{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MARY   L GUPTON","gend":1,"add":"421 RALEIGH AVE","city":"HAMPTON","state":"VA","zip":"23661-9998","dob":"1959-04-12","age":"","mstatus":"","insh":"900042482*01","cliId":"4TP9X62NG25","pno":"757\/722-8089","cno":"757\/722-8089","email":"","ename":"","eno":"","pphy":"KHANNA, SIDDHARTH MD","ppno":"757\/868-7709","pcpadd":"370A WYTHE CREEK ROAD","pcpcity":"POQUOSON","pcpstate":"VA","pcpzip":23662,"pcpcounty":"","pcpid":168390,"pcpname":"MARYVIEW HOSPITALISTS","plan":"OHP","program":"MEDICARE","lob":"DSNP","region":"TIDEWATER","aligned":"Y","ano":"Non-DSNP","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/868-7603","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["I10.","E78.5"],"date":["2021-04-12","2021-04-12"],"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":[["","67877019805","AMLODIPINE","TAB 5MG","90","Select","Select",""],["","27808015601","ROSUVASTATIN","TAB 10MG","36","Select","Select",""],["","31722070290","LOSARTAN POT","TAB 100MG","90","Select","Select",""],["","16729018201","HYDROCHLOROT","TAB 12.5MG","90","Select","Select",""],["","27808015601","ROSUVASTATIN CALCIUM ","","30","Select","Select",""],["","67877019805","AMLODIPINE BESYLATE","","90","Select","Select",""],["","31722070290","LOSARTAN POTASSIUM ","","90","Select","Select",""],["","16729018201","HYDROCHLOROTHIAZIDE","","90","Select","Select",""],["","31722070290","LOSARTAN POTASSIUM","","90","Select","Select",""],["","27808015601","ROSUVASTATIN CALCIUM","","30","Select","Select",""],["","67877019805","AMLODIPINE BESYLATE                                                   ","TAB 5MG","90","Select","Select",""],["","27808015601","ROSUVASTATIN CALCIUM                                                  ","TAB 10MG","30","Select","Select",""],["","16729018201","HYDROCHLOROTHIAZIDE                                                   ","TAB 12.5MG","90","Select","Select",""],["","31722070290","LOSARTAN POTASSIUM                                                    ","TAB 100MG","90","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":""}]}]}