{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"LISA   P COLLIE","gend":1,"add":"154 KENTUCK ROAD APT 1A","city":"DANVILLE","state":"VA","zip":"24540-9998","dob":"1961-11-20","age":"","mstatus":"","insh":"900039262*01","cliId":"9DM4ND6RP89","pno":"434\/770-1531","cno":"434\/770-1531","email":"","ename":"","eno":"","pphy":"MILAM, JAMES MD","ppno":"434\/791-4122","pcpadd":"705 MAIN ST","pcpcity":"DANVILLE","pcpstate":"VA","pcpzip":24541,"pcpcounty":"DANVILLE CITY","pcpid":140236,"pcpname":"","plan":"OHP","program":"MEDICARE","lob":"DSNP","region":"CHARLOTTESVILLE WESTERN","aligned":"N","ano":"Non-DSNP","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"434\/791-4126","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["H25.813","E11.9","Z79.84","D31.31","Z12.31","Z12.11","I10.","E66.9","Z12.4","M25.511","G89.29","M75.111"],"date":["2020-06-04","2021-07-15","2020-06-04","2020-06-04","2020-06-30","2020-09-14","2021-03-28","2021-07-15","2021-01-25","2021-05-26","2021-05-26","2021-05-26"],"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":{"indx":["","",""],"comment":["","",""],"sub":[]}},{"a":{"indx":["","",""],"comment":["","",""],"sub":[]}}]},{"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":[["","70377000315","SIMVASTATIN TAB ","20MG","90","Select","Select",""],["","23155000810","HYDROCHLOROT TAB ","25MG","90","Select","Select",""],["","70010049110","METFORMIN TAB ","500MG ER","360","Select","Select",""],["","33332032001","AFLURIA QUAD ","INJ 2020-21","0","Select","Select",""],["","65162075310","BENAZEPRIL TAB ","20MG","90","Select","Select",""],["","58160082311","SHINGRIX  ","INJ 50\/0.5ML","1","Select","Select",""],["","50742063460","METFORMIN ER ","TAB 1000MG","180","Select","Select",""],["","50742063360","METFORMIN","TAB 500MG ER","30","Select","Select",""],["","58160081912","SHINGRIX","INJ 50\/0.5ML","1","Select","Select",""],["","69097015907","MELOXICAM","TAB 15MG","30","Select","Select",""],["","65162075310","BENAZEPRIL","TAB 20MG","90","Select","Select",""],["","23155000810","HYDROCHLOROT","TAB 25MG","90","Select","Select",""],["","70377000315","SIMVASTATIN","TAB 20MG","-90","Select","Select",""],["","33332032001","AFLURIA QUAD","INJ 2020-21","0","Select","Select",""],["","50742063460","METFORMIN ER","TAB 1000MG","180","Select","Select",""],["","23155000810","HYDROCHLOROTHIAZIDE","","90","Select","Select",""],["","50742063360","METFORMIN HYDROCHLORIDE ER","","30","Select","Select",""],["","33332032001","AFLURIA QUADRIVALENT 2020-2021","","0","Select","Select",""],["","65162075310","BENAZEPRIL HYDROCHLORIDE","","90","Select","Select",""],["","69097015907","MELOXICAM ","","30","Select","Select",""],["","55111032101","GLIMEPIRIDE","2MG","90","Select","Select",""],["","23155000810","HYDROCHLOROTHIAZIDE                                                   ","TAB 25MG","90","Select","Select",""],["","70377000315","SIMVASTATIN                                                           ","TAB 20MG","90","Select","Select",""],["","65162075310","BENAZEPRIL HYDROCHLORIDE                                              ","TAB 20MG","90","Select","Select",""],["","50742063360","METFORMIN HYDROCHLORIDE ER                                            ","TAB 500MG ER","30","Select","Select",""],["","58160081912","SHINGRIX                                                              ","INJ 50\/0.5ML","-1","Select","Select",""],["","33332032001","AFLURIA QUADRIVALENT 2020-2021                                        ","INJ 2020-21","0","Select","Select",""],["","69097015907","MELOXICAM                                                             ","TAB 15MG","30","Select","Select",""],["","55111032101","GLIMEPIRIDE                                                           ","TAB 2MG","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":[[["Yes","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["Yes","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":""}]}]}