{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"DAVID   E HOFFMAN","gend":0,"add":"613 SCOTLAND ST APT 215","city":"WILLIAMSBURG","state":"VA","zip":"23185-9998","dob":"1971-03-30","age":"","mstatus":"","insh":"900048409*01","cliId":"4NF1U08RM12","pno":"757\/561-8520","cno":"757\/561-8520","email":"","ename":"","eno":"","pphy":"","ppno":"","pcpadd":"","pcpcity":"","pcpstate":"","pcpzip":"","pcpcounty":"","pcpid":"","pcpname":"","plan":"OHP","program":"MEDICARE","lob":"DSNP","region":"TIDEWATER","aligned":"N","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":["L02.31","Z00.00","F31.70","R78.89","B35.1","Z12.11","J44.9","E03.9","I10.","I25.708","R79.9","I26.99"],"date":["2021-07-21","2021-07-21","2021-07-21","2021-07-21","2021-07-21","2021-07-21","2021-07-21","2021-07-15","2021-07-15","2021-07-15","2021-07-15","2021-07-08"],"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":[["","69315013701","BENZTROPINE MESYLATE","1MG","60","Select","Select",""],["","47781066590","LEVOTHYROXINE SODIUM","175MCG","90","Select","Select",""],["","55111016730","OLANZAPINE","15MG","30","Select","Select",""],["","66993001968","ALBUTEROL SULFATE HFA","HFA","18","Select","Select",""],["","68645014059","FAMOTIDINE","20MG","90","Select","Select",""],["","65162027250","SULFAMETHOXAZOLE\/TRIMETHOPRIM DS","800-160","20","Select","Select",""],["","00093505898","ATORVASTATIN CALCIUM","40MG","90","Select","Select",""],["","68462029855","CLOTRIMAZOLE\/BETAMETHASONE DIPROPIONATE","DIPROP","45","Select","Select",""],["","51672129802","KETOCONAZOLE","2%","-60","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":""}]}]}