{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"SHEILA   L WILEY","gend":1,"add":"336 WHITING LN","city":"VIRGINIA BEACH","state":"VA","zip":"23456-9998","dob":"1949-03-15","age":"","mstatus":"","insh":"900042201*01","cliId":"7Y82YP4PH13","pno":"540\/309-2481","cno":"540\/309-2481","email":"","ename":"","eno":"","pphy":"BAKHSHI, ELIZABETH MD","ppno":"757\/481-3770","pcpadd":"1821 OLD DONATION PKWY SUITE #4","pcpcity":"VIRGINIA BEACH","pcpstate":"VA","pcpzip":23454,"pcpcounty":"","pcpid":120796,"pcpname":"","plan":"OHP","program":"MEDICARE","lob":"MA-Non DSNP","region":"TIDEWATER","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/496-4046","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["H04.123","H43.813","H40.013","Z96.1","E87.1","R53.83","R06.02","Z13.1","M79.7","Z20.828","R91.1","R07.89","E78.2","R00.2","I49.3","R07.9","I08.1","I51.7","E22.2","J98.4","L64.8","L30.9","I51.89","U09.9","E66.3","M53.3"],"date":["2021-10-21","2021-10-21","2021-10-21","2021-10-21","2021-08-03","2021-05-11","2021-10-18","2021-06-13","2021-09-30","2021-04-28","2021-10-13","2021-08-03","2021-07-01","2021-08-02","2021-07-27","2021-07-27","2021-07-27","2021-07-27","2021-09-30","2021-09-16","2021-10-15","2021-10-15","2021-10-13","2021-10-13","2021-09-30","2021-09-30"],"priorHcc":[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":[["","068645051054","HYDROCHLOROT ","25MG","30","Select","Select",""],["","016729017217","AMITRIPTYLIN ","25MG","90","Select","Select",""],["","065862092790","FINASTERIDE ","1MG","90","Select","Select",""],["","000023916360","RESTASIS ","0.05%","-180","Select","Select",""],["","050742061610","METOPROL ","50MG ER","30","Select","Select",""],["","053489011802","DOXYCYCL ","50MG","30","Select","Select",""],["","072205000390","ROSUVASTATIN ","10MG","30","Select","Select",""],["","066993001968","ALBUTEROL ","HFA","18","Select","Select",""],["","059746021701","SPIRONOLACT ","50MG","30","Select","Select",""],["","68645051054","","25MG","30","Select","Select",""],["","68645051054","HYDROCHLOROT","25MG","30","Select","Select",""],["","59746021701","SPIRONOLACT","50MG","30","Select","Select",""],["","00023916360","RESTASIS","0.05%","-180","Select","Select",""],["","16729017217","AMITRIPTYLIN","25MG","90","Select","Select",""],["","65862092790","FINASTERIDE","1MG","90","Select","Select",""],["","53489011802","DOXYCYCL","50MG","-30","Select","Select",""],["","52817036000","METOPROL","25MG","180","Select","Select",""],["","66993001968","ALBUTEROL","HFA","18","Select","Select",""],["","72205000390","ROSUVASTATIN","10MG","30","Select","Select",""],["","62332014231","CELECOXIB","200MG","30","Select","Select",""],["","00172392660","DIAZEPAM","5MG","15","Select","Select",""],["","68462059089","FLUOCIN","SCALP","116","Select","Select",""],["","13107006101","PHENTERMINE","37.5MG","30","Select","Select",""],["","49281012165","FLUZONE","2021-22","1","Select","Select",""],["","45802048526","FLUOCIN ","OIL 0.01% SC","118","Select","Select",""],["","13107006101","PHENTERMINE ","TAB 37.5MG","30","Select","Select",""],["","00172392660","DIAZEPAM ","TAB 5MG","15","Select","Select",""],["","62332014231","CELECOXIB ","CAP 200MG","30","Select","Select",""],["","49281012165","FLUZONE ","INJ 2021-22","1","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":""}]}]}