{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"GUY   S BAILEY","gend":0,"add":"PO BOX 294","city":"MONTPELIER","state":"VA","zip":"23192-9998","dob":"1952-12-29","pno":"804\/938-0594","cno":"804\/938-0594","email":"","pphy":"COOK, JAMES MD","ppno":"","pcpadd":"15078 BROWN PLEASANTS ROAD","pcpcity":"MONTPELIER","pcpstate":"VA","pcpzip":23192,"pcpcounty":"","pcpid":199498,"pcpname":"","insh":"900046669*01","cliId":"5RH9AU9DA35","plan":"OHP","program":"MEDICARE","lob":"MA-Non DSNP","region":"CENTRAL","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"804\/883-0048","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z20.828","Z20.822","Z79.899","Z12.5","I25.9","I10.","E78.5","E55.9","N39.0","M17.11"],"date":["2021-07-29","2021-07-29","2021-10-14","2021-10-14","2021-10-14","2021-10-14","2021-10-14","2021-10-14","2021-10-14","2021-11-24"],"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":[["","00078077720","ENTRESTO","49-51MG","60","Select","Select",""],["","50742061605","METOPROL","50MG ER","45","Select","Select",""],["","67877021560","CEFUROXIME","250MG","20","Select","Select",""],["","60505267108","ATORVASTATIN","80MG","90","Select","Select",""],["","58160082311","SHINGRIX","50\/0.5ML","1","Select","Select",""],["","67877019810","AMLODIPINE","5MG","30","Select","Select",""],["","50383077504","LIDOCAINE","2% VISC","100","Select","Select",""],["","00078077720","ENTRESTO ","TAB 49-51MG","60","Select","Select",""],["","50742061605","METOPROL ","TAB 50MG ER","-45","Select","Select",""],["","67877019810","AMLODIPINE ","TAB 5MG","30","Select","Select",""],["","60505267108","ATORVASTATIN ","TAB 80MG","90","Select","Select",""],["","67877021560","CEFUROXIME ","TAB 250MG","20","Select","Select",""],["","50383077504","LIDOCAINE ","SOL 2% VISC","100","Select","Select",""],["","58160082311","SHINGRIX ","INJ 50\/0.5ML","-1","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":""}]}]}