{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MARY   H HENLE","gend":1,"add":"147 LONDONDERRY LN","city":"WILLIAMSBURG","state":"VA","zip":"23188-9998","dob":"1955-08-28","age":"","mstatus":"","insh":"900039635*01","cliId":"3PW6WJ9QV52","pno":"612\/655-5710","cno":"612\/655-5710","email":"","ename":"","eno":"","pphy":"MCLEAN, JENNIFER L MD","ppno":"757\/969-1755","pcpadd":"BLDG 6 SUITE A 12695 MCMANUS BLVD","pcpcity":"NEWPORT NEWS","pcpstate":"VA","pcpzip":23602,"pcpcounty":"","pcpid":157510,"pcpname":"COLONIAL FAMILY MEDICINE","plan":"OHP","program":"MEDICARE","lob":"MA-Non DSNP","region":"TIDEWATER","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/345-0644","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["M81.0","E88.81","Z12.31","E04.1","E03.9","E06.3","Z68.23","N95.9","E55.9","J45.998","E78.5","Z12.11"],"date":["2021-03-02","2021-10-17","2021-02-08","2021-03-08","2021-03-08","2021-03-08","2021-03-08","2021-02-08","2020-12-29","2020-12-29","2020-12-29","2021-08-30"],"priorHcc":["",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":[["","069238183207","LEVOTHYROXIN ","75MCG","90","Select","Select",""],["","000378623201","CITALOPRAM ","20MG","90","Select","Select",""],["","068462053435","TACROLIMUS ","0.10%","-30","Select","Select",""],["","049281012065","FLUZONE ","PF 20-21","1","Select","Select",""],["","000093317431","ALBUTEROL ","HFA","8","Select","Select",""],["","000713022580","TRIAMCINOLON ","0.10%","80","Select","Select",""],["","69238183207","","75MCG","90","Select","Select",""],["","69238183207","LEVOTHYROXIN","75MCG","-90","Select","Select",""],["","00378623201","CITALOPRAM","20MG","90","Select","Select",""],["","49281012065","FLUZONE","PF 20-21","1","Select","Select",""],["","68462053435","TACROLIMUS","0.10%","30","Select","Select",""],["","00093317431","ALBUTEROL","HFA","8","Select","Select",""],["","00713022580","TRIAMCINOLON","0.10%","80","Select","Select",""],["","50383091205","BIMATOPROST","0.03%","5","Select","Select",""],["","58160088752","FLUARIX ","INJ 2021-22","0","Select","Select",""],["","50383091205","BIMATOPROST ","SOL 0.0003","5","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":""}]}]}