{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"DACIA   L JUHN","gend":1,"add":"811 STEPHANIE CT","city":"VIRGINIA BEACH","state":"VA","zip":"23462-9998","dob":"1953-03-31","age":"","mstatus":"","insh":"900047521*01","cliId":"1A19D28QG35","pno":"757\/998-9581","cno":"757\/998-9581","email":"","ename":"","eno":"","pphy":"ELHASSAN, AMIRA MD","ppno":"757\/305-1797","pcpadd":"828 HEALTHY WAY STE 220","pcpcity":"VIRGINIA BEACH","pcpstate":"VA","pcpzip":23462,"pcpcounty":"","pcpid":143824,"pcpname":"BON SECOURS MEDICAL ASSOCIATES","plan":"OHP","program":"MEDICARE","lob":"DSNP","region":"TIDEWATER","aligned":"Y","ano":"Non-DSNP","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/309-4715","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["G56.01","M65.332","M65.342","S52.572D","M25.532","S52.502D","X58.XXXD","M25.512","M19.012","G89.29","R23.3","E03.9","F31.5","F42.3","F60.3","R19.4","F41.1"],"date":["2021-05-26","2021-05-26","2021-05-26","2021-05-26","2021-05-26","2021-05-26","2021-05-26","2021-06-14","2021-06-14","2021-06-14","2021-07-06","2021-07-06","2021-09-23","2021-09-23","2021-09-23","2021-07-19","2021-09-23"],"priorHcc":["","","","","","","","","","","","",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":[["","68462025601","ROPINIROLE","TAB 2MG","30","Select","Select",""],["","69097081512","GABAPENTIN","CAP 400MG","-120","Select","Select",""],["","67877024601","QUETIAPINE","TAB 200MG","30","Select","Select",""],["","68180031909","BUPROPN HCL","TAB 150MG XL","30","Select","Select",""],["","68382009810","PAROXETINE","TAB 20MG","30","Select","Select",""],["","69315090405","LORAZEPAM","TAB 0.5MG","90","Select","Select",""],["","43547029010","BUPROPION","TAB 200MG SR","30","Select","Select",""],["","43547029010","BUPROPION HYDROCHLORIDE ER (SR) ","","30","Select","Select",""],["","67877024601","QUETIAPINE FUMARATE","","30","Select","Select",""],["","16729044315","BUPROPION HYDROCHLORIDE ER (XL) ","","30","Select","Select",""],["","69315090405","LORAZEPAM ","","90","Select","Select",""],["","68382009810","PAROXETINE HYDROCHLORIDE","","-30","Select","Select",""],["","68462025601","ROPINIROLE HCL","","30","Select","Select",""],["","69238183007","LEVOTHYROXINE SODIUM ","","90","Select","Select",""],["","43547029010","BUPROPION HYDROCHLORIDE ER (SR)","","30","Select","Select",""],["","68180031909","BUPROPION HYDROCHLORIDE ER (XL)","","-30","Select","Select",""],["","69238183007","LEVOTHYROXINE SODIUM","","90","Select","Select",""],["","65862086001","FAMOTIDINE","40MG","180","Select","Select",""],["","70194000330","TRULANCE","3MG","30","Select","Select",""],["","43547029010","BUPROPION HYDROCHLORIDE ER (SR)                                       ","TAB 200MG SR","30","Select","Select",""],["","69315090405","LORAZEPAM                                                             ","TAB 0.5MG","-90","Select","Select",""],["","65162010350","GABAPENTIN                                                            ","CAP 400MG","120","Select","Select",""],["","67877024760","QUETIAPINE FUMARATE                                                   ","TAB 300MG","30","Select","Select",""],["","68382009810","PAROXETINE HYDROCHLORIDE                                              ","TAB 20MG","-30","Select","Select",""],["","16729044315","BUPROPION HYDROCHLORIDE ER (XL)                                       ","TAB 150MG XL","30","Select","Select",""],["","68462025601","ROPINIROLE HCL                                                        ","TAB 2MG","30","Select","Select",""],["","69238183007","LEVOTHYROXINE SODIUM                                                  ","TAB 25MCG","90","Select","Select",""],["","70194000330","TRULANCE                                                              ","TAB 3MG","30","Select","Select",""],["","65862086001","FAMOTIDINE                                                            ","TAB 40MG","180","Select","Select",""],["","54092054701","MOTEGRITY                                                             ","TAB 2MG","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":[[["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":""}]}]}