{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"DONNA   D BURDEN","gend":1,"add":"6305 BARNARD WAY","city":"VIRGINIA BEACH","state":"VA","zip":"23464-9998","dob":"1955-05-01","age":"","mstatus":"","insh":"900039380*01","cliId":"3UG5VC5XC84","pno":"757\/524-5400","cno":"757\/524-5400","email":"","ename":"","eno":"","pphy":"LAIBSTAIN, ROBERT B MD","ppno":"757\/420-8297","pcpadd":"1016 JUSTIS ST","pcpcity":"CHESAPEAKE","pcpstate":"VA","pcpzip":23325,"pcpcounty":"","pcpid":163774,"pcpname":"INDIAN RIVER FAMILY PRACTICE","plan":"OHP","program":"MEDICARE","lob":"MA-NON DSNP","region":"TIDEWATER","aligned":"","ano":"757\/352-1811","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["M25.572","M76.829","Q66.6","M76.822","I10.","R73.03","E78.2","E66.01","Z00.00","E11.9","H35.033","M21.42","M77.52","S96.812A","Z13.31","E11.65","Z12.11","N30.01","M79.672","Z20.828","S86.312A","S93.492A","S93.422A"],"date":["2021-01-12","2021-06-01","2020-12-16","2021-01-19","2021-03-04","2021-03-04","2021-03-04","2021-03-04","2021-03-04","2021-07-08","2021-07-08","2021-01-12","2021-01-12","2021-01-12","2020-05-12","2021-02-25","2020-09-21","2020-08-29","2021-04-01","2021-04-24","2021-01-12","2021-01-12","2021-01-12"],"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":[["","68180059101","RAMIPRIL ","10MG","-30","Select","Select",""],["","68382097001","CHLORTHALID ","25MG","30","Select","Select",""],["","00185012201","NITROFURANTN ","100MG","10","Select","Select",""],["","69097015807","MELOXICAM ","7.5MG","30","Select","Select",""],["","59746000103","METHYLPRED ","4MG","21","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":""}]}]}