{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"CIARA GRAY","gend":1,"add":"859 LEXINGTON ST APT B","city":"NORFOLK","state":"VA","zip":"23504-9998","dob":"1993-06-02","age":"","mstatus":"","insh":"900035580*01","cliId":"9VV7FX8NE58","pno":"757\/647-2311","cno":"757\/647-2311","email":"","ename":"","eno":"","pphy":"RUBINO, MARY C 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":"DSNP","region":"TIDEWATER","aligned":"Y","ano":7576235695,"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":["F25.0","F70.","O09.90","O9A.212","R10.31","Z3A.24","Y04.0XXA","O09.893","F32.9","G40.89","Z3A.27","R73.09","I61.5","R56.9","F25.1","K59.00","R41.82","T14.90XA","O26.892","R07.81","Z3A.16","O98.812","B37.3","O23.12","Z3A.18","R39.15","T18.9XXA","F25.9","J45.909","G40.909","F90.9","F79.","Z91.14","Z79.899","F31.70","F14.10","R53.1","F33.2","S49.92XA","S69.92XA","T76.21XA","R78.2","F31.9","Z79.1","F44.5","Z86.73","R42.","F33.9","O36.8120","R10.2","O99.342","O99.89","F99.","O46.93","O99.353","O99.513","O99.343","Z3A.29","Z45.2","J98.4","R91.8","L76.82","Z86.59","Z74.3","R10.9","G89.29","Z51.81","S01.551A","S09.90XA","S19.9XXA","O36.80X0","O35.1XX0","Z3A.12","R10.811","Z04.3","W01.0XXA","F84.0","O99.512","O99.282","E16.2","O99.352","F91.3","F60.3","Z78.1","G89.18","Z39.1","Z34.82","Z34.83","S39.012A","Z87.81","G89.28","O26.891","O64.1XX0","O36.8130","O36.8330","Z3A.33","O76.","O32.2XX0","Z37.0","Z11.3","O26.852","S39.91XA","O22.43","Z3A.32","Z91.5","Z91.410","Z83.3","J34.89","R43.0","J34.2","O09.00","Z04.9","S39.92XA","S89.92XA","Z33.1","Z84.89","R10.32","Z3A.23","F20.9","R07.0","T71.193A","S10.81XA","M54.2","S46.912A","S80.02XA","M25.512","V87.7XXA","M79.5","S61.012A","S61.411A","Z23.","M54.5","M25.562","X50.0XXA","R19.00","V43.02XA","Y92.488","Y93.89","O46.8X1","O41.8X10","Z3A.01","O99.341","R11.0","O09.892","O35.9XX0","O09.899","O34.219","Z3A.11","O20.8","O21.9","O99.331","O99.511","F17.210","Z65.1","R11.2","O09.92","N39.0","Z12.4","Z3A.20","R10.30","Z3A.13"],"date":["2021-01-18","2021-01-18","2021-09-20","2019-11-07","2019-11-04","2019-11-10","2019-11-04","2019-11-22","2020-01-04","2019-11-22","2019-11-22","2019-11-22","2020-01-28","2020-11-24","2020-09-15","2021-06-14","2020-11-04","2020-10-22","2021-10-27","2019-09-07","2019-09-07","2019-09-19","2019-09-19","2019-09-19","2021-10-13","2019-09-19","2019-11-10","2021-07-18","2021-10-19","2020-11-04","2021-06-14","2021-07-18","2020-11-01","2021-08-23","2020-11-02","2020-11-04","2020-11-04","2021-02-19","2020-10-04","2019-11-03","2019-11-03","2020-11-01","2021-08-23","2020-11-01","2020-11-21","2020-11-21","2020-11-21","2020-11-24","2019-11-02","2021-08-23","2019-11-07","2019-11-07","2020-04-16","2019-12-04","2020-01-04","2020-01-04","2020-01-04","2019-12-04","2020-01-05","2020-01-06","2020-01-06","2021-04-06","2020-04-12","2020-11-01","2021-10-27","2021-05-06","2020-06-30","2020-10-22","2020-10-22","2020-10-22","2021-09-01","2019-08-08","2019-08-08","2019-09-07","2019-09-19","2019-09-19","2019-11-07","2019-11-07","2019-11-07","2019-11-07","2019-11-07","2019-11-07","2019-11-07","2019-11-07","2020-01-06","2020-01-20","2020-01-20","2020-01-20","2020-10-05","2020-10-05","2021-04-06","2021-08-23","2020-01-04","2020-01-04","2020-01-04","2020-01-04","2020-01-04","2020-01-04","2020-01-04","2020-08-14","2019-10-27","2019-11-07","2019-12-27","2019-12-27","2020-01-04","2020-01-04","2020-01-04","2020-11-05","2020-11-05","2020-11-05","2019-09-17","2020-05-23","2021-06-14","2021-06-14","2019-08-06","2019-08-08","2019-10-24","2019-10-24","2019-10-24","2020-05-23","2020-05-23","2020-05-23","2020-05-23","2020-10