{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"HAROLD   J SIMMERS","gend":0,"add":"459 ACME COMPANY ST","city":"BROADWAY","state":"VA","zip":"22815-9998","dob":"1941-07-04","age":"","mstatus":"","insh":"900041521*01","cliId":"4NU9QT7PH29","pno":"540\/820-8102","cno":"540\/820-8102","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,"pcpcounty":"","pcpid":117706,"pcpname":"Carilion Family Medicine - Dayton","plan":"OHP","program":"MEDICARE","lob":"MA-Non DSNP","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"540\/879-9627","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["E06.3","E78.00","R73.01","I10.","F32.9","F41.1","Z51.81","D75.1","Z79.899","Z00.00","R41.3","R06.83","R53.83","F39."],"date":["2021-09-30","2021-09-30","2021-09-30","2021-11-10","2021-09-30","2021-09-30","2021-09-30","2021-11-10","2021-09-30","2021-09-30","2021-09-30","2021-11-10","2021-11-10","2021-11-10"],"priorHcc":[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":[["","69543038190","OLANZAPINE ","5MG","30","Select","Select",""],["","24689093306","BUSPIRONE ","30MG","60","Select","Select",""],["","51672400105","NORTRIPTYLIN ","10MG","30","Select","Select",""],["","70436001102","BUPROPN ","300MG XL","30","Select","Select",""],["","29300024310","AMLODIPINE ","10MG","15","Select","Select",""],["","00456114030","VIIBRYD ","40MG","30","Select","Select",""],["","00781518610","LEVOTHYROXIN ","125MCG","45","Select","Select",""],["","75834011001","CHLORTHALID ","50MG","90","Select","Select",""],["","69097094712","ATORVASTATIN ","80MG","45","Select","Select",""],["","69543038190","","5MG","30","Select","Select",""],["","69543038190","OLANZAPINE","5MG","30","Select","Select",""],["","29300024310","AMLODIPINE","10MG","15","Select","Select",""],["","51672400105","NORTRIPTYLIN","10MG","30","Select","Select",""],["","70436001102","BUPROPN","300MG XL","30","Select","Select",""],["","24689093306","BUSPIRONE","30MG","60","Select","Select",""],["","00456114030","VIIBRYD","40MG","-30","Select","Select",""],["","69097094712","ATORVASTATIN","80MG","45","Select","Select",""],["","75834011001","CHLORTHALID","50MG","90","Select","Select",""],["","00781518610","LEVOTHYROXIN","125MCG","45","Select","Select",""],["","00168009960","KETOCONAZOLE","2%","60","Select","Select",""],["","00168009960","KETOCONAZOLE ","CRE 0.02","60","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","",""],["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":""}]}]}