{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"JENIE   E TATE","gend":1,"add":"2013 QUEEN VICTORIA","city":"VIRGINIA BEACH","state":"VA","zip":"23454-9998","dob":"1964-04-17","age":"","mstatus":"","insh":"900045668*01","cliId":"7FM7U76QR61","pno":"757\/300-3263","cno":"757\/300-3263","email":"","ename":"","eno":"","pphy":"SAN-MARINA, ANDREI MD","ppno":"757\/425-3610","pcpadd":"STE A 940 GENERAL BOOTH BLV","pcpcity":"VIRGINIA BEACH","pcpstate":"VA","pcpzip":23451,"pcpcounty":"","pcpid":153229,"pcpname":"","plan":"OHP","program":"MEDICARE","lob":"DSNP","region":"TIDEWATER","aligned":"Y","ano":"Non-DSNP","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/425-3625","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["G47.00","F17.210","Z12.11","M54.00","M47.817","M51.36","M54.16","M70.62","E78.5","I10.","J44.9","Z12.39","F32.9","Z23.","M53.3","M79.10"],"date":["2021-11-05","2021-08-04","2021-11-05","2021-11-22","2021-11-22","2021-11-22","2021-11-22","2021-11-22","2021-11-05","2021-11-05","2021-11-05","2021-11-05","2021-11-05","2021-11-05","2021-11-22","2021-11-22"],"priorHcc":[null,"",null,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":[["","61442014201","LOVASTATIN","TAB 20MG","90","Select","Select",""],["","67877019905","AMLODIPINE","TAB 10MG","90","Select","Select",""],["","172392670","DIAZEPAM","TAB 5MG","4","Select","Select",""],["","93317431","ALBUTEROL","AER HFA","8","Select","Select",""],["","69547035302","NARCAN","SPR ","2","Select","Select",""],["","65162062710","TRAMADOL HCL","TAB 50MG","120","Select","Select",""],["","68382080501","TRAZODONE","TAB 50MG","30","Select","Select",""],["","31722071390","PANTOPRAZOLE","TAB 40MG","90","Select","Select",""],["","55111017915","TIZANIDINE","TAB 2MG","90","Select","Select",""],["","93317431","ALBUTEROL SULFATE HFA","","8","Select","Select",""],["","55111017915","TIZANIDINE HCL","","90","Select","Select",""],["","68382080501","TRAZODONE HYDROCHLORIDE","","30","Select","Select",""],["","31722071390","PANTOPRAZOLE SODIUM","","90","Select","Select",""],["","67877019905","AMLODIPINE BESYLATE","","90","Select","Select",""],["","70954008510","CHLORZOXAZONE ","","120","Select","Select",""],["","11822316910","RA ASPIRIN EC","","90","Select","Select",""],["","70954008510","CHLORZOXAZONE","","120","Select","Select",""],["","65162062710","TRAMADOL HCL                                                          ","TAB 50MG","120","Select","Select",""],["","00093317431","ALBUTEROL SULFATE HFA                                                 ","AER HFA","8","Select","Select",""],["","69547035302","NARCAN                                                                ","SPR ","2","Select","Select",""],["","31722071390","PANTOPRAZOLE SODIUM                                                   ","TAB 40MG","90","Select","Select",""],["","55111017915","TIZANIDINE HCL                                                        ","TAB 2MG","90","Select","Select",""],["","68382080501","TRAZODONE HYDROCHLORIDE                                               ","TAB 50MG","30","Select","Select",""],["","61442014201","LOVASTATIN                                                            ","TAB 20MG","90","Select","Select",""],["","00172392670","DIAZEPAM                                                              ","TAB 5MG","4","Select","Select",""],["","67877019905","AMLODIPINE BESYLATE                                                   ","TAB 10MG","90","Select","Select",""],["","70954008510","CHLORZOXAZONE                                                         ","TAB 500MG","120","Select","Select",""],["","11822316910","RA ASPIRIN EC                                                         ","TAB 81MG EC","90","Select","Select",""],["","76204020025","ALBUTEROL SULFATE                                                     ","NEB 0.00083","225","Select","Select",""],["","49483048112","ASPIRIN LOW DOSE                                                      ","TAB 81MG EC","90","Select","Select",""],["","65862001230","SERTRALINE HCL                                                        ","TAB 50MG","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":[[["No","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["Yes","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":""}]}]}