{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"RICHARD FENSTERMAKER JR","gend":0,"add":"21 W POLLUX CIRCLE","city":"PORTSMOUTH","state":"VA","zip":"23701-2029","dob":"1974-02-14","age":"","mstatus":"","insh":7821713,"cliId":"","pno":7573722774,"cno":7573722774,"email":"","ename":"","eno":"","pphy":"ABDELSHAHEED, SAMIR T","ppno":7574883333,"pcpadd":"6111 PORTSMOUTH BLVD, ","pcpcity":"PORTSMOUTH","pcpstate":"VA","pcpzip":237011445,"pcpcounty":"","pcpid":"","pcpname":"","plan":"VPHP","program":"MEDICAID","lob":"VPM4","region":"TIDEWATER","aligned":"","ano":"","add2":"                                                            ","add3":"","madd1":"4144 Cornland Rd","madd2":"                                                            ","madd3":"","mcity":"Chesapeake","mstate":"VA","mzip":"23322-3178","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R07.9","I38","R60.0","B19.20","A41.01","R78.81","T82.7XXD","G89.29","E87.1","R00.1","A41.9","Z95.0","K12.2","R55","I82.622","Z45.018","I82.B12","B18.2","S19.9XXA","S09.90XA","S82.131A","S32.401A","V87.7XXA","S32.409A","S82.143A","S32.421A","S73.014A","S72.051A","G47.00","F41.9","S60.221A","S69.91XA","W22.8XXA","F17.210","B99.9","M79.89","L03.012","M54.9","Z87.39","B95.62","I49.5","Z86.59","M65.9","F17.200","L08.9","M20.011","R06.00","J18.9","I95.9","B95.8","R91.8","F11.90","F12.90","B95.61","T82.7XXA","D69.6","F19.10","R60.9","R52","M25.551","Z68.26","I82.722","F11.10","Z87.898","S61.205A","I25.10","M00.9","M54.5","A49.02","M25.512","Z86.718","M79.609","Z79.899","Z88.8","Z87.891","R06.02","I82.729","B34.9","F12.10","F11.20","Y83.1","E87.0","I82.611","I82.A12","S29.9XXA","S39.91XA","S39.93XA","S73.004A","S82.141A","S27.321A","S32.491A","V48.0XXA","S82.144A","S00.31XA","M25.561","Z86.19","Z88.5","R40.4","F15.10","Z91.018","M51.36","S32.421D","X58.XXXD","Z98.890","S69.92XA","M65.842","Z86.14","Z79.01","G43.909","Z91.81","Z87.81","Z86.79","M65.852","R51","R03.1","I44.30","R41.82","T40.601A","M51.37","M41.9","M79.602","S72.001A","I82.629","F19.11","S73.014D","M65.042","M12.542","L02.512","R07.89","R53.83","R94.31","Z83.3","I26.90","R16.1","F11.11","R82.5","M47.816","T82.897A","M79.645","M65.00","M77.9","T84.84XA","M65.88","M79.642","M61.451","I49.9","J43.2","R07.81","Z20.828","M19.041","M54.10","M54.2","R94.6","J44.0","A49.01","R00.0","L03.90","I51.7","R05","I44.2","S89.91XA","R40.0","T14.90XA","M54.6","M79.641","S61.210A","W26.0XXA","Z88.6","M20.019","E86.0","J81.1","Z01.818","Z01.810","R41.0","V89.2XXA","Y92.410","S72.091A","S00.91XA","S73.011A","E78.5","E55.9","N42.9","Z13.31"],"date":["2021-05-08","2019-05-03","2019-08-05","2021-03-27","2019-06-07","2019-06-07","2019-06-07","2021-03-26","2019-05-18","2019-05-20","2019-05-16","2021-05-08","2019-05-15","2019-06-07","2019-05-25","2019-05-21","2019-08-05","2021-03-26","2019-06-25","2019-06-25","2019-06-28","2019-07-10","2019-07-01","2019-07-01","2019-07-01","2019-07-01","2019-11-12","2019-07-01","2020-07-09","2021-05-08","2019-10-02","2019-10-02","2019-10-02","2021-05-08","2019-12-30","2021-03-27","2020-02-03","2020-02-05","2020-02-03","2020-02-04","2020-06-22","2020-02-05","2020-03-02","2021-03-28","2020-02-22","2021-02-02","2021-03-26","2019-05-03","2019-04-30","2019-05-03","2019-05-03","2019-05-03","2019-05-03","2019-05-05","2019-06-07","2019-05-03","2020-02-05","2021-05-08","2021-02-02","2021-03-27","2019-07-16","2019-12-31