{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"GAIL   S DAY","gend":1,"add":"2421 E PRINCESS ANNE ROAD APT J","city":"NORFOLK","state":"VA","zip":"23504-9998","dob":"1948-10-17","age":"","mstatus":"","insh":"900034973*01","cliId":"2Y34W69NN82","pno":"757\/679-4230","cno":"757\/679-4230","email":"","ename":"","eno":"","pphy":"GRANT JR, THOMAS R MD","ppno":"757\/446-5955","pcpadd":"825 FAIRFAX AVE STE 118","pcpcity":"NORFOLK","pcpstate":"VA","pcpzip":23507,"pcpcounty":"","pcpid":100070,"pcpname":"EVMS Ghent Family Medicine","plan":"OHP","program":"MEDICARE","lob":"MA-Non DSNP","region":"TIDEWATER","aligned":"","ano":"757\/469-8237","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/446-5196","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["I10.","F17.200","Z90.710","Z78.0","Z12.31","F32.9","N95.1","H25.13","H43.22","H40.053","H40.003","G47.00","Z12.11","F32.0","E78.5","J45.20","K21.9","E55.9","H26.9","N32.81","Z72.0","Z82.5","R19.7","Z00.00","H25.12","I11.0","I50.9","F41.9","Z13.31","H25.11","H20.00","J45.909","F17.210"],"date":["2021-09-10","2021-07-28","2020-08-20","2020-08-20","2021-08-23","2021-07-26","2020-08-20","2021-07-21","2021-07-13","2021-07-13","2021-07-13","2021-07-26","2020-05-14","2020-11-28","2021-08-10","2020-11-28","2020-11-28","2021-08-10","2021-09-10","2020-11-28","2020-11-28","2020-11-28","2020-05-11","2021-07-28","2021-07-30","2021-07-30","2021-07-30","2021-07-30","2021-07-28","2021-09-10","2021-11-09","2021-09-10","2021-09-10"],"priorHcc":[null,"","","","","","","","","","","","","","","","","",null,"","","","","","","","","","",null,null,null,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":[["","24979010202","BUPROPN ","300MG XL","-30","Select","Select",""],["","64980043110","OXYBUTYNIN ","5MG","60","Select","Select",""],["","67877019910","AMLODIPINE ","10MG","30","Select","Select",""],["","67877051310","ATORVASTATIN ","40MG","30","Select","Select",""],["","62332000271","FAMOTIDINE ","40MG","30","Select","Select",""],["","16729011917","MONTELUKAST ","10MG","-30","Select","Select",""],["","51672129802","KETOCONAZOLE ","2%","90","Select","Select",""],["","00173071720","ADVAIR ","230\/21","36","Select","Select",""],["","59310057922","PROAIR ","","8","Select","Select",""],["","58160082311","SHINGRIX ","50\/0.5ML","1","Select","Select",""],["","68180051202","LISINOPRIL ","2.5MG","-30","Select","Select",""],["","00781286810","OMEPRAZOLE ","20MG DR","-30","Select","Select",""],["","64380080308","RANITIDINE ","150MG","30","Select","Select",""],["","68382004001","PROMETHAZINE ","12.5MG","20","Select","Select",""],["","37000035905","PRILOSEC ","20MG","30","Select","Select",""],["","40985025073","VITAMIN ","2000UNIT","30","Select","Select",""],["","68645056259","IBUPROFEN ","600MG","15","Select","Select",""],["","49281012065","FLUZONE ","PF 20-21","1","Select","Select",""],["","69097084507","CYCLOBENZAPR ","5MG","9","Select","Select",""],["","50111056001","TRAZODONE ","50MG","-30","Select","Select",""],["","65162083366","DICLOFENAC ","1%","100","Select","Select",""],["","00591352530","LIDOCAINE ","5%","15","Select","Select",""],["","024208060203","PROLENSA ","0.07%","-3","Select","Select",""],["","017478071310","OFLOXACIN ","0.3% OP","-5","Select","Select",""],["","024208050707","LOTEMAX ","0.38%","5","Select","Select",""],["","51672129802","KETOCONAZOLE","2%","30","Select","Select",""],["","68180051202","LISINOPRIL","2.5MG","-30","Select","Select",""],["","24979010202","","300MG XL","30","Select","Select",""],["","24979010202","BUPROPN","300MG XL","30","Select","Select",""],["","67877051310","ATORVASTATIN","40MG","30","Select","Select",""],["","67877019910","AMLODIPINE","10MG","30","Select","Select",""],["","59310057922","PROAIR","","-8","Select","Select",""],["","00173071720","ADVAIR","230\/21","36","Select","Select",""],["","62332000271","FAMOTIDINE","40MG","30","Select","Select",""],["","16729011917","MONTELUKAST","10MG","30","Select","Select",""],["","64980043110","OXYBUTYNIN","5MG","60","Select","Select",""],["","58160082311","SHINGRIX","50\/0.5ML","1","Select","Select",""],["","68382004001","PROMETHAZINE","12.5MG","20","Select","Select",""],["","00781286810","OMEPRAZOLE","20MG DR","-30","Select","Select",""],["","64380080308","RANITIDINE","150MG","30","Select","Select",""],["","40985025073","VITAMIN","2000UNIT","30","Select","Select",""],["","49281012065","FLUZONE","PF 20-21","-1","Select","Select",""],["","68645056259","IBUPROFEN","600MG","15","Select","Select",""],["","69097084507","CYCLOBENZAPR","5MG","9","Select","Select",""],["","50111056001","TRAZODONE","50MG","-30","Select","Select",""],["","65162083366","DICLOFENAC","1%","100","Select","Select",""],["","00591352530","LIDOCAINE","5%","15","Select","Select",""],["","37000045504","PRILOSEC","20MG","30","Select","Select",""],["","24208060203","PROLENSA","0.07%","3","Select","Select",""],["","24208050707","LOTEMAX","0.38%","-5","Select","Select",""],["","17478071310","OFLOXACIN","0.3% OP","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","",""],["No","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["N\/A","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":""}]}]}