{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"KEVIN   M ROBERTS","gend":0,"add":"963 GALT ST APT 4","city":"NORFOLK","state":"VA","zip":"23504-9998","dob":"1988-09-18","age":"","mstatus":"","insh":"900048799*01","cliId":"4JW9W03KQ40","pno":"757\/621-3849","cno":"757\/621-3849","email":"","ename":"","eno":"","pphy":"BHOWMIK, NIHAR MD","ppno":"757\/399-0701","pcpadd":"301 GOODE WAY #103","pcpcity":"PORTSMOUTH","pcpstate":"VA","pcpzip":23704,"pcpcounty":"","pcpid":410060,"pcpname":"","plan":"OHP","program":"MEDICARE","lob":"DSNP","region":"TIDEWATER","aligned":"Y","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/399-3731","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["T14.90XA","Z20.2","N34.2","Z11.3","F17.210","F20.0","Z79.899","S02.2XXB","S01.21XA","Y04.0XXA","Z74.3","S02.2XXA","F20.9","J34.2","S01.81XA","F17.200","Z23.","S09.92XA"],"date":["2021-09-08","2021-08-19","2021-08-19","2021-08-19","2021-08-19","2021-09-19","2021-09-09","2021-09-09","2021-09-09","2021-09-09","2021-09-08","2021-09-14","2021-09-05","2021-09-14","2021-09-14","2021-09-09","2021-09-09","2021-09-09"],"priorHcc":[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":[["","16714071503","OMEPRAZOLE","20MG","30","Select","Select",""],["","10147092205","HALOPERIDOL DECANOATE","100MG\/ML","1","Select","Select",""],["","63304061650","DOXYCYCLINE MONOHYDRATE","100MG","20","Select","Select",""],["","16714048402","DIVALPROEX SODIUM ER","250MG ER","30","Select","Select",""],["","00143980350","DOXYCYCLINE HYCLATE","100MG","14","Select","Select",""],["","00603243932","BENZTROPINE MESYLATE","2MG","60","Select","Select",""],["","57896040110","DOCUSATE SODIUM","100MG","60","Select","Select",""],["","68180012202","CEPHALEXIN","500MG","40","Select","Select",""],["","00603243932","BENZTROPINE MESYLATE                                                  ","TAB 2MG","60","Select","Select",""],["","57896040110","DOCUSATE SODIUM                                                       ","CAP 100MG","60","Select","Select",""],["","00143980350","DOXYCYCLINE HYCLATE                                                   ","CAP 100MG","14","Select","Select",""],["","16714048402","DIVALPROEX SODIUM ER                                                  ","TAB 250MG ER","30","Select","Select",""],["","68180012202","CEPHALEXIN                                                            ","CAP 500MG","40","Select","Select",""],["","63304061650","DOXYCYCLINE MONOHYDRATE                                               ","CAP 100MG","20","Select","Select",""],["","16714071503","OMEPRAZOLE                                                            ","CAP 20MG","30","Select","Select",""],["","10147092205","HALOPERIDOL DECANOATE                                                 ","INJ 100MG\/ML","1","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":""}]}]}