","2020-01-03","2019-12-31","2019-12-31","2020-08-12","2020-01-03","2020-06-22","2020-02-05","2020-06-22","2021-05-08","2021-03-26","2021-05-08","2021-03-26","2021-03-27","2021-05-08","2021-03-29","2021-05-08","2019-12-31","2019-05-01","2019-05-03","2019-05-03","2019-05-03","2019-06-25","2019-06-25","2019-06-25","2019-06-25","2019-06-25","2019-06-25","2019-06-25","2019-06-25","2019-06-25","2019-06-25","2019-06-25","2019-06-25","2021-05-08","2021-05-08","2019-07-08","2019-07-08","2020-08-12","2019-07-10","2019-11-12","2019-10-07","2021-02-02","2019-12-27","2020-02-03","2020-02-03","2020-02-03","2020-02-03","2020-02-03","2021-03-27","2021-03-27","2021-03-28","2019-04-30","2019-04-30","2019-05-21","2019-07-09","2019-07-08","2019-07-08","2019-07-08","2019-08-05","2019-08-12","2019-12-30","2019-08-12","2019-11-12","2019-12-31","2019-12-31","2020-03-02","2021-05-08","2021-05-08","2021-05-08","2021-05-08","2019-04-30","2019-04-30","2019-04-30","2019-04-30","2019-04-30","2019-05-02","2020-02-22","2020-02-04","2020-02-22","2020-08-12","2021-03-26","2019-06-26","2019-07-01","2019-08-05","2019-08-05","2020-02-03","2020-08-10","2021-02-02","2021-03-27","2021-03-27","2021-03-27","2019-05-03","2019-05-03","2019-05-02","2019-05-03","2019-05-07","2019-05-08","2019-05-21","2019-06-25","2019-07-08","2019-12-27","2019-07-09","2019-07-09","2020-03-09","2020-03-09","2020-03-09","2020-03-19","2019-04-30","2019-05-04","2019-05-05","2019-05-06","2019-06-07","2019-06-25","2019-06-25","2019-06-25","2019-06-25","2019-06-25","2021-01-13","2021-01-13","2021-01-13","2021-01-13"],"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":[["","68382080510","TRAZODONE ","TAB 50MG","60","Select","Select",""],["","42806016105","HYDROXYZ ","TAB 50MG","30","Select","Select",""],["","68001019703","ESCITALOPRAM ","TAB 20MG","30","Select","Select",""],["","65862001205","SERTRALINE ","TAB 50MG","90","Select","Select",""],["","68382005005","MELOXICAM ","TAB 7.5MG","20","Select","Select",""],["","00591024105","LORAZEPAM ","TAB 1MG","16","Select","Select",""],["","10702002301","OXYCODONE ","CAP 5MG","10","Select","Select",""],["","00093321205","CLONAZEPAM ","TAB 1MG","16","Select","Select",""],["","69547035302","NARCAN ","SPR ","2","Select","Select",""],["","00003089421","ELIQUIS ","TAB 5MG","60","Select","Select",""],["","65162046650","IBUPROFEN ","TAB 800MG","90","Select","Select",""],["","70010077005","METHOCARBAM ","TAB 750MG","30","Select","Select",""],["","13668000810","ZOLPIDEM ","TAB 10MG","30","Select","Select",""],["","61442012110","FAMOTIDINE ","TAB 20MG","60","Select","Select",""],["","55111015330","ONDANSETRON ","TAB 4MG","30","Select","Select",""],["","53746027205","SMZ\/TMP ","TAB 800-160","46","Select","Select",""],["","42858010201","OXYCOD\/APAP ","TAB 5-325MG","6","Select","Select",""],["","00143980305","DOXYCYCL ","CAP 100MG","20","Select","Select",""],["","13668001005","CITALOPRAM ","TAB 20MG","30","Select","Select",""],["","27241009990","DULOXETINE ","CAP 60MG","30","Select","Select",""],["","68462019005","NAPROXEN ","TAB 500MG","20","Select","Select",""],["","57237023301","SMZ-TMP ","TAB 800-160","42","Select","Select",""],["","00904645780","DOK ","CAP 100MG","30","Select","Select",""],["","42571016242","AMOX\/K ","TAB 875-125","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":[[["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":""}]}]}