{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"FAY   K KING","gend":1,"add":"10523 TEA OLIVE CIR","city":"PROVIDENCE FORGE","state":"VA","zip":"23140-9998","dob":"1951-11-03","age":"","mstatus":"","insh":"900043228*01","cliId":"1KM4N16TP99","pno":"804\/836-7737","cno":"804\/836-7737","email":"","ename":"","eno":"","pphy":"THOMAS, DENNIS L MD","ppno":"804\/932-4388","pcpadd":"1850 POCAHONTAS TRAIL","pcpcity":"QUINTON","pcpstate":"VA","pcpzip":23141,"pcpcounty":"","pcpid":671676,"pcpname":"","plan":"OHP","program":"MEDICARE","lob":"MA-NON DSNP","region":"CENTRAL","aligned":"","ano":"","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":["Z01.810","L29.9","L82.1","D48.5","R10.13","K21.9","R93.3","R07.9","I10.","R06.02","E78.2","Z68.38","F33.1","E66.01","E11.59","G47.33","E03.8","R42.","J43.9","L30.4","L81.4","D22.9","L57.8","L82.0","R19.5","J03.90","J35.8","H90.3","R13.10","E03.9","G47.30","Z45.320","J02.9","H90.5","D49.0","Z01.818","Z01.812","Z20.822","L30.9","K21.00","R94.8","Z68.41","Z68.39","D47.3","F41.1","L23.9","K29.50","K31.89","R19.4","H90.41"],"date":["2021-04-07","2021-07-16","2021-05-25","2021-05-25","2021-06-08","2021-07-15","2021-06-08","2021-06-23","2021-07-15","2021-06-23","2021-06-23","2021-02-11","2021-02-11","2021-07-15","2021-07-15","2021-04-27","2021-07-15","2021-04-27","2021-04-27","2021-03-23","2021-03-23","2021-03-23","2021-03-23","2021-03-23","2021-06-08","2021-02-15","2021-03-10","2021-04-20","2021-06-08","2021-06-08","2021-04-20","2021-02-01","2021-02-05","2021-02-16","2021-03-10","2021-04-07","2021-04-16","2021-04-16","2021-05-25","2021-06-08","2021-06-08","2021-06-08","2021-07-15","2021-07-15","2021-07-15","2021-07-16","2021-06-08","2021-06-08","2021-06-08","2021-07-13"],"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":[["","53489014405","SPIRONO\/HCTZ ","25\/25","90","Select","Select",""],["","60505001608","DILT-XR ","240MG","90","Select","Select",""],["","69238183207","LEVOTHYROXIN ","75MCG","90","Select","Select",""],["","65862069705","VENLAFAXINE ","150MG ER","90","Select","Select",""],["","00781223410","OMEPRAZOLE ","40MG","180","Select","Select",""],["","00591544305","PREDNISONE ","20MG","9","Select","Select",""],["","62756014202","METFORMIN ","500MG ER","90","Select","Select",""],["","000536100901","FERROUS ","325MG","180","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":""}]}]}