{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"LARRY SMITH","gend":0,"add":"753 KELLEY NECK ROAD","city":"LANCASTER","state":"VA","zip":"22503-9998","dob":"1954-04-15","age":"","mstatus":"","insh":"900041054*01","cliId":"8A37XA6TV48","pno":"804\/296-9507","cno":"804\/296-9507","email":"","ename":"","eno":"","pphy":"GRISWOLD, STEVEN MD","ppno":"804\/462-5155","pcpadd":"36 LIVELY OAKS ROAD","pcpcity":"LIVELY","pcpstate":"VA","pcpzip":22507,"pcpcounty":"","pcpid":200954,"pcpname":"BON SECOURS HARTFIELD MEDICAL CENTER","plan":"OHP","program":"MEDICARE","lob":"MA-Non DSNP","region":"CENTRAL","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"804\/462-5922","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z95.2","M25.421","M25.521","I12.9","E11.22","N18.31","I25.10","I35.0","I50.42","I42.0","E11.9","Z79.4","Z95.810","Z45.02","H25.811","Z96.1","B35.1","A31.8","Z16.11","Z16.29","I35.8","I11.0","Z01.812","Z20.822","Z95.0"],"date":["2021-04-28","2021-06-09","2021-06-09","2021-04-05","2021-04-05","2021-04-05","2021-02-22","2021-02-01","2021-11-15","2021-11-15","2021-11-12","2021-10-21","2021-11-15","2021-11-15","2021-11-12","2021-11-12","2021-08-30","2021-08-30","2021-08-30","2021-08-30","2021-09-24","2021-09-24","2021-10-25","2021-10-25","2021-10-28"],"priorHcc":["","","","","","","","",null,null,null,null,null,null,null,null,null,null,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":[["","00006027731","JANUVIA ","100MG","30","Select","Select",""],["","68645057559","GLIPIZIDE ","10MG","180","Select","Select",""],["","68645051054","HYDROCHLOROT ","25MG","90","Select","Select",""],["","59746021601","SPIRONOLACT ","25MG","90","Select","Select",""],["","68382009505","CARVEDILOL ","25MG","60","Select","Select",""],["","33342006310","VALSARTAN ","80MG","90","Select","Select",""],["","68645051654","AMLODIPINE ","10MG","90","Select","Select",""],["","70010006510","METFORMIN ","1000MG","180","Select","Select",""],["","00006027731","","100MG","30","Select","Select",""],["","00006027731","JANUVIA","100MG","30","Select","Select",""],["","68645051054","HYDROCHLOROT","25MG","90","Select","Select",""],["","59746021601","SPIRONOLACT","25MG","90","Select","Select",""],["","68645051654","AMLODIPINE","10MG","90","Select","Select",""],["","33342006310","VALSARTAN","80MG","90","Select","Select",""],["","68382009505","CARVEDILOL","25MG","-60","Select","Select",""],["","70010006510","METFORMIN","1000MG","180","Select","Select",""],["","68645057559","GLIPIZIDE","10MG","180","Select","Select",""],["","62135030905","CIPROFLOXACN ","TAB 500MG","20","Select","Select",""],["","45802041926","AMMONIUM ","LOT 0.12","400","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":""}]}]}