{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"ELVA   H RATLIFF","gend":1,"add":"1750 PEAR STREET APT A","city":"HARRISONBURG","state":"VA","zip":"22801-9998","dob":"1927-03-04","age":"","mstatus":"","insh":"900043162*01","cliId":"6RF9U19NA13","pno":"540\/410-4536","cno":"540\/410-4536","email":"","ename":"","eno":"","pphy":"ALLEYNE, LISA ANTHONY MD","ppno":"540\/248-3413","pcpadd":"1371 LEE HIGHWAY","pcpcity":"VERONA","pcpstate":"VA","pcpzip":24482,"pcpcounty":"","pcpid":147705,"pcpname":"Carilion Family Medicine - Dayton","plan":"OHP","program":"MEDICARE","lob":"MA-Non DSNP","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"540\/248-8413","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R39.15","K52.9","N17.9","E03.9","N39.0","I10.","Z79.899","A41.9","Z66.","A09.","E87.1","I69.354","Z85.828","Z88.1","Z87.891","Z82.49","Z79.02","Z79.890","Z28.21","R10.32","K59.00","R10.84","R09.02","R11.0","R19.7","Z96.1","J95.831","Z00.00","I63.9","N18.30","C44.320","Z23.","N18.31","M54.41","N39.46","G25.81","G89.29"],"date":["2021-03-17","2021-02-25","2021-01-29","2021-09-09","2021-01-29","2021-09-09","2021-09-09","2021-01-28","2021-01-28","2021-01-28","2021-01-28","2021-01-28","2021-01-28","2021-01-28","2021-01-28","2021-01-28","2021-01-28","2021-01-28","2021-01-28","2021-02-25","2021-02-25","2021-01-27","2021-01-27","2021-01-27","2021-01-27","2021-01-25","2021-05-19","2021-01-19","2021-09-09","2021-01-19","2021-09-09","2021-09-09","2021-09-09","2021-09-09","2021-09-09","2021-09-09","2021-09-09"],"priorHcc":["","","",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":[["","68645059090","CLOPIDOGREL ","75MG","30","Select","Select",""],["","68645055354","LISINOPRIL ","20MG","-30","Select","Select",""],["","00406012501","HYDROCO\/APAP ","10-325MG","90","Select","Select",""],["","72305010030","EUTHYROX ","100MCG","30","Select","Select",""],["","68462026005","VERAPAMIL ","240MG ER","90","Select","Select",""],["","67877021660","CEFUROXIME ","500MG","10","Select","Select",""],["","69238183407","LEVOTHYROXIN ","100MCG","90","Select","Select",""],["","50111033402","METRONIDAZOL ","500MG","10","Select","Select",""],["","45802086802","POLYETH ","3350 NF","714","Select","Select",""],["","68645059090","","75MG","30","Select","Select",""],["","72305010030","EUTHYROX","100MCG","30","Select","Select",""],["","00406012501","HYDROCO\/APAP","10-325MG","90","Select","Select",""],["","68645059090","CLOPIDOGREL","75MG","30","Select","Select",""],["","68645055354","LISINOPRIL","20MG","30","Select","Select",""],["","50111033402","METRONIDAZOL","500MG","10","Select","Select",""],["","68462026005","VERAPAMIL","240MG ER","90","Select","Select",""],["","69238183407","LEVOTHYROXIN","100MCG","90","Select","Select",""],["","67877021660","CEFUROXIME","500MG","10","Select","Select",""],["","45802086802","POLYETH","3350 NF","714","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","",""],["Yes","Select","","","","","Select","",""],["No","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":""}]}]}