{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"ALICE   M WILLIAMS","gend":1,"add":"424 HARBOUR NORTH DR","city":"CHESAPEAKE","state":"VA","zip":"23320-9998","dob":"1937-11-17","age":"","mstatus":"","insh":"900042503*01","cliId":"9YM2F49CC10","pno":"757\/547-3761","cno":"757\/547-3761","email":"","ename":"","eno":"","pphy":"HIGGINS, CHRISTINE MD","ppno":"757\/547-9286","pcpadd":"113 GAINSBOROUGH SQ STE 300","pcpcity":"CHESAPEAKE","pcpstate":"VA","pcpzip":23320,"pcpcounty":"","pcpid":210342,"pcpname":"","plan":"OHP","program":"MEDICARE","lob":"DSNP","region":"TIDEWATER","aligned":"Y","ano":"Non-DSNP","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/410-0186","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z12.31","E53.9","E11.9","H04.123","H52.4","H35.363"],"date":["2021-01-11","2021-05-17","2021-07-16","2021-07-16","2021-07-16","2021-07-16"],"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":[["","68180051703","LISINOPRIL","TAB 40MG","90","Select","Select",""],["","781207401","TRIAMT\/HCTZ","CAP 37.5-25","30","Select","Select",""],["","42806005609","AMLODIPINE","TAB 5MG","-90","Select","Select",""],["","62332014231","CELECOXIB","CAP 200MG","30","Select","Select",""],["","58160082311","SHINGRIX","INJ 50\/0.5ML","-1","Select","Select",""],["","781207401","TRIAMTERENE\/HYDROCHLOROTHIAZIDE ","","30","Select","Select",""],["","42806005609","AMLODIPINE BESYLATE","","-90","Select","Select",""],["","62332014231","CELECOXIB ","","30","Select","Select",""],["","69097052444","DICLOFENAC SODIUM","","100","Select","Select",""],["","11845009661","VITAMIN B-12","","90","Select","Select",""],["","00781207401","TRIAMTERENE\/HYDROCHLOROTHIAZIDE","","30","Select","Select",""],["","70010006510","METFORMIN HYDROCHLORIDE","","180","Select","Select",""],["","68180047903","SIMVASTATIN","20MG","90","Select","Select",""],["","68180051703","LISINOPRIL                                                            ","TAB 40MG","90","Select","Select",""],["","42806005609","AMLODIPINE BESYLATE                                                   ","TAB 5MG","90","Select","Select",""],["","62332014231","CELECOXIB                                                             ","CAP 200MG","30","Select","Select",""],["","00781207401","TRIAMTERENE\/HYDROCHLOROTHIAZIDE                                       ","CAP 37.5-25","30","Select","Select",""],["","58160082311","SHINGRIX                                                              ","INJ 50\/0.5ML","1","Select","Select",""],["","69097052444","DICLOFENAC SODIUM                                                     ","GEL 0.01","100","Select","Select",""],["","70010006510","METFORMIN HYDROCHLORIDE                                               ","TAB 1000MG","180","Select","Select",""],["","59267100002","PFIZER-BIONTECH COVID-19 VACCINE                                      ","INJ COVID-19","0","Select","Select",""],["","11845009661","VITAMIN B-12                                                          ","SUB 1000MCG","90","Select","Select",""],["","68180047903","SIMVASTATIN                                                           ","TAB 20MG","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":[[["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":""}]}]}