{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MICHELLE GIVENS","gend":1,"add":"168 ROLFE HWY","city":"WAKEFIELD","state":"VA","zip":"23888-9998","dob":"1968-12-15","age":"","mstatus":"","insh":"1040322*01","cliId":"","pno":"757\/556-7669","cno":"757\/556-7669","email":"","ename":"","eno":"","pphy":"COLEMAN, GEORGE C MD","ppno":"804\/834-8871","pcpadd":"344 WEST MAIN ST","pcpcity