{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"CANDIDA   R GALARZA","gend":1,"add":"2754 CONRAD AVE 2","city":"CHESAPEAKE","state":"VA","zip":"23323-9998","dob":"1944-02-01","age":"","mstatus":"","insh":"900047482*01","cliId":"2WN0R01UU04","pno":"757\/292-1714","cno":"757\/292-1714","email":"","ename":"","eno":"","pphy":"CRISOSTOMO, CHRISTEN MD","ppno":"757\/923-9660","pcpadd":"SUITE 3 2401 GODWIN BLVD","pcpcity":"SUFFOLK","pcpstate":"VA","pcpzip":23434,"pcpcounty":"","pcpid":133029,"pcpname":"Cedar Road Medical Associates","plan":"OHP","program":"MEDICARE","lob":"DSNP","region":"TIDEWATER","aligned":"Y","ano":"757\/292-1714","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":["K57.32","N28.1","Z90.49","Z90.710","K57.92","R10.32","K59.00","F32.9","M19.90","E11.9","K21.9","I10.","E78.00","Z83.3","Z82.49","Z79.899","Z88.6","Z88.5","R10.9","Z20.828","Z08.","Z85.3","Z79.811","M85.80","E55.9","M25.50","K57.90","E11.3291","Z96.1","R10.13","R09.1","R06.00","K43.9","F41.9","K42.9","I25.2","K57.30","Z79.84","R93.89","Z68.33","R10.11","L98.9","Z68.32","E78.2","R30.9","N39.0","N30.90","L82.1","R07.9","D48.5","L85.3","Z12.83","Z71.9","N39.46","R41.3","Z11.59","N13.30","R06.02","R11.0","R30.0","R51.9","F41.8","F32.A","Z86.59","Z17.0","Z13.31","H10.45","H43.813"],"date":["2021-04-24","2021-07-10","2021-04-24","2021-04-24","2021-06-07","2021-07-10","2021-04-23","2021-04-24","2021-07-10","2021-09-20","2021-07-10","2021-11-02","2021-07-10","2021-04-24","2021-04-24","2021-07-10","2021-04-24","2021-04-24","2021-07-10","2021-04-27","2021-08-25","2021-08-25","2021-08-25","2021-08-25","2021-08-25","2021-08-25","2021-08-25","2021-09-28","2021-06-28","2021-07-10","2021-07-10","2021-07-10","2021-07-10","2021-08-25","2021-07-10","2021-07-10","2021-07-10","2021-07-10","2021-06-07","2021-09-20","2021-07-10","2021-06-07","2021-11-02","2021-09-20","2021-06-22","2021-06-22","2021-06-28","2021-07-14","2021-07-10","2021-07-14","2021-07-14","2021-07-14","2021-07-14","2021-09-20","2021-09-20","2021-08-20","2021-06-02","2021-07-10","2021-07-10","2021-07-10","2021-11-02","2021-09-20","2021-11-02","2021-10-30","2021-08-25","2021-09-03","2021-09-28","2021-09-28"],"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":[["","42571016242","AMOX\/K CLAV","TAB 875-125","20","Select","Select",""],["","50111033402","METRONIDAZOL","TAB 500MG","30","Select","Select",""],["","456120130","LINZESS","CAP 145MCG","30","Select","Select",""],["","527058601","DICYCLOMINE","CAP 10MG","20","Select","Select",""],["","68382020906","ANASTROZOLE","TAB 1MG","90","Select","Select",""],["","42806054701","VITAMIN D","CAP 1.25MG","4","Select","Select",""],["","591024010","LORAZEPAM","TAB 0.5MG","30","Select","Select",""],["","58657067601","CIPROFLOXACN","TAB 500MG","20","Select","Select",""],["","42806054701","VITAMIN D ","","4","Select","Select",""],["","591024010","LORAZEPAM ","","30","Select","Select",""],["","50111033402","METRONIDAZOLE ","","30","Select","Select",""],["","527058601","DICYCLOMINE HYDROCHLORIDE ","","20","Select","Select",""],["","456120130","LINZESS ","","30","Select","Select",""],["","58657067601","CIPROFLOXACIN HYDROCHLORIDE ","","20","Select","Select",""],["","53885000810","ONETOUCH DELICA PLUS LANCETS EXTRA FINE 33G ","","100","Select","Select",""],["","254200801","COLCHICINE","","6","Select","Select",""],["","68645051554","AMLODIPINE BESYLATE","","90","Select","Select",""],["","53885024510","ONETOUCH ULTRA","","100","Select","Select",""],["","72205000390","ROSUVASTATIN CALCIUM ","","90","Select","Select",""],["","69097031602","EXEMESTANE","","90","Select","Select",""],["","42571016242","AMOXICILLIN\/CLAVULANATE POTASSIUM ","","20","Select","Select",""],["","65162063609","PANTOPRAZOLE SODIUM","","30","Select","Select",""],["","00527058601","DICYCLOMINE