{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"GRACE   M GARDNER","gend":1,"add":"11179 FREDENBURG ROAD","city":"WAKEFIELD","state":"VA","zip":"23888-9998","dob":"1953-03-22","age":"","mstatus":"","insh":"900038839*01","cliId":"8AU6M37RQ65","pno":"757\/899-2661","cno":"757\/899-2661","email":"","ename":"","eno":"","pphy":"POPE, SHANNON MD","ppno":"757\/357-3331","pcpadd":"201 GUMWOOD DRIVE","pcpcity":"SMITHFIELD","pcpstate":"VA","pcpzip":23430,"pcpcounty":"","pcpid":131791,"pcpname":"","plan":"OHP","program":"MEDICARE","lob":"MA-Non DSNP","region":"CENTRAL","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"000\/000-0000","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["H04.123","H25.13","H47.321","T78.40XA","H25.12","Z96.1","H02.831","H02.834","Z00.00","Z68.29","Z13.89","Z12.11","I10.","M54.16","F41.1","E78.5","H35.3131","H26.491","H26.492","G47.00","D50.8","Z98.41","B88.0","H25.11","H10.45","Z98.49"],"date":["2021-08-20","2020-10-05","2021-08-20","2020-10-27","2020-10-27","2021-08-20","2021-02-17","2021-02-17","2020-08-26","2020-08-26","2020-08-26","2021-05-23","2020-08-26","2020-08-26","2020-08-26","2020-08-26","2021-08-20","2021-03-30","2021-05-07","2020-07-21","2020-08-28","2021-05-07","2021-08-20","2020-10-20","2021-08-20","2021-08-20"],"priorHcc":[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":[["","33342006510","VALSARTAN ","320MG","30","Select","Select",""],["","33342007810","VALSART\/HCTZ ","320-25MG","90","Select","Select",""],["","13668000905","CITALOPRAM ","10MG","90","Select","Select",""],["","65162044210","MECLIZINE ","25MG","30","Select","Select",""],["","00378064205","PREDNISONE ","20MG","10","Select","Select",""],["","69315030805","CIPROFLOXACN ","0.3% OP","5","Select","Select",""],["","49281012065","FLUZONE ","PF 20-21","1","Select","Select",""],["","24208083060","NEO\/POLY\/DEX ","0.1% OP","5","Select","Select",""],["","65862001401","AMOXICILLIN ","500MG","12","Select","Select",""],["","00005197102","PREVNAR ","","0","Select","Select",""],["","67405060301","FLUCONAZOLE ","150MG","1","Select","Select",""],["","00078091112","XIIDRA ","5%","180","Select","Select",""],["","00406012310","HYDROCO\/APAP ","5-325MG","8","Select","Select",""],["","60758011905","PREDNISOLONE ","1% OP","15","Select","Select",""],["","33342006510","","320MG","30","Select","Select",""],["","33342006510","VALSARTAN","320MG","30","Select","Select",""],["","13668000905","CITALOPRAM","10MG","90","Select","Select",""],["","33342007810","VALSART\/HCTZ","320-25MG","90","Select","Select",""],["","65162044210","MECLIZINE","25MG","-30","Select","Select",""],["","67405060301","FLUCONAZOLE","150MG","1","Select","Select",""],["","69315030805","CIPROFLOXACN","0.3% OP","5","Select","Select",""],["","65862001401","AMOXICILLIN","500MG","12","Select","Select",""],["","24208083060","NEO\/POLY\/DEX","0.1% OP","5","Select","Select",""],["","00005197102","PREVNAR","","0","Select","Select",""],["","00406012310","HYDROCO\/APAP","5-325MG","8","Select","Select",""],["","00078091112","XIIDRA","5%","180","Select","Select",""],["","60758011905","PREDNISOLONE","1% OP","15","Select","Select",""],["","70377002711","ATORVASTATIN","10MG","90","Select","Select",""],["","69097083305","SERTRALINE","25MG","30","Select","Select",""],["","49281012065","FLUZONE","PF 20-21","1","Select","Select",""],["","00378064205","PREDNISONE","20MG","10","Select","Select",""],["","69097083305","SERTRALINE ","TAB 25MG","30","Select","Select",""],["","70377002711","ATORVASTATIN ","TAB 10MG","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":""}]}]}