{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"IONA FAISON","gend":1,"add":"24016 BRYANTS CHURCH RD","city":"CAPRON","state":"VA","zip":"23829-9998","dob":"1948-01-08","age":"","mstatus":"","insh":"900042965*01","cliId":"6DW4QG6AC07","pno":"434\/658-4566","cno":"434\/658-4566","email":"","ename":"","eno":"","pphy":"","ppno":"","pcpadd":"","pcpcity":"","pcpstate":"","pcpzip":"","pcpcounty":"","pcpid":"","pcpname":"","plan":"OHP","program":"MEDICARE","lob":"DSNP","region":"CENTRAL","aligned":"Y","ano":"Non-DSNP","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["G30.9","F02.80","G20.","I10.","Z86.16","Z86.73","Z91.81","I63.9","W18.11XD","Z74.09","N95.0","K59.04","R53.83","N85.00","E63.9","N39.0","Z46.6","E86.0","Z79.02","G93.41","R53.1","I69.959","R41.82","M19.90","E11.9","E78.5","E78.00","Z79.899","F03.90","F03.91","Z09.","Z71.89","K66.8","R41.0"],"date":["2021-07-22","2021-07-15","2021-07-15","2021-07-27","2021-07-15","2021-07-15","2021-07-15","2021-06-15","2021-03-01","2021-07-22","2021-06-01","2021-05-10","2021-07-27","2021-06-01","2021-06-24","2021-07-26","2021-07-15","2021-07-15","2021-07-15","2021-07-13","2021-07-27","2021-07-27","2021-07-27","2021-07-27","2021-07-27","2021-07-27","2021-07-27","2021-07-27","2021-07-27","2021-08-09","2021-08-09","2021-08-09","2021-07-26","2021-07-26"],"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":[["","68645059090","CLOPIDOGREL","TAB 75MG","30","Select","Select",""],["","68180044601","QUETIAPINE","TAB 50MG","90","Select","Select",""],["","45802058046","SCOPOLAMINE","DIS 1MG\/3DAY","10","Select","Select",""],["","16729000517","SIMVASTATIN","TAB 20MG","30","Select","Select",""],["","60505621103","MEMANTINE HC","CAP 28MG ER","30","Select","Select",""],["","378907293","RIVASTIGMINE","DIS 13.3\/24","30","Select","Select",""],["","68645055554","LISINOPRIL","TAB 40MG","30","Select","Select",""],["","68645052354","SERTRALINE","TAB 100MG","30","Select","Select",""],["","68180044601","QUETIAPINE FUMARATE","","90","Select","Select",""],["","16714011702","RIVASTIGMINE TRANSDERMAL SYSTEM ","","30","Select","Select",""],["","68645052354","SERTRALINE HYDROCHLORIDE","","30","Select","Select",""],["","60505621109","MEMANTINE HYDROCHLORIDE ER","","30","Select","Select",""],["","45802086803","POLYETHYLENE GLYCOL 3350","","510","Select","Select",""],["","16714011702","RIVASTIGMINE TRANSDERMAL SYSTEM","","30","Select","Select",""],["","68180044101","CEPHALEXIN","250\/5ML","300","Select","Select",""],["","68180071160","CEFDINIR","300MG","10","Select","Select",""],["","00832532511","POTASSIUM CHLORIDE ER","20MEQ ER","6","Select","Select",""],["","00143992701","CIPROFLOXACIN HYDROCHLORIDE","250MG","10","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","",""],["Yes","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":""}]}]}