{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"BARBARA   L HACKLER","gend":1,"add":"172 MAPLE SHADE ROAD","city":"LAUREL FORK","state":"VA","zip":"24352-9998","dob":"1954-04-16","age":"","mstatus":"","insh":"900046630*01","cliId":"2JC0QG3MM20","pno":"717\/683-8448","cno":"717\/683-8448","email":"","ename":"","eno":"","pphy":"BESS, WILLIAM R MD","ppno":"276\/398-2292","pcpadd":"14558 DANVILLE PIKE","pcpcity":"LAUREL FORK","pcpstate":"VA","pcpzip":24352,"pcpcounty":"","pcpid":107122,"pcpname":"","plan":"OHP","program":"MEDICARE","lob":"MA-Non DSNP","region":"SOUTHWEST","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"276\/398-3331","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["E66.09","Z68.36","Z12.11","D22.39","D17.1","Z78.0","Z12.31","D22.5","D22.62","L82.1","L81.4","D48.5","K57.90","K63.5","R73.03","E03.9","E78.2","M67.911","M25.511","G89.29","R73.01","M79.605","Z72.0","J01.90","F17.210","F17.200"],"date":["2021-04-21","2021-04-21","2021-07-01","2021-04-06","2021-04-06","2021-05-13","2021-05-13","2021-04-06","2021-04-06","2021-04-06","2021-04-06","2021-04-06","2021-07-01","2021-07-01","2021-08-12","2021-10-20","2021-10-20","2021-09-16","2021-09-16","2021-09-16","2021-10-20","2021-06-16","2021-10-13","2021-08-12","2021-08-12","2021-08-12"],"priorHcc":["","","","","","","","","","","","","","","",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":[["","66685100200","AMOX\/K ","500-125","21","Select","Select",""],["","41167580003","NASACORT ","55MCG\/AC","11","Select","Select",""],["","00093505998","ATORVASTATIN ","20MG","-90","Select","Select",""],["","00054327099","FLUTICASONE ","50MCG","16","Select","Select",""],["","47781064390","LEVOTHYROXIN ","50MCG","90","Select","Select",""],["","66685100200","","500-125","21","Select","Select",""],["","66685100200","AMOX\/K","500-125","21","Select","Select",""],["","41167580003","NASACORT","55MCG\/AC","11","Select","Select",""],["","00054327099","FLUTICASONE","50MCG","16","Select","Select",""],["","00093505998","ATORVASTATIN","20MG","-90","Select","Select",""],["","00378180310","LEVOTHYROXIN","50MCG","-90","Select","Select",""],["","68382005005","MELOXICAM","7.5MG","30","Select","Select",""],["","72305005030","EUTHYROX ","TAB 50MCG","90","Select","Select",""],["","68382005005","MELOXICAM ","TAB 7.5MG","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":""}]}]}