011905","DOXYCYCL","100MG","20","Select","Select",""],["","57237003105","AMOXICILLIN","500MG","30","Select","Select",""],["","52817032000","BACLOFEN","10MG","60","Select","Select",""],["","52817033200","CYCLOBENZAPR","10MG","30","Select","Select",""],["","62559043130","HYDROCORTISO","2.50%","30","Select","Select",""],["","69618004410","DOCUSATE","100MG","30","Select","Select",""],["","00904759180","FERROUS","325MG","30","Select","Select",""],["","13107004401","OXYCOD\/APAP","5-325MG","25","Select","Select",""],["","41167005840","ASPERCREME","LIDO 4%","30","Select","Select",""],["","50804083805","PAIN","4% MAX","30","Select","Select",""],["","69292053010","PROPRANOLOL","10MG","90","Select","Select",""],["","00115169449","EPINEPHRINE","0.3MG","2","Select","Select",""],["","00574041202","POLYETH","3350 NF","255","Select","Select",""],["","00536589688","NICOTINE","21MG\/24H","28","Select","Select",""],["","00173068220","VENTOLIN ","AER ","18","Select","Select",""],["","49483060750","GABAPENTIN ","CAP 400MG","90","Select","Select",""],["","00054455025","METHOTREXATE ","TAB 2.5MG","14","Select","Select",""],["","00168001431","HYDROCORT ","CRE 0.005","30","Select","Select",""],["","27808003702","HYDROCO\/APAP ","TAB 10-325MG","10","Select","Select",""],["","31722053405","METHOCARBAM ","TAB 750MG","120","Select","Select",""],["","67877026410","DULOXETINE ","CAP 30MG","30","Select","Select",""],["","66993001968","ALBUTEROL ","AER HFA","18","Select","Select",""],["","65862001305","SERTRALINE ","TAB 100MG","30","Select","Select",""],["","64980016905","HYDROXYZ ","CAP 25MG","28","Select","Select",""],["","65862066230","ARIPIPRAZOLE ","TAB 5MG","30","Select","Select",""],["","00904531346","PRENATAL ","TAB 27-0.8MG","30","Select","Select",""],["","68180012202","CEPHALEXIN ","CAP 500MG","40","Select","Select",""],["","59267100002","PFIZER ","INJ COVID-19","0.3","Select","Select",""],["","51293084610","FOLIC ","TAB 1MG","30","Select","Select",""],["","55111015810","OMEPRAZOLE ","CAP 20MG","30","Select","Select",""],["","65862064163","AZITHROMYCIN ","TAB 250MG","6","Select","Select",""],["","00054418425","DEXAMETHASON ","TAB 4MG","10","Select","Select",""],["","00487980125","IPRATROPIUM ","SOL 0.02%INH","62.5","Select","Select",""],["","00527169505","BUT\/APAP\/CAF ","TAB ","60","Select","Select",""],["","70461031903","FLUCLVX ","INJ 2019-20","0.5","Select","Select",""],["","00054472831","PREDNISONE ","TAB 5MG","30","Select","Select",""],["","63402030430","LATUDA ","TAB 40MG","30","Select","Select",""],["","67877057305","BENZONATATE ","CAP 100MG","30","Select","Select",""],["","00378561505","LEVETIRACETA ","TAB 500MG","60","Select","Select",""],["","69097012212","TOPIRAMATE ","TAB 25MG","60","Select","Select",""],["","00093747243","RIZATRIPTAN ","TAB 10MG","9","Select","Select",""],["","59746011506","PROCHLORPER ","TAB 10MG","6","Select","Select",""],["","43547035211","LISINOPRIL ","TAB 5MG","30","Select","Select",""],["","65862019399","FLUOXETINE ","CAP 20MG","30","Select","Select",""],["","60432060416","PROMETHAZINE ","SYP DM","200","Select","Select",""],["","53489011905","DOXYCYCL ","CAP 100MG","20","Select","Select",""],["","57237003105","AMOXICILLIN ","CAP 500MG","30","Select","Select",""],["","52817032000","BACLOFEN ","TAB 10MG","60","Select","Select",""],["","52817033200","CYCLOBENZAPR ","TAB 10MG","30","Select","Select",""],["","62559043130","HYDROCORTISO ","CRE 0.025","30","Select","Select",""],["","69618004410","DOCUSATE ","CAP 100MG","30","Select","Select",""],["","00904759180","FERROUS ","TAB 325MG","30","Select","Select",""],["","13107004401","OXYCOD\/APAP ","TAB 5-325MG","25","Select","Select",""],["","41167005840","ASPERCREME ","PAD LIDO 4%","30","Select","Select",""],["","69292053010","PROPRANOLOL ","TAB 10MG","90","Select","Select",""],["","50804083805","PAIN ","PAD 4% MAX","30","Select","Select",""],["","52268001201","SUPREP ","SOL PREP KIT","354","Select","Select",""],["","57896048914","POLYETH ","POW 3350 NF","238","Select","Select",""],["","00115169449","EPINEPHRINE ","INJ 0.3MG","2","Select","Select",""],["","00536589688","NICOTINE ","DIS 21MG\/24H","28","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","",""],["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":""}]}]}