{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"ELIZABETH GRANT","gend":1,"add":"6   CARLSBAD DRIVE                                          ","city":"STAFFORD                      ","state":"VA","zip":"22554-7754","dob":"1973-09-20","age":"","mstatus":"","insh":10159435,"cliId":"","pno":7032269466,"cno":"","email":"","ename":"","eno":"","pphy":"AHMAD, NAEEM                                                ","ppno":"","pcpadd":"4510 Plank Rd","pcpcity":"Fredericksburg                ","pcpstate":"VA","pcpzip":224070138,"pcpcounty":"","pcpid":"P0060175","pcpname":"PRIMARY AND URGENT CARE LLC","plan":"VPHP","program":"MEDICAID","lob":"VPM4","region":"CENTRAL","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"6   CARLSBAD DRIVE                                          ","madd2":"                                                            ","madd3":"","mcity":"STAFFORD                      ","mstate":"VA","mzip":"22554-7754","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R09.89","Z00.00","Z13.220","Z13.1","Z12.31","Z12.4","Z11.59","Z23","R07.81","M54.2","N85.2","R03.0","R73.9","E78.2","Z20.828"],"date":["2020-07-14","2020-11-11","2020-11-11","2020-11-11","2020-11-11","2020-11-11","2020-11-11","2020-11-11","2020-11-11","2020-11-11","2020-11-11","2020-11-11","2020-11-17","2020-11-17","2021-05-31"],"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":[["","68180072103","AMLODIPINE","10MG","30","Select","Select",""],["","66993006002","ATOVAQ\/PROGU","250-100","21","Select","Select",""],["","68180072103","AMLODIPINE ","TAB 10MG","30","Select","Select",""],["","66993006002","ATOVAQ\/PROGU ","TAB 250-100","21","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":""}]}]}