{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"AMBER TAYLOR","gend":1,"add":"108 MILLER STREET","city":"STAUNTON","state":"VA","zip":"24401-8842","dob":"1988-04-06","age":"","mstatus":"","insh":6828025,"cliId":"","pno":5402806067,"cno":5402803260,"email":"","ename":"","eno":"","pphy":"DIANA JENSEN MD PC","ppno":5408860827,"pcpadd":"934 N Augusta St Ste B, ","pcpcity":"Staunton","pcpstate":"VA","pcpzip":244013282,"pcpcounty":"","pcpid":"","pcpname":"DIANA JENSEN MD PC","ano":5402809331,"add2":"APARTMENT 44","add3":"","madd1":"108 MILLER STREET","madd2":"APARTMENT 44","madd3":"","mcity":"STAUNTON","mstate":"VA","mzip":"24401-8842","plan":"VPHP","program":"MEDICAID","lob":"VPM4","region":"WESTERN\/ CHARLOTTESVILLE","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["L03.221","M54.9","M79.18","M25.512","M54.6","I10","K21.9","Z72.0","Z79.899","Z88.8","Z88.5","R51","R11.0","K08.89","K02.9","S02.5XXA","F32.9","R00.0","M53.3","S30.0XXA","M54.5","W19.XXXA","W01.198A","Y92.008","M41.9","Z79.818","R73.09","K43.9","R10.9","R10.33","G89.4","G47.33","R10.0","Z01.818","K43.2","E87.6","E78.5","R10.13","R10.10","Z90.49","Z90.710","Z98.890","Z87.898","Z79.84","Z79.891","E11.49","E78.1","G60.9","F33.1","L02.92","B37.2","G89.29","R07.9","F17.210","E01.0","K08.109","I49.3","I49.1","K42.9","R74.0","Z95.818","K43.6","K29.70","Z01.810","Z01.812","Z51.81","F41.9","G89.18","R06.81","R10.84","E11.9","G47.00","Z87.19","F11.90","K76.0","R10.819","R16.0","K82.4","J22","E78.00","M79.605","Z00.00","E66.01","R74.8","L02.91","Z68.41","R00.1","N39.0","R93.5","Z23","K21.0","K29.60","T39.395A","K46.0","Z48.89","R30.0","Z48.815","K08.9","R60.0","Z98.818","F41.1","F41.0","R53.83","G47.9","K42.0","J45.909","M19.90","R16.2","F51.04","J20.9","S99.912A","K46.9","T83.79XA","J02.0","R29.818"],"date":["2019-04-23","2019-07-23","2019-07-23","2019-07-23","2019-07-23","2021-05-05","2020-09-25","2021-05-05","2021-04-21","2021-05-05","2020-11-07","2019-11-18","2021-05-05","2019-12-15","2019-11-23","2019-11-23","2021-05-05","2021-05-05","2019-12-26","2019-12-26","2019-12-26","2019-12-26","2019-12-26","2019-12-26","2020-09-25","2019-12-26","2020-01-27","2020-09-25","2021-05-20","2021-05-05","2020-05-20","2020-11-12","2021-05-05","2020-09-17","2020-09-25","2021-05-05","2020-09-25","2021-01-29","2021-05-18","2021-05-05","2021-05-05","2021-05-05","2021-05-05","2021-05-05","2021-04-21","2021-03-24","2021-03-24","2021-03-24","2021-05-20","2021-05-20","2021-05-20","2021-05-20","2019-07-23","2020-09-25","2019-06-18","2019-12-15","2020-02-25","2020-02-25","2020-09-25","2020-02-26","2020-02-26","2020-09-25","2020-03-13","2020-09-17","2020-09-17","2020-09-17","2021-05-05","2020-11-07","2020-07-30","2020-11-07","2020-12-10","2020-12-10","2021-05-18","2021-02-01","2021-05-18","2021-05-18","2021-05-18","2021-05-18","2019-10-11","2020-07-22","2020-01-10","2020-03-10","2020-11-07","2020-03-10","2020-03-10","2020-09-03","2020-09-22","2020-11-07","2021-01-29","2020-11-12","2019-07-24","2019-07-24","2019-07-24","2020-09-25","2020-09-25","2020-11-07","2020-11-07","2019-11-30","2019-11-30","2019-11-30","2020-01-23","2020-01-23","2020-07-30","2020-07-30","2020-09-25","2020-09-25","2020-09-25","2021-01-29","2021-03-24","2019-03-13","2019-08-30","2020-09-25","2021-05-18","2020-03-02","2020-05-20"],"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":[["","68180037803","LOSARTAN ","TAB 100MG","30","Select","Select",""],["","68462015713","ONDANSETRON ","TAB 4MG ODT","20","Select","Select",""],["","00093005805","TRAMADOL ","TAB 