-04","2020-10-04","2020-10-04","2020-10-04","2021-04-20","2021-04-20","2021-04-20","2021-04-20","2021-06-14","2021-06-14","2019-11-03","2021-06-07","2021-06-14","2021-06-14","2021-06-14","2021-07-18","2021-07-18","2021-07-19","2021-08-23","2021-07-18","2021-09-14","2021-10-13","2021-10-13","2021-10-13","2021-08-24","2021-08-24","2021-08-23","2021-08-23","2021-08-23","2021-08-23","2021-08-23","2021-08-23","2021-09-14","2021-09-14","2021-09-20","2021-10-27","2021-10-27","2021-09-01"],"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]}},{"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":[["","55111016730","OLANZAPINE","TAB 15MG","-30","Select","Select",""],["","62332024331","FLUOXETINE","TAB 20MG","30","Select","Select",""],["","69784018014","POLYETH GLYC","POW 3350 NF","28","Select","Select",""],["","11822029233","RA LAXATIVE","TAB 5MG EC","30","Select","Select",""],["","62756018488","OXCARBAZEPIN","TAB 300MG","-90","Select","Select",""],["","69315013601","BENZTROPINE","TAB 0.5MG","-60","Select","Select",""],["","11822365670","ACETAMIN","TAB 500MG","30","Select","Select",""],["","11822010233","PAIN RELIEF","TAB 500MG","30","Select","Select",""],["","65162083366","DICLOFENAC","GEL 0.01","100","Select","Select",""],["","50228018005","GABAPENTIN","CAP 300MG","-15","Select","Select",""],["","60505084805","AZELASTINE","SPR 0.0015","30","Select","Select",""],["","60432026415","FLUTICASONE","SPR 50MCG","16","Select","Select",""],["","49483060450","IBUPROFEN","TAB 800MG","-30","Select","Select",""],["","77333071510","PRENATAL","TAB ","2","Select","Select",""],["","904680861","MONTELUKAST","TAB 10MG","2","Select","Select",""],["","904645780","DOK","CAP 100MG","30","Select","Select",""],["","904585652","CALCIUM + D3","TAB 600MG","60","Select","Select",""],["","42494030124","HYDROCORT AC","SUP 25MG","30","Select","Select",""],["","42858010250","OXYCOD\/APAP","TAB 5-325MG","18","Select","Select",""],["","173071920","FLOVENT HFA","AER 110MCG","12","Select","Select",""],["","57896086905","PROBIOTIC","CAP 250MG","2","Select","Select",""],["","62584089701","FOLIC ACID","TAB 1MG","84","Select","Select",""],["","904626945","ZIPRASIDONE","CAP 20MG","10","Select","Select",""],["","29300022701","METRONIDAZOL","TAB 500MG","4","Select","Select",""],["","69543025810","PREPLUS","TAB 27-1MG","30","Select","Select",""],["","245010801","FERROUS SULF","TAB 325MG EC","90","Select","Select",""],["","39328002430","LIDOCAINE","CRE 0.04","30","Select","Select",""],["","68382005001","MELOXICAM","TAB 7.5MG","21","Select","Select",""],["","904198359","MAPAP","TAB 500MG","30","Select","Select",""],["","10939057833","3 DAY VAGINL","CRE 0.02","21","Select","Select",""],["","24385011009","CLOTRIMAZOLE","CRE 3 DAY","21","Select","Select",""],["","65862001901","CEPHALEXIN","CAP 500MG","14","Select","Select",""],["","68462010340","FLUCONAZOLE","TAB 150MG","1","Select","Select",""],["","8290236850","LACTINEX","CHW ","30","Select","Select",""],["","63044015001","PRENATAL VIT","TAB LOW IRON","-30","Select","Select",""],["","904759080","FEROSUL","TAB 325MG","30","Select","Select",""],["","904642281","PEG 3350","POW ","48","Select","Select",""],["","85126001","GYNE-LOTRIMI","CRE 3","21","Select","Select",""],["","65862019105","CYCLOBENZAPR","TAB 10MG","15","Select","Select",""],["","904680861","MONTELUKAST SODIUM ","","9","Select","Select",""],["","85126001","GYNE-LOTRIMIN 3 ","","21","Select","Select",""],["","62756018388","OXCARBAZEPINE ","","60","Select","Select",""],["","49483060450","IBUPROFEN ","","-30","Select","Select",""],["","24385011009","GNP CLOTRIMAZOLE 3 ","","21","Select","Select",""],["","69543025810","PREPLUS ","","30","Select","Select",""],["","42858010250","OXYCODONE\/ACETAMINOPHEN","","18","Select","Select",""],["","904759080","FEROSUL ","","30","Select","Select",""],["","29300022701","METRONIDAZOLE ","","4","Select","Select",""],["","536408501","PRENATAL VITAMINS","","30","Select","Select",""],["","57896086905","PROBIOTIC ","","1","Select","Select",""],["","63044015001","PRENATAL VITAMINS PLUS LOW IRON ","","30","Select","Select",""],["","10939057833","SM 3-DAY VAGINAL","","21","Select","Select",""],["","904626945","ZIPRASIDONE HYDROCHLORIDE ","","10","Select","Select",""],["","69315013601","BENZTROPINE MESYLATE ","","60","Select","Select",""],["","42494030124","HYDROCORTISONE ACETATE","","30","Select","Select",""],["","904645780","DOK ","","30","Select","Select",""],["","62332024331","FLUOXETINE HYDROCHLORIDE","","30","Select","Select",""],["","245010801","FERROUS SULFATE ","","90","Select","Select",""],["","11822365670","RA ACETAMINOPHEN EXTRA STRENGTH ","","30","Select","Select",""],["","68382005001","MELOXICAM ","","21","Select","Select",""],["","45802086803","POLYETHYLENE GLYCOL 3350","","510","Select","Select",""],["","39328002430","LIDOCAINE ","","30","Select","Select",""],["","60432026415","FLUTICASONE PROPIONATE","","16","Select","Select",""],["","65862019105","CYCLOBENZAPRINE HYDROCHLORIDE","","15","Select","Select",""],["","60505084805","AZELASTINE HCL","","30","Select","Select",""],["","16571020110","DICLOFENAC SODIUM DR ","","20","Select","Select",""],["","65162083366","DICLOFENAC SODIUM","","-100","Select","Select",""],["","11822010233","RA PAIN RELIEF ACETAMINOPHEN","","30","Select","Select",""],["","31722072890","MONTELUKAST SODIUM","","-30","Select","Select",""],["","24385011009","GNP CLOTRIMAZOLE 3","","21","Select","Select",""],["","00085126001","GYNE-LOTRIMIN 3","","21","Select","Select",""],["","29300022701","METRONIDAZOLE","","4","Select","Select",""],["","63044015001","PRENATAL VITAMINS PLUS LOW IRON","","-30","Select","Select",""],["","00904626945","ZIPRASIDONE HYDROCHLORIDE","","-10","Select","Select",""],["","62756018388","OXCARBAZEPINE","","60","Select","Select",""],["","69315013601","BENZTROPINE MESYLATE","","60","Select","Select",""],["","11822365670","RA ACETAMINOPHEN EXTRA STRENGTH","","30","Select","Select",""],["","00245010801","FERROUS SULFATE","","90","Select","Select",""],["","16571020110","DICLOFENAC SODIUM DR","","20","Select","Select",""],["","31604002766","PRENATAL MULTI +DHA","","90","Select","Select",""],["","66993001968","ALBUTEROL SULFATE HFA","HFA","-18","Select","Select",""],["","65162046650","IBUPROFEN                                                             ","TAB 800MG","30","Select","Select",""],["","62756018488","OXCARBAZEPINE                                                         ","TAB 300MG","90","Select","Select",""],["","62332024331","FLUOXETINE HYDROCHLORIDE                                              ","TAB 20MG","30","Select","Select",""],["","55111016730","OLANZAPINE                                                            ","TAB 15MG","30","Select","Select",""],["","00904645780","DOK                                                                   ","CAP 100MG","30","Select","Select",""],["","00904585652","CALCIUM + D3                                                          ","TAB 600MG","60","Select","Select",""],["","42858010250","OXYCODONE\/ACETAMINOPHEN                                               ","TAB 5-325MG","18","Select","Select",""],["","39328010610","PRENATAL                                                              ","TAB 27-1MG","-30","Select","Select",""],["","69315013601","BENZTROPINE MESYLATE                                                  ","TAB 0.5MG","60","Select","Select",""],["","00245010801","FERROUS SULFATE                                                       ","TAB 325MG EC","90","Select","Select",""],["","45802086803","POLYETHYLENE GLYCOL 3350                                              ","POW 3350 NF","510","Select","Select",""],["","42494030124","HYDROCORTISONE ACETATE                                                ","SUP 25MG","30","Select","Select",""],["","00904759080","FEROSUL                                                               ","TAB 325MG","30","Select","Select",""],["","63044015005","PRENATAL VITAMINS PLUS LOW IRON                                       ","TAB LOW IRON","30","Select","Select",""],["","68382005001","MELOXICAM                                                             ","TAB 7.5MG","21","Select","Select",""],["","11822365670","RA ACETAMINOPHEN EXTRA STRENGTH                                       ","TAB 500MG","30","Select","Select",""],["","11822029233","RA LAXATIVE                                                           ","TAB 5MG EC","30","Select","Select",""],["","39328002430","LIDOCAINE                                                             ","CRE 0.04","30","Select","Select",""],["","00904642281","PEG 3350                                                              ","POW ","48","Select","Select",""],["","16571020110","DICLOFENAC SODIUM DR                                                  ","TAB 75MG DR","20","Select","Select",""],["","65862019105","CYCLOBENZAPRINE HYDROCHLORIDE                                         ","TAB 10MG","15","Select","Select",""],["","60505084805","AZELASTINE HCL                                                        ","SPR 0.0015","30","Select","Select",""],["","60432026415","FLUTICASONE PROPIONATE                                                ","SPR 50MCG","16","Select","Select",""],["","11822010233","RA PAIN RELIEF ACETAMINOPHEN                                          ","TAB 500MG","30","Select","Select",""],["","50228018005","GABAPENTIN                                                            ","CAP 300MG","-15","Select","Select",""],["","65162083366","DICLOFENAC SODIUM                                                     ","GEL 0.01","100","Select","Select",""],["","66993001968","ALBUTEROL SULFATE HFA                                                 ","AER HFA","18","Select","Select",""],["","76204020025","ALBUTEROL SULFATE                                                     ","NEB 0.00083","-75","Select","Select",""],["","59088081903","LIDOCAINE HCL\/HYDROCORTISONE ACETATE                                  ","CRE 3%-0.5%","28","Select","Select",""],["","31604002766","PRENATAL MULTI +DHA                                                   ","","90","Select","Select",""],["","00904699860","DOCUSATE SODIUM                                                       ","CAP 100MG","60","Select","Select",""],["","59267100002","PFIZER-BIONTECH COVID-19 VACCINE                                      ","INJ COVID-19","0","Select","Select",""],["","00173071920","FLOVENT HFA                                                           ","AER 110MCG","-12","Select","Select",""],["","11822316500","RA COL-RITE                                                           ","CAP 100MG","60","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","",""],["Yes","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["Yes","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":""}]}]}