{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MOHAMED BENJELLOUN","gend":0,"add":"7077 CUMBERLAND DR","city":"WARRENTON","state":"VA","zip":"20187-9998","dob":"1943-03-21","age":"","mstatus":"","insh":"900044299*01","cliId":"1PD1WT9ED33","pno":"571\/217-0104","cno":"571\/217-0104","email":"","ename":"","eno":"","pphy":"ACKERMAN, MICHAEL K DO","ppno":"540\/878-5408","pcpadd":"225 OAK SPRINGS DR STE 201","pcpcity":"WARRENTON","pcpstate":"VA","pcpzip":20186,"pcpcounty":"","pcpid":175636,"pcpname":"","plan":"OHP","program":"MEDICARE","lob":"MA-Non DSNP","region":"NORTHERN & WINCHESTER","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"545\/878-5731","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z20.828","R07.9","F43.9","R42.","M25.561","M17.0","M25.562","Z11.1","M17.10","R07.89","E11.9","Z12.5","E78.5"],"date":["2021-03-26","2021-09-13","2021-03-22","2021-03-22","2021-10-01","2021-10-01","2021-10-01","2021-09-13","2021-09-13","2021-09-27","2021-09-16","2021-09-16","2021-09-16"],"priorHcc":["",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":[["","68462018556","FLUOCIN ","0.01%","20","Select","Select",""],["","70377002811","ATORVASTATIN ","20MG","30","Select","Select",""],["","69097083305","SERTRALINE ","25MG","30","Select","Select",""],["","59746012106","MECLIZINE ","25MG","10","Select","Select",""],["","16571020106","DICLOFENAC ","75MG DR","30","Select","Select",""],["","00597002402","COMBIVENT ","20-100","-4","Select","Select",""],["","53746010901","HYDROCO\/APAP ","5-325MG","60","Select","Select",""],["","16571020106","","75MG DR","30","Select","Select",""],["","00597002402","COMBIVENT","20-100","-4","Select","Select",""],["","68462018556","FLUOCIN","0.01%","20","Select","Select",""],["","16571020106","DICLOFENAC","75MG DR","30","Select","Select",""],["","70377002811","ATORVASTATIN","20MG","30","Select","Select",""],["","59746012106","MECLIZINE","25MG","10","Select","Select",""],["","69097083305","SERTRALINE","25MG","90","Select","Select",""],["","69097015907","MELOXICAM","15MG","30","Select","Select",""],["","31722066530","ESOMEPRA","40MG DR","90","Select","Select",""],["","13668013601","ESCITALOPRAM","10MG","90","Select","Select",""],["","53746010901","HYDROCO\/APAP","5-325MG","60","Select","Select",""],["","13668013601","ESCITALOPRAM ","TAB 10MG","90","Select","Select",""],["","69097015907","MELOXICAM ","TAB 15MG","-30","Select","Select",""],["","31722066530","ESOMEPRA ","CAP 40MG DR","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":""}]}]}