50MG","30","Select","Select",""],["","00054327099","FLUTICASONE ","SPR 50MCG","16","Select","Select",""],["","16571040250","CETIRIZINE ","TAB 10MG","30","Select","Select",""],["","70377002911","ATORVASTATIN ","TAB 40MG","30","Select","Select",""],["","00406055201","OXYCODONE ","TAB 5MG","84","Select","Select",""],["","24658031205","DOXYCYCL ","TAB 100MG","28","Select","Select",""],["","00591352530","LIDOCAINE ","PAD 0.05","30","Select","Select",""],["","55111015930","OMEPRAZOLE ","CAP 40MG","60","Select","Select",""],["","57237000930","MIRTAZAPINE ","TAB 30MG","30","Select","Select",""],["","00006027754","JANUVIA ","TAB 100MG","30","Select","Select",""],["","62037056005","POT  CHLORIDE","CAP 10MEQ ER","60","Select","Select",""],["","00093117410","PENICILLN ","TAB 500MG","28","Select","Select",""],["","00116200116","CHLORHEX ","SOL 0.0012","473","Select","Select",""],["","70710122901","AMITRIPTYLIN ","TAB 100MG","30","Select","Select",""],["","68645058259","METFORMIN ","TAB 500MG","30","Select","Select",""],["","53746010901","HYDROCO\/APAP ","TAB 5-325MG","6","Select","Select",""],["","63304069301","CLINDAMYCIN ","CAP 300MG","30","Select","Select",""],["","67877032105","IBUPROFEN ","TAB 800MG","30","Select","Select",""],["","99073070822","FREESTYLE    TES LITE","TES LITE","50","Select","Select",""],["","68645051054","HYDROCHLOROT ","TAB 25MG","90","Select","Select",""],["","50742061710","METOPROL ","TAB 100MG ER","30","Select","Select",""],["","42858010201","OXYCOD\/APAP ","TAB 5-325MG","6","Select","Select",""],["","67877057305","BENZONATATE ","CAP 100MG","30","Select","Select",""],["","16571020106","DICLOFENAC ","TAB 75MG DR","60","Select","Select",""],["","51991074710","DULOXETINE ","CAP 30MG","30","Select","Select",""],["","69097084507","CYCLOBENZAPR ","TAB 5MG","15","Select","Select",""],["","00591079501","DICYCLOMINE ","TAB 20MG","60","Select","Select",""],["","69543025204","VIRTUSSIN ","SOL 100-10\/5","118","Select","Select",""],["","65862067899","ALPRAZOLAM ","TAB 1MG","30","Select","Select",""],["","67877021905","CEPHALEXIN ","CAP 500MG","14","Select","Select",""],["","64679096105","AZITHROMYCIN ","TAB 250MG","6","Select","Select",""],["","00093221001","SUCRALFATE ","TAB 1GM","120","Select","Select",""],["","31722053401","METHOCARBAM ","TAB 750MG","14","Select","Select",""],["","13668011810","LOSARTAN\/HCT ","TAB 100-25","30","Select","Select",""],["","99073070805","FREESTYLE    MIS LITE","MIS LITE","1","Select","Select",""],["","99073013001","FREESTYLE    MIS LANCETS","MIS LANCETS","100","Select","Select",""],["","62756052269","SUMATRIPTAN ","TAB 100MG","9","Select","Select",""],["","65162027250","SMZ\/TMP ","TAB 800-160","20","Select","Select",""],["","65862001501","AMOXICILLIN ","TAB 875MG","20","Select","Select",""],["","69097015907","MELOXICAM ","TAB 15MG","30","Select","Select",""],["","67877019805","AMLODIPINE ","TAB 5MG","30","Select","Select",""],["","69547035302","NARCAN ","SPR ","2","Select","Select",""],["","45802005911","NYSTATIN ","CRE 100000","60","Select","Select",""],["","00254100752","ALBUTEROL ","AER HFA","6.7","Select","Select",""],["","69097067805","PREGABALIN ","CAP 50MG","60","Select","Select",""],["","00378064110","PREDNISONE ","TAB 10MG","30","Select","Select",""],["","63824000834","MUCINEX ","TAB 600MG ER","28","Select","Select",""],["","65162074510","PROMETHAZINE ","12.5MG","20","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":[[["Yes","Select","","","","","Select","",""],["Yes","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":""}]}]}