{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MABLE   D PATTERSON","gend":1,"add":"1098 HENDRICKS RD","city":"PAMPLIN","state":"VA","zip":"23958-9998","dob":"1960-02-08","age":"","mstatus":"","insh":"900046868*01","cliId":"4G28FT5CP32","pno":"434\/315-4936","cno":"434\/315-4936","email":"","ename":"","eno":"","pphy":"BASHORE, RANDALL T MD","ppno":"434\/581-3271","pcpadd":"RT 15 SOUTH","pcpcity":"NEW CANTON","pcpstate":"VA","pcpzip":23123,"pcpcounty":"","pcpid":105792,"pcpname":"","plan":"OHP","program":"MEDICARE","lob":"DSNP","region":"CHARLOTTESVILLE WESTERN","aligned":"Y","ano":"Non-DSNP","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"434\/581-1105","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z01.419","Z71.89","Z71.3","Z12.31","Z12.11","I10.","R52.","E55.9","M51.36","J44.0","R07.89","Z80.3","F51.01","Z11.59"],"date":["2021-07-15","2021-10-07","2021-10-07","2021-09-24","2021-07-15","2021-09-01","2021-08-12","2021-07-15","2021-09-01","2021-07-15","2021-10-07","2021-09-24","2021-09-01","2021-09-28"],"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":[["","93005805","TRAMADOL HCL","TAB 50MG","90","Select","Select",""],["","68180098103","LISINOPRIL","TAB 20MG","-90","Select","Select",""],["","456140530","BYSTOLIC","TAB 5MG","-90","Select","Select",""],["","65862052405","GABAPENTIN","TAB 800MG","270","Select","Select",""],["","310737020","BUDES\/FORMOT","AER 160-4.5","31","Select","Select",""],["","70436005901","BUPROPION","TAB 150MG SR","60","Select","Select",""],["","186037020","SYMBICORT","AER 160-4.5","31","Select","Select",""],["","70436005901","BUPROPION HYDROCHLORIDE ER (SR) ","","60","Select","Select",""],["","310737020","BUDESONIDE\/FORMOTEROL FUMARATE DIHYDRATE","","31","Select","Select",""],["","186037020","SYMBICORT ","","31","Select","Select",""],["","70436005901","BUPROPION HYDROCHLORIDE ER (SR)","","-60","Select","Select",""],["","50111056101","TRAZODONE HYDROCHLORIDE","100MG","30","Select","Select",""],["","68180051901","LISINOPRIL\/HYDROCHLOROTHIAZIDE","20-12.5","30","Select","Select",""],["","68180072003","AMLODIPINE BESYLATE","5MG","30","Select","Select",""],["","00536589488","NICOTINE TRANSDERMAL SYSTEM","7MG\/24HR","30","Select","Select",""],["","00093005805","TRAMADOL HCL                                                          ","TAB 50MG","21","Select","Select",""],["","65862052405","GABAPENTIN                                                            ","TAB 800MG","-270","Select","Select",""],["","00456140530","BYSTOLIC                                                              ","TAB 5MG","-90","Select","Select",""],["","70436005901","BUPROPION HYDROCHLORIDE ER (SR)                                       ","TAB 150MG SR","-60","Select","Select",""],["","00310737020","BUDESONIDE\/FORMOTEROL FUMARATE DIHYDRATE                              ","AER 160-4.5","31","Select","Select",""],["","68180098103","LISINOPRIL                                                            ","TAB 20MG","90","Select","Select",""],["","00186037020","SYMBICORT                                                             ","AER 160-4.5","-31","Select","Select",""],["","68180072003","AMLODIPINE BESYLATE                                                   ","TAB 5MG","90","Select","Select",""],["","50111056101","TRAZODONE HYDROCHLORIDE                                               ","TAB 100MG","30","Select","Select",""],["","00536589488","NICOTINE TRANSDERMAL SYSTEM                                           ","DIS 7MG\/24HR","30","Select","Select",""],["","68180051901","LISINOPRIL\/HYDROCHLOROTHIAZIDE                                        ","TAB 20-12.5","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":""}]}]}