{"version":"0.4","data":[{"t":"Demographics","q":[{"name":" QUANNA S SELBY","gend":1,"add":"2115 KECOUGHTAN ROAD APT 73A","city":"HAMPTON","state":"VA","zip":"23661-9998","dob":"1956-06-26","age":"","mstatus":"","insh":"900047367*01","cliId":"","pno":"757\/748-3247","cno":"757\/748-3247, ","email":"","ename":"","eno":"","pphy":"TANNOUS, GEORGE MD","ppno":"757\/305-1797","pcpadd":"STE 220 828 HEALTHY WAY","pcpcity":"VIRGINIA BEACH","pcpstate":"VA","pcpzip":23462,"pcpcounty":"VIRGINIA BEACH CITY","pcpid":143824,"pcpname":"BON SECOURS MEDICAL ASSOCIATES","plan":"OHP - OPTIMA","program":"MEDICARE","lob":"DSNP","aligned":"Y","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","region":"TIDEWATER","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["D50.0","R19.5","K92.2","B37.0","E11.59","I73.9","J44.9","R53.81","Z91.81","I15.2"],"date":["2021-06-15","2021-06-15","2021-06-23","2021-06-23","2021-06-23","2021-06-23","2021-06-23","2021-06-23","2021-06-23","2021-06-23"],"priorHcc":["","","","","","","","","",""]}},{"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":[["","00406051201","OXYCODONE\/ACETAMINOPHEN","","10","Select","Select",""],["","55111019690","CLOPIDOGREL","","-30","Select","Select",""],["","59746017306","PREDNISONE","","6","Select","Select",""],["","66993001968","ALBUTEROL SULFATE HFA","","18","Select","Select",""],["","00487020103","IPRATROPIUM BROMIDE\/ALBUTEROL SULFATE","","360","Select","Select",""],["","68462083335","ARFORMOTEROL TARTRATE","","-160","Select","Select",""],["","76204020025","ALBUTEROL SULFATE","","75","Select","Select",""],["","11822361530","RA ASPIRIN ADULT LOW STRENGTH","","30","Select","Select",""],["","53885000810","ONETOUCH DELICA PLUS LANCETS EXTRA FINE 33G","","100","Select","Select",""],["","57237001830","DULOXETINE HYDROCHLORIDE","","30","Select","Select",""],["","68180098430","BUDESONIDE","","-180","Select","Select",""],["","00173088710","TRELEGY ELLIPTA","","60","Select","Select",""],["","00121086816","NYSTATIN","","60","Select","Select",""],["","68180096501","LEVOTHYROXINE SODIUM","","30","Select","Select",""],["","57237010099","METOPROLOL TARTRATE","","180","Select","Select",""],["","00310737020","BUDESONIDE\/FORMOTEROL FUMARATE DIHYDRATE","","10","Select","Select",""],["","00904404073","ASPIRIN","","30","Select","Select",""],["","31722071390","PANTOPRAZOLE SODIUM","","90","Select","Select",""],["","29300012810","HYDROCHLOROTHIAZIDE","","90","Select","Select",""],["","69238110005","DOXYCYCLINE HYCLATE","","14","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":[[["Yes","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["No","Select","","","","","Select","",""],["Yes","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":""}]}]}