{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"CYNTHIA BAKER","gend":1,"add":"114 CROMWELL PKWY APT A104","city":"NORFOLK","state":"VA","zip":"23505-9998","dob":"1954-04-11","age":"","mstatus":"","insh":"900035742*01","cliId":"8Q75E39MU71","pno":"757\/650-6855","cno":"757\/650-6855","email":"","ename":"","eno":"","pphy":"GENTRY, BARRY C MD","ppno":"757\/446-5955","pcpadd":"825 FAIRFAX AVENUE SUITE 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":"Non-DSNP","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":["E78.5","I65.29","Z87.891","Z00.00","Z90.2","Z85.118","I73.9","I10.","Z48.3","R91.8","Z79.899","Z79.82","Z79.02","Z77.120","Z12.31","Z23.","I35.1","C34.11","Z08.","I25.10","Q26.8","R00.2","H04.123","H25.813","I70.90","D36.10","R91.1","Z12.11"],"date":["2020-01-28","2020-01-28","2020-01-28","2020-01-28","2021-06-10","2021-06-10","2021-05-06","2020-11-09","2020-11-09","2021-05-12","2020-11-09","2020-11-09","2020-11-09","2020-11-09","2020-11-23","2020-01-28","2020-08-10","2021-05-12","2020-08-05","2019-08-07","2019-08-07","2019-12-18","2019-12-30","2019-12-30","2020-02-05","2021-05-06","2021-06-10","2021-05-23"],"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":[["","70436000203","POT CHLORIDE","TAB 10MEQ ER","180","Select","Select",""],["","68180072003","AMLODIPINE","TAB 5MG","30","Select","Select",""],["","70377003012","ATORVASTATIN","TAB 80MG","90","Select","Select",""],["","70461012003","FLUAD QUADRI","INJ 0.5ML","0","Select","Select",""],["","23155000810","HYDROCHLOROT","TAB 25MG","90","Select","Select",""],["","65862035790","CLOPIDOGREL","TAB 75MG","90","Select","Select",""],["","23155000301","HYDRALAZINE","TAB 50MG","180","Select","Select",""],["","69097094312","GABAPENTIN","CAP 300MG","90","Select","Select",""],["","23916360","RESTASIS","EMU 0.0005","180","Select","Select",""],["","45802091987","CETIRIZINE","TAB 10MG","60","Select","Select",""],["","115169449","EPINEPHRINE","INJ 0.3MG","2","Select","Select",""],["","68180072003","AMLODIPINE BESYLATE","","90","Select","Select",""],["","45802091987","CETIRIZINE HYDROCHLORIDE","","60","Select","Select",""],["","23155000301","HYDRALAZINE HYDROCHLORIDE ","","180","Select","Select",""],["","70436000203","POTASSIUM CHLORIDE ER","","-60","Select","Select",""],["","23155000810","HYDROCHLOROTHIAZIDE","","90","Select","Select",""],["","70377003012","ATORVASTATIN CALCIUM ","","90","Select","Select",""],["","70461012003","FLUAD QUADRIVALENT INFLUENZA VACCINE FOR ADULTS","","0","Select","Select",""],["","23155000301","HYDRALAZINE HYDROCHLORIDE","","180","Select","Select",""],["","70377003012","ATORVASTATIN CALCIUM","","-90","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":""}]}]}