{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"BERNARD   B ELMORE","gend":0,"add":"1509 9TH ST","city":"VICTORIA","state":"VA","zip":"23974-9998","dob":"1943-04-05","age":"","mstatus":"","insh":"900047067*01","cliId":"1J16XQ3YR73","pno":"434\/321-9391","cno":"434\/321-9391","email":"","ename":"","eno":"","pphy":"HOLLAND JR, JOHN A MD","ppno":"434\/696-2165","pcpadd":"1508 K V ROAD","pcpcity":"VICTORIA","pcpstate":"VA","pcpzip":23974,"pcpcounty":"","pcpid":670645,"pcpname":"","plan":"OHP","program":"MEDICARE","lob":"MA-Non DSNP","region":"CENTRAL","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["C67.9","N32.3","N40.1","J96.11","Z90.79","Z46.6","N39.0","N32.89","Z99.81","J44.9","G56.02","N20.0","K80.20","J98.11","R91.8","R06.00","R39.9","J44.1","Z20.822","Z87.891","I26.99","N50.1","Z74.3","J96.01","Z77.22","E83.39","I50.9","E66.9","R07.9","R09.02","Z68.29","E66.3","Z11.59","Z71.1","D41.4","Z85.51","Z01.818"],"date":["2021-10-20","2021-10-20","2021-09-03","2021-09-14","2021-05-17","2021-05-17","2021-04-21","2021-04-21","2021-09-14","2021-11-01","2021-04-13","2021-04-21","2021-04-21","2021-07-23","2021-07-23","2021-07-23","2021-09-03","2021-07-24","2021-10-15","2021-07-30","2021-07-30","2021-04-21","2021-04-21","2021-07-24","2021-07-24","2021-07-24","2021-07-24","2021-07-24","2021-07-23","2021-09-24","2021-07-23","2021-07-23","2021-10-15","2021-10-15","2021-10-20","2021-10-20","2021-09-24"],"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":[["","69097017364","IPRATROPIUM\/ ","ALBUTER","360","Select","Select",""],["","69238149105","BUMETANIDE ","2MG","90","Select","Select",""],["","67877021905","CEPHALEXIN ","500MG","15","Select","Select",""],["","59310057922","PROAIR ","","8","Select","Select",""],["","68180096301","ALBUTEROL ","HFA","8","Select","Select",""],["","000003089421","ELIQUIS ","5MG","60","Select","Select",""],["","029300022019","MONTELUKAST ","10MG","30","Select","Select",""],["","055111028050","LEVOFLOXACIN ","500MG","5","Select","Select",""],["","69097017364","","ALBUTER","360","Select","Select",""],["","69097017364","IPRATROPIUM\/","ALBUTER","360","Select","Select",""],["","67877021905","CEPHALEXIN","500MG","15","Select","Select",""],["","69238149105","BUMETANIDE","2MG","90","Select","Select",""],["","68180096301","ALBUTEROL","HFA","8","Select","Select",""],["","29300022019","MONTELUKAST","10MG","-30","Select","Select",""],["","00003089421","ELIQUIS","5MG","60","Select","Select",""],["","59310057922","PROAIR","","-8","Select","Select",""],["","55111028050","LEVOFLOXACIN","500MG","5","Select","Select",""],["","00143992801","CIPROFLOXACN","500MG","14","Select","Select",""],["","47781030301","NITROFURANTN ","CAP 100MG","-14","Select","Select",""],["","47781030801","NITROFUR ","CAP 100MG","14","Select","Select",""],["","00143992801","CIPROFLOXACN ","TAB 500MG","14","Select","Select",""],["","75826011510","PHENAZOPYRID ","TAB 200MG","10","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","",""],["No","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":""}]}]}