{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"JESSICA   M PUFFENBARGER","gend":1,"add":"1476 GUTHRIE ROAD","city":"STAUNTON","state":"VA","zip":"24401-9998","dob":"1984-10-25","age":"","mstatus":"","insh":"900047795*01","cliId":"4CA9PK7NH25","pno":"540\/280-2372","cno":"540\/280-2372","email":"","ename":"","eno":"","pphy":"MARSH, JOHN O MD","ppno":"540\/887-2627","pcpadd":"40 CHERRY GROVE ROAD","pcpcity":"MIDDLEBROOK","pcpstate":"VA","pcpzip":24459,"pcpcounty":"","pcpid":210524,"pcpname":"VelocityCare Raphine","plan":"OHP","program":"MEDICARE","lob":"MA-Non DSNP","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"540\/886-2726","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R06.83","G47.9","G47.10","G47.19","R20.2","M79.641","M79.642","R53.1","M25.512","R09.81","R52.","Z20.822","Z00.00","G47.419","Z20.828","S29.9XXA","S46.912A","R00.0","V89.2XXA","Z01.812","G47.61","F31.9","K21.9","Z79.899","Z79.891"],"date":["2021-07-02","2021-07-02","2021-10-26","2021-10-27","2021-08-03","2021-08-03","2021-08-03","2021-08-03","2021-10-04","2021-09-20","2021-09-20","2021-10-26","2021-10-19","2021-11-19","2021-09-22","2021-10-02","2021-10-02","2021-10-02","2021-10-02","2021-10-26","2021-10-26","2021-10-26","2021-10-26","2021-10-26","2021-10-26"],"priorHcc":["","",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":[["","065862057490","MONTELUKAST ","10MG","-90","Select","Select",""],["","016571020150","DICLOFENAC ","75MG DR","60","Select","Select",""],["","000527150637","AMPHET\/DEXTR ","30MG","60","Select","Select",""],["","069315090505","LORAZEPAM ","1MG","60","Select","Select",""],["","000406055201","OXYCODONE ","5MG","3","Select","Select",""],["","16571020150","","75MG DR","60","Select","Select",""],["","69315090505","LORAZEPAM","1MG","60","Select","Select",""],["","16571020150","DICLOFENAC","75MG DR","60","Select","Select",""],["","65862057490","MONTELUKAST","10MG","-90","Select","Select",""],["","00527150637","AMPHET\/DEXTR","30MG","60","Select","Select",""],["","00406055201","OXYCODONE","5MG","3","Select","Select",""],["","76204020025","ALBUTEROL","0.08%","75","Select","Select",""],["","50228043605","NAPROXEN","500MG","20","Select","Select",""],["","51672128202","TRIAMCINOLON","0.10%","-30","Select","Select",""],["","65862060230","MODAFINIL","200MG","90","Select","Select",""],["","65862053820","LEVOFLOXACIN","750MG","7","Select","Select",""],["","68462010805","TOPIRAMATE","25MG","-180","Select","Select",""],["","00378027105","DIAZEPAM","2MG","40","Select","Select",""],["","76204020025","ALBUTEROL ","NEB 0.00083","-75","Select","Select",""],["","65862060230","MODAFINIL ","TAB 200MG","90","Select","Select",""],["","51672128202","TRIAMCINOLON ","CRE 0.001","-30","Select","Select",""],["","00378027105","DIAZEPAM ","TAB 2MG","40","Select","Select",""],["","68462010805","TOPIRAMATE ","TAB 25MG","180","Select","Select",""],["","50228043605","NAPROXEN ","TAB 500MG","20","Select","Select",""],["","65862053820","LEVOFLOXACIN ","TAB 750MG","7","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":""}]}]}