{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"CLIFFORD   R PALMER II","gend":0,"add":"1203 BUOY CT","city":"SUFFOLK","state":"VA","zip":"23435-9998","dob":"1959-04-05","pno":"757\/641-7546","cno":"757\/641-7546","email":"","pphy":"QUIRK, JESSICA L MD","ppno":"","pcpadd":"3920 A BRIDGE RD STE 107","pcpcity":"SUFFOLK","pcpstate":"VA","pcpzip":23435,"pcpcounty":"","pcpid":139537,"pcpname":"EVMS Portsmouth Family Medicine","insh":"900035294*01","cliId":"4YC7GA9CK40","plan":"OHP","program":"MEDICARE","lob":"MA-Non DSNP","region":"TIDEWATER","aligned":"","ano":"757\/641-7236","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/983-2201","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["B35.1","L60.3","Z09.","B07.8","L82.1","D18.00","D22.9","L81.4","Z12.83","Z71.9","E78.00","R32.","Z12.5","I10.","Z79.899","Z13.1","G40.009","G93.89","I67.82","G80.9","G81.91","R97.20","N32.81","R35.0","R39.15","R35.1","D75.89","G40.89","G80.2","M85.80","Z79.51","D48.5","H53.40","H40.013","H25.013","Z00.00","G40.919","E55.9","E78.5","Z13.0","R73.9","H61.21","G40.909","K21.9","L82.0","H92.01","H93.291","D64.9","Z13.820","M85.89","F32.9"],"date":["2021-04-27","2021-04-27","2021-04-27","2021-06-08","2021-10-25","2021-06-08","2021-06-08","2021-06-08","2021-06-08","2021-10-25","2021-02-26","2021-08-27","2021-02-26","2021-08-27","2020-08-26","2020-01-18","2021-09-20","2021-07-19","2021-07-19","2021-07-19","2021-07-19","2021-09-29","2021-09-29","2021-09-29","2021-09-29","2021-09-29","2021-07-02","2021-05-17","2021-06-07","2021-07-13","2021-07-13","2021-10-25","2020-08-20","2020-08-20","2020-08-20","2021-08-27","2020-08-26","2020-08-26","2020-08-26","2020-08-26","2020-08-26","2021-08-27","2021-08-27","2020-01-17","2020-06-08","2020-09-30","2020-09-30","2021-05-17","2021-07-13","2021-07-13","2021-08-27"],"priorHcc":[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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":[["","68382050010","OMEPRAZOLE","40MG","90","Select","Select",""],["","55111012205","ATORVASTATIN","20MG","90","Select","Select",""],["","65162021210","PHENYTOIN","100MG","90","Select","Select",""],["","68180098103","LISINOPRIL","20MG","60","Select","Select",""],["","68180072103","AMLODIPINE","10MG","30","Select","Select",""],["","00378623201","CITALOPRAM","20MG","90","Select","Select",""],["","58160082311","SHINGRIX","50\/0.5ML","1","Select","Select",""],["","42037010478","DEBROX","6.5% OT","15","Select","Select",""],["","51862094205","DIAZEPAM","5MG","-1","Select","Select",""],["","33332032001","AFLURIA","2020-21","0","Select","Select",""],["","70461032103","FLUCLVX","2021-22","0","Select","Select",""],["","68382050010","OMEPRAZOLE ","CAP 40MG","90","Select","Select",""],["","68180098103","LISINOPRIL ","TAB 20MG","60","Select","Select",""],["","55111012205","ATORVASTATIN ","TAB 20MG","90","Select","Select",""],["","65162021210","PHENYTOIN ","CAP 100MG","-90","Select","Select",""],["","00378623201","CITALOPRAM ","TAB 20MG","-90","Select","Select",""],["","68180072103","AMLODIPINE ","TAB 10MG","30","Select","Select",""],["","33332032001","AFLURIA ","INJ 2020-21","0","Select","Select",""],["","58160082311","SHINGRIX ","INJ 50\/0.5ML","1","Select","Select",""],["","42037010478","DEBROX ","SOL 6.5% OT","15","Select","Select",""],["","51862094205","DIAZEPAM ","TAB 5MG","-1","Select","Select",""],["","70461032103","FLUCLVX ","INJ 2021-22","0","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":""}]}]}