{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MARY   J ZURN","gend":1,"add":"132 WEST WILL CT","city":"PAMPLIN","state":"VA","zip":"23958-9998","dob":"1942-04-11","age":"","mstatus":"","insh":"900042390*01","cliId":"9GF0KU9CK41","pno":"903\/372-5453","cno":"903\/372-5453","email":"","ename":"","eno":"","pphy":"HOFFMAN, RICHARD H MD","ppno":"804\/276-9305","pcpadd":"2500 POCOSHOCK PL","pcpcity":"NORTH CHESTERFIELD","pcpstate":"VA","pcpzip":23235,"pcpcounty":"","pcpid":207954,"pcpname":"BON SECOURS CHESTERFIELD FAMILY MEDICINE","plan":"OHP","program":"MEDICARE","lob":"MA-Non DSNP","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"804\/674-4145","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["I50.32","E78.5","I25.10","I48.0","Z95.1","G30.9","E03.9","I48.91","E11.9","F02.81","Z00.00","Z11.59","D72.829","N18.32","H52.222","B39.9","Z68.32","G30.1","R44.1","R44.0","R45.4"],"date":["2021-02-04","2021-05-14","2021-04-30","2021-02-04","2021-02-04","2021-03-26","2021-05-14","2021-01-21","2021-05-14","2021-06-07","2021-04-30","2021-05-14","2021-05-14","2021-04-30","2021-05-21","2021-05-21","2021-03-22","2021-06-07","2021-06-07","2021-06-07","2021-06-07"],"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":[["","70436000506","GALANTAMINE ","8MG","180","Select","Select",""],["","69238183007","LEVOTHYROXIN ","25MCG","90","Select","Select",""],["","45963067796","METOPROL ","100MG ER","90","Select","Select",""],["","69315011710","FUROSEMIDE ","40MG","90","Select","Select",""],["","00003089421","ELIQUIS ","5MG","180","Select","Select",""],["","13107000305","MIRTAZAPINE ","30MG","90","Select","Select",""],["","16729021815","CLOPIDOGREL ","75MG","90","Select","Select",""],["","72578000314","MEMANTINE ","HCL 5MG","70","Select","Select",""],["","60505257908","ATORVASTATIN ","20MG","90","Select","Select",""],["","13668010510","ISOSORB ","60MG ER","90","Select","Select",""],["","67877024210","QUETIAPINE ","25MG","90","Select","Select",""],["","00006483703","PNEUMOVAX ","25\/0.5","0","Select","Select",""],["","58160084252","BOOSTRIX ","","0","Select","Select",""],["","58160082311","SHINGRIX ","50\/0.5ML","1","Select","Select",""],["","67877021620","CEFUROXIME ","500MG","14","Select","Select",""],["","70436000506","","8MG","180","Select","Select",""],["","69238183007","LEVOTHYROXIN","25MCG","90","Select","Select",""],["","60505257908","ATORVASTATIN","20MG","90","Select","Select",""],["","67877024210","QUETIAPINE","25MG","90","Select","Select",""],["","00003089421","ELIQUIS","5MG","180","Select","Select",""],["","13107000305","MIRTAZAPINE","30MG","90","Select","Select",""],["","16729021815","CLOPIDOGREL","75MG","90","Select","Select",""],["","70436000506","GALANTAMINE","8MG","180","Select","Select",""],["","13668010510","ISOSORB","60MG ER","90","Select","Select",""],["","45963067796","METOPROL","100MG ER","90","Select","Select",""],["","69315011710","FUROSEMIDE","40MG","90","Select","Select",""],["","33342029815","MEMANTINE","HCL 10MG","180","Select","Select",""],["","00006483703","PNEUMOVAX","25\/0.5","0","Select","Select",""],["","58160084252","BOOSTRIX","","0","Select","Select",""],["","58160082311","SHINGRIX","50\/0.5ML","1","Select","Select",""],["","67877021620","CEFUROXIME","500MG","14","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","",""],["No","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":""}]}]}