{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MONICA HEDGEPETH","gend":1,"add":"500A W MAIN STREET                                          ","city":"DANVILLE                      ","state":"VA","zip":"24541-3614","dob":"1986-06-17","age":"","mstatus":"","insh":10160580,"cliId":"","pno":3364308278,"cno":3364308278,"email":"","ename":"","eno":"","pphy":"SHAH, MINESH R                                              ","ppno":"","pcpadd":"19144 HIGHTWAY 29 NORTH","pcpcity":"CHATHAM                       ","pcpstate":"VA","pcpzip":245310001,"pcpcounty":"","pcpid":"P0060084","pcpname":"DRMC FAMILY MEDICINE RESIDENCY CLINIC","plan":"VPHP","program":"MEDICAID","lob":"VPM4","region":"WESTERN\/ CHARLOTTESVILLE","aligned":"","ano":"","add2":"REAR A HOUSE BEHIND APARTMENTS                              ","add3":"","madd1":"500A W MAIN STREET                                          ","madd2":"REAR A HOUSE BEHIND APARTMENTS                              ","madd3":"","mcity":"DANVILLE                      ","mstate":"VA","mzip":"24541-3614","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","1",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["J11.1","N92.6","R73.03","D25.1","D25.2","O26.891","R07.89","Z3A.01","R11.0","R06.02","O26.91","Z88.0","Z88.6","K21.9","R53.83","Z71.82","Z71.3","E66.01","E55.9","G47.00","Z22.1","Z00.00","Z13.220","Z00.01","R07.9","M79.602","R60.9","R42","N92.0","Z32.02"],"date":["2019-03-27","2019-04-30","2020-05-07","2019-04-30","2019-04-30","2019-08-20","2019-08-21","2019-08-21","2019-08-20","2019-08-20","2019-08-21","2019-08-21","2019-08-21","2020-07-02","2020-06-05","2020-07-02","2020-06-24","2020-07-02","2021-07-28","2020-06-05","2020-07-02","2021-07-28","2021-07-28","2021-07-28","2021-07-28","2021-07-28","2021-07-28","2021-07-28","2021-07-28","2021-07-28"],"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":[["","50111043401","TRAZODONE","100MG","30","Select","Select",""],["","65862056090","PANTOPRAZOLE","40MG","30","Select","Select",""],["","69452015120","VITAMIN","50000UNT","4","Select","Select",""],["","70710122501","AMITRIPTYLIN","10MG","30","Select","Select",""],["","31722072690","MONTELUKAST","10MG","30","Select","Select",""],["","60505082901","FLUTICASONE","50MCG","16","Select","Select",""],["","10370011710","ZOLPIDEM","6.25MG","5","Select","Select",""],["","50111043401","TRAZODONE ","TAB 100MG","30","Select","Select",""],["","65862056090","PANTOPRAZOLE ","TAB 40MG","30","Select","Select",""],["","69452015120","VITAMIN ","CAP 50000UNT","4","Select","Select",""],["","70710122501","AMITRIPTYLIN ","TAB 10MG","30","Select","Select",""],["","31722072690","MONTELUKAST ","TAB 10MG","30","Select","Select",""],["","60505082901","FLUTICASONE ","SPR 50MCG","16","Select","Select",""],["","10370011710","ZOLPIDEM ","TAB 6.25MG","5","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":""}]}]}