{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"DANIEL   A CUSTER","gend":0,"add":"5640 IRISH ROAD ","city":"CHATHAM ","state":"VA","zip":"24531-4896","dob":"2003-09-17","age":"","mstatus":"","insh":10160200,"cliId":"","pno":"","cno":"","email":"","ename":"","eno":"","pphy":"HUNDLEY, SUSAN D","ppno":"","pcpadd":"705 Main St, ","pcpcity":"Danville","pcpstate":"VA","pcpzip":245411803,"pcpcounty":"","pcpid":"","pcpname":"HEALTH CENTER OF THE PIEDMONT CHATHAM","plan":"VPHP","program":"MEDICAID","lob":"VPM4","region":"WESTERN\/ CHARLOTTESVILLE","aligned":"","ano":"","add2":"","add3":"","madd1":"5640 IRISH ROAD ","madd2":"","madd3":"","mcity":"CHATHAM ","mstate":"VA","mzip":"24531-4896","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["M79.671","M20.40","M20.10","B07.0","M79.672","R10.9","K58.9","K58.0","R10.84","E55.9","H52.13","H01.02A","H01.02B","J20.9","M25.571","M25.572","Y93.02","Z02.5","M25.552","R93.6","S73.191D","M25.551","M76.892","Z20.828","M25.852","S73.192A","R07.89","R07.9","V89.2XXA","Z23"],"date":["2019-05-01","2019-05-01","2019-05-01","2019-05-01","2019-03-19","2019-05-29","2019-05-29","2020-12-07","2020-06-10","2020-06-10","2019-11-11","2019-11-11","2019-11-11","2019-11-26","2020-02-25","2020-02-25","2020-02-25","2020-08-04","2021-03-30","2020-09-17","2020-11-25","2020-11-25","2020-10-29","2020-12-11","2021-06-03","2021-03-30","2021-07-12","2021-07-12","2021-07-12","2021-08-17"],"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":[["","16571020150","DICLOFENAC","75MG DR","60","Select","Select",""],["","49100036404","CULTURELLE","HLTH\/WEL","14","Select","Select",""],["","00115175701","CYPROHEPTAD","4MG","30","Select","Select",""],["","00591079501","DICYCLOMINE","20MG","90","Select","Select",""],["","11917017096","VITAMIN","2000UNIT","30","Select","Select",""],["","74312052807","D3","50MCG","30","Select","Select",""],["","43199001101","HYOSCYAMINE","0.125MG","90","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":""}]}]}