{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"JARED-LEE   D FUTCH","gend":0,"add":"8110   SHEFFIELD  DRIVE                                     ","city":"GLOUCESTER                    ","state":"VA","zip":"23061-5232","dob":"1986-08-21","age":"","mstatus":"","insh":1265641,"cliId":"","pno":7575049010,"cno":7575049010,"email":"","ename":"","eno":"","pphy":"DOWLING, NEQUITA                                            ","ppno":"","pcpadd":"2148 W Mercury Blvd","pcpcity":"Hampton                       ","pcpstate":"VA","pcpzip":236663111,"pcpcounty":"","pcpid":"P9059016","pcpname":"RIVERSIDE MERCURY WEST","plan":"VPHP","program":"MEDICAID","lob":"VPM4","region":"TIDEWATER","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"8110   SHEFFIELD  DRIVE                                     ","madd2":"                                                            ","madd3":"","mcity":"GLOUCESTER                    ","mstate":"VA","mzip":"23061-5232","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["ASIAN\/PACIFIC"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["K44.9","K21.0","G62.9","M79.673","M25.561","M25.562","G89.29","R20.2","R20.0","M17.12","M17.11","M23.91","M22.42","M22.40","M94.8X8","R29.2","K31.84","M54.16","F41.9","R52","M54.2","R26.81","M17.0"],"date":["2019-01-09","2019-01-09","2019-01-09","2019-01-09","2021-10-25","2019-01-09","2021-10-25","2019-09-25","2019-09-25","2019-02-22","2019-05-10","2019-05-01","2019-05-10","2019-05-17","2019-05-20","2021-08-21","2019-08-19","2019-08-26","2020-03-31","2020-03-31","2021-08-23","2021-08-21","2021-10-25"],"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":[["","65862019105","CYCLOBENZAPR","10MG","30","Select","Select",""],["","16571020110","DICLOFENAC","75MG DR","60","Select","Select",""],["","50228018005","GABAPENTIN","300MG","540","Select","Select",""],["","65862019105","CYCLOBENZAPR ","TAB 10MG","30","Select","Select",""],["","16571020110","DICLOFENAC ","TAB 75MG DR","60","Select","Select",""],["","50228018005","GABAPENTIN ","CAP 300MG","540","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":""}]}]}