{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"CYNTHIA GULICK","gend":1,"add":"1203 RANDALL RD APT D27 PO BOX 1434","city":"GROTTOES","state":"VA","zip":"24441-9998","dob":"1956-02-01","age":"","mstatus":"","insh":"900046273*01","cliId":"3U37X13QV67","pno":"540\/209-6505","cno":"540\/209-6505","email":"","ename":"","eno":"","pphy":"HERNANDEZ, MARIA A MD","ppno":"540\/442-6144","pcpadd":"STE E 129 UNIVERSITY BLVD","pcpcity":"HARRISONBURG","pcpstate":"VA","pcpzip":22801,"pcpcounty":"","pcpid":169185,"pcpname":"","plan":"OHP","program":"MEDICARE","lob":"DSNP","region":"CHARLOTTESVILLE WESTERN","aligned":"Y","ano":"Non-DSNP","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"540\/442-6145","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["M17.0","M25.562","I10.","E78.5","E55.9","M25.561","F32.9","F41.9","E66.01","Z87.19","Z68.42","G89.29","R52.","R39.81","M19.91","M17.11","M17.12","Z11.52","R53.83","K45.8","N28.9","R79.89","L65.9","R63.5"],"date":["2021-07-01","2021-07-01","2021-10-21","2021-10-21","2021-10-21","2021-07-01","2021-10-21","2021-10-21","2021-10-21","2021-06-23","2021-10-21","2021-06-23","2021-07-01","2021-08-10","2021-08-10","2021-07-01","2021-07-01","2021-09-24","2021-09-24","2021-08-24","2021-08-25","2021-08-25","2021-08-25","2021-10-21"],"priorHcc":["","",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":[["","00054429931","FUROSEMIDE","","30","Select","Select",""],["","00093505698","ATORVASTATIN CALCIUM","","30","Select","Select",""],["","42806054701","VITAMIN D","","8","Select","Select",""],["","57237001830","DULOXETINE HYDROCHLORIDE","","30","Select","Select",""],["","00054429931","FUROSEMIDE                                                            ","TAB 40MG","30","Select","Select",""],["","57237001830","DULOXETINE HYDROCHLORIDE                                              ","CAP 30MG","30","Select","Select",""],["","00093505698","ATORVASTATIN CALCIUM                                                  ","TAB 10MG","-30","Select","Select",""],["","42806054701","VITAMIN D                                                             ","CAP 1.25MG","8","Select","Select",""],["","31722070090","LOSARTAN POTASSIUM                                                    ","TAB 25MG","30","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":""}]}]}