{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"DORIS HENDRICKSON","gend":1,"add":"1745 KITIMAL DR","city":"VIRGINIA BEACH","state":"VA","zip":"23454-9998","dob":"1934-05-27","age":"","mstatus":"","insh":"900047417*01","cliId":"1V19A30CY19","pno":"757\/412-7710","cno":"757\/412-7710","email":"","ename":"","eno":"","pphy":"","ppno":"","pcpadd":"","pcpcity":"","pcpstate":"","pcpzip":"","pcpcounty":"","pcpid":"","pcpname":"","plan":"OHP","program":"MEDICARE","lob":"MA-Non DSNP","region":"TIDEWATER","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":["E11.319","E11.42","Z79.4","Z95.0","I25.10","E78.00","I10.","R42.","R21.","R41.3","H40.1130","H25.9","E11.9","I44.2","R06.00","Z00.01","F03.90","R26.9","M79.674","M79.675","R47.81","Z23.","R06.02","G45.9","I16.0","Z74.09","I34.0","I70.0","R29.818"],"date":["2021-11-05","2021-11-05","2021-11-05","2021-11-19","2021-11-05","2021-09-28","2021-11-05","2021-04-13","2021-09-10","2021-04-13","2021-09-10","2021-09-10","2021-07-16","2021-11-19","2021-09-28","2021-05-28","2021-11-05","2021-11-02","2021-06-02","2021-06-02","2021-11-05","2021-11-05","2021-10-27","2021-10-29","2021-10-29","2021-11-02","2021-10-28","2021-10-28","2021-10-28"],"priorHcc":[null,null,null,null,null,null,null,"",null,"",null,null,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":[["","59746012206","MECLIZINE ","12.5MG","60","Select","Select",""],["","68462047301","URSODIOL ","250MG","180","Select","Select",""],["","67877025130","TRIAMCINOLON ","0.10%","30","Select","Select",""],["","68382065005","ISOSORB ","30MG ER","360","Select","Select",""],["","57664050658","METOPROL ","25MG","180","Select","Select",""],["","68180071909","AMLODIPINE ","2.5MG","90","Select","Select",""],["","00002880559","HUMULIN ","U-100KWP","-15","Select","Select",""],["","65862048901","QUETIAPINE ","25MG","60","Select","Select",""],["","00093101042","MUPIROCIN ","2%","22","Select","Select",""],["","31722070090","LOSARTAN ","25MG","180","Select","Select",""],["","00093727098","PRAVASTATIN ","80MG","90","Select","Select",""],["","08290320550","BD  PEN NEEDL","32GX5\/32","100","Select","Select",""],["","099073013001","FREESTYLE    MIS LANCETS","LANCETS","100","Select","Select",""],["","099073070827","FREESTYLE    TES LITE","LITE","100","Select","Select",""],["","053746017360","MEMANTINE ","HCL 5MG","60","Select","Select",""],["","064980051401","TIMOLOL ","0.5% OP","20","Select","Select",""],["","000023079815","REFRESH ","0.5% OP","15","Select","Select",""],["","31722070090","","25MG","180","Select","Select",""],["","68382065005","ISOSORB","30MG ER","360","Select","Select",""],["","57664050658","METOPROL","25MG","180","Select","Select",""],["","67877025130","TRIAMCINOLON","0.10%","30","Select","Select",""],["","59746012206","MECLIZINE","12.5MG","60","Select","Select",""],["","68462047301","URSODIOL","250MG","180","Select","Select",""],["","31722070090","LOSARTAN","25MG","180","Select","Select",""],["","00002880559","HUMULIN","U-100KWP","15","Select","Select",""],["","68180071909","AMLODIPINE","2.5MG","90","Select","Select",""],["","00093727098","PRAVASTATIN","80MG","90","Select","Select",""],["","00093101042","MUPIROCIN","2%","22","Select","Select",""],["","65862048901","QUETIAPINE","25MG","60","Select","Select",""],["","08290320550","BD PEN NEEDL","32GX5\/32","100","Select","Select",""],["","99073013001","FREESTYLE MIS LANCETS","LANCETS","100","Select","Select",""],["","64980051401","TIMOLOL","0.5% OP","20","Select","Select",""],["","00023079815","REFRESH","0.5% OP","15","Select","Select",""],["","99073070827","FREESTYLE TES LITE","LITE","100","Select","Select",""],["","53746017360","MEMANTINE","HCL 5MG","-60","Select","Select",""],["","00169300415","NOVOLIN","100 UNIT","-15","Select","Select",""],["","45802075830","PROMETHAZINE","12.5MG","6","Select","Select",""],["","53746051101","SPIRONOLACT","25MG","30","Select","Select",""],["","53746051101","SPIRONOLACT ","TAB 25MG","90","Select","Select",""],["","00169300415","NOVOLIN ","INJ 100 UNIT","-15","Select","Select",""],["","45802075830","PROMETHAZINE ","SUP 12.5MG","6","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","",""],["No","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":""}]}]}