HYDROCHLORIDE","","20","Select","Select",""],["","53885000810","ONETOUCH DELICA PLUS LANCETS EXTRA FINE 33G","","-100","Select","Select",""],["","50111033402","METRONIDAZOLE","","30","Select","Select",""],["","58657067601","CIPROFLOXACIN HYDROCHLORIDE","","20","Select","Select",""],["","42571016242","AMOXICILLIN\/CLAVULANATE POTASSIUM","","20","Select","Select",""],["","68645055554","LISINOPRIL","","90","Select","Select",""],["","72205000390","ROSUVASTATIN CALCIUM","","90","Select","Select",""],["","65162047810","NITROFURANTOIN MONOHYDRATE\/MACROCRYSTALS","","10","Select","Select",""],["","68645014059","FAMOTIDINE","20MG","20","Select","Select",""],["","68382004101","PROMETHAZINE HYDROCHLORIDE","25MG","12","Select","Select",""],["","31604002717","B-12","1000MCG","30","Select","Select",""],["","13668001990","VENLAFAXINE HYDROCHLORIDE ER","75MG ER","-30","Select","Select",""],["","31604003143","","","30","Select","Select",""],["","68382020906","ANASTROZOLE                                                           ","TAB 1MG","-90","Select","Select",""],["","00143312610","DICYCLOMINE HYDROCHLORIDE                                             ","CAP 10MG","28","Select","Select",""],["","53885000810","ONETOUCH DELICA PLUS LANCETS EXTRA FINE 33G                           ","MIS PLUS 33G","-100","Select","Select",""],["","69097031602","EXEMESTANE                                                            ","TAB 25MG","-90","Select","Select",""],["","00143924920","AMOXICILLIN\/CLAVULANATE POTASSIUM                                     ","TAB 875-125","21","Select","Select",""],["","42806054701","VITAMIN D                                                             ","CAP 1.25MG","4","Select","Select",""],["","29300022705","METRONIDAZOLE                                                         ","TAB 500MG","14","Select","Select",""],["","58657067601","CIPROFLOXACIN HYDROCHLORIDE                                           ","TAB 500MG","20","Select","Select",""],["","00591024010","LORAZEPAM                                                             ","TAB 0.5MG","30","Select","Select",""],["","68382004101","PROMETHAZINE HYDROCHLORIDE                                            ","TAB 25MG","12","Select","Select",""],["","00456120130","LINZESS                                                               ","CAP 145MCG","30","Select","Select",""],["","72205000390","ROSUVASTATIN CALCIUM                                                  ","TAB 10MG","90","Select","Select",""],["","68645051554","AMLODIPINE BESYLATE                                                   ","TAB 5MG","90","Select","Select",""],["","65162047810","NITROFURANTOIN MONOHYDRATE\/MACROCRYSTALS                              ","CAP 100MG","10","Select","Select",""],["","53885024510","ONETOUCH ULTRA                                                        ","TES ULTRA","100","Select","Select",""],["","68645055554","LISINOPRIL                                                            ","TAB 40MG","90","Select","Select",""],["","00254200801","COLCHICINE                                                            ","TAB 0.6MG","6","Select","Select",""],["","65162063609","PANTOPRAZOLE SODIUM                                                   ","TAB 20MG","30","Select","Select",""],["","68645014059","FAMOTIDINE                                                            ","TAB 20MG","20","Select","Select",""],["","13668001990","VENLAFAXINE HYDROCHLORIDE ER                                          ","CAP 75MG ER","30","Select","Select",""],["","31604002717","B-12                                                                  ","LOZ 1000MCG","30","Select","Select",""],["","31604003143","                                                                      "," ","30","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":""}]}]}