{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"KHALIFAH   S WALLACE","gend":1,"add":"4040 BROOKLAND DRIVE APT A","city":"CHESAPEAKE","state":"VA","zip":"23324-9998","dob":"1998-04-18","age":"","mstatus":"","insh":"900048340*01","cliId":"9Y13U24TU05","pno":"757\/753-2131","cno":"757\/753-2131","email":"","ename":"","eno":"","pphy":"SHAH, DHARMESH K MD","ppno":"757\/543-6861","pcpadd":"710 LIBERTY STREET","pcpcity":"CHESAPEAKE","pcpstate":"VA","pcpzip":23324,"pcpcounty":"","pcpid":122310,"pcpname":"","plan":"OHP","program":"MEDICARE","lob":"DSNP","region":"TIDEWATER","aligned":"Y","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/543-4082","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F25.0","Z39.2","O99.345","R45.851","F17.210","F29.","Z02.2","R30.0","N89.8","F31.12","N39.0","Z20.822","Z79.899","Z79.3","R45.850","R31.9","R45.1","F25.1","Z91.19","Z78.1","Z91.5","R05.","R09.81"],"date":["2021-09-10","2021-10-20","2021-09-06","2021-09-06","2021-10-30","2021-09-16","2021-09-16","2021-10-30","2021-10-30","2021-09-15","2021-09-16","2021-09-25","2021-09-16","2021-09-04","2021-09-04","2021-09-15","2021-09-15","2021-09-16","2021-09-16","2021-09-16","2021-09-16","2021-09-25","2021-09-25"],"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":[["","43547034106","RISPERIDONE","1MG","28","Select","Select",""],["","43547028111","ESCITALOPRAM OXALATE","10MG","-30","Select","Select",""],["","68180071160","CEFDINIR","300MG","20","Select","Select",""],["","72060014230","CAPLYTA","42MG","-14","Select","Select",""],["","62756018388","OXCARBAZEPINE","150MG","60","Select","Select",""],["","00555032302","HYDROXYZINE PAMOATE","25MG","30","Select","Select",""],["","69315013701","BENZTROPINE MESYLATE","1MG","30","Select","Select",""],["","00832154011","HALOPERIDOL","5MG","60","Select","Select",""],["","43547034106","RISPERIDONE                                                           ","TAB 1MG","28","Select","Select",""],["","72060014230","CAPLYTA                                                               ","CAP 42MG","-14","Select","Select",""],["","43547028111","ESCITALOPRAM OXALATE                                                  ","TAB 10MG","-30","Select","Select",""],["","68180071160","CEFDINIR                                                              ","CAP 300MG","20","Select","Select",""],["","00555032302","HYDROXYZINE PAMOATE                                                   ","CAP 25MG","30","Select","Select",""],["","00832154011","HALOPERIDOL                                                           ","TAB 5MG","60","Select","Select",""],["","62756018388","OXCARBAZEPINE                                                         ","TAB 150MG","60","Select","Select",""],["","70069038305","HALOPERIDOL DECANOATE                                                 ","INJ 100MG\/ML","1","Select","Select",""],["","69315013701","BENZTROPINE MESYLATE                                                  ","TAB 1MG","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":[[["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":""}]}]}