{"version":"0.4","data":[{"t":"Demographics","q":[{"name":" DONNIE M MOOMAW","gend":0,"add":"1487 NEWDALE SCHOOL ROAD","city":"TIMBERVILLE","state":"VA","zip":"22853-9998","dob":"1932-06-15","age":"","mstatus":"","insh":"900041120*01","cliId":"","pno":"540\/896-8072","cno":"540\/896-8072, ","email":"","ename":"","eno":"","pphy":"PENCE, ROBERT P MD","ppno":"540\/879-4300","pcpadd":"HWY 42 S 15 KILLDEER LANE","pcpcity":"DAYTON","pcpstate":"VA","pcpzip":"22821-9998","pcpcounty":"","pcpid":117706,"pcpname":"Carilion Family Medicine - Dayton","plan":"OHP - OPTIMA","program":"MEDICARE","lob":"MA-NON DSNP","region":"WESTERN\/ CHARLOTTESVILLE","aligned":"","ano":"","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":["M54.5","M43.16","M47.816","M47.26","M48.061","M54.16","R35.0","R41.3","E66.9","E78.2","C61.","G40.909","I10.","N18.31","R73.01","Z51.81","M89.9","Z79.899","M51.16","Z00.00","Z85.828","L57.0","R10.9","M94.9"],"date":["2021-05-26","2021-05-26","2021-05-26","2021-03-10","2021-05-19","2021-05-19","2021-03-17","2021-03-17","2021-03-17","2021-03-17","2021-03-17","2021-03-17","2021-03-17","2021-03-17","2021-03-17","2021-03-17","2021-03-17","2021-03-17","2021-03-10","2021-03-17","2021-01-13","2021-01-13","2021-01-28","2021-03-17"],"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":[["","71930006560","LEVETIRACETA ","1000MG","60","Select","Select",""],["","68382025010","ATORVASTATIN ","20MG","93","Select","Select",""],["","29300011105","LAMOTRIGINE ","25MG","90","Select","Select",""],["","23155000810","HYDROCHLOROT ","25MG","93","Select","Select",""],["","00054001829","PREDNISONE ","20MG","20","Select","Select",""],["","29300024310","AMLODIPINE ","10MG","90","Select","Select",""],["","00378875006","DICLOFENAC ","1%","200","Select","Select",""],["","52817031910","BACLOFEN ","5MG","30","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","",""],["Yes","Select","","","","","Select","",""],["No","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":""}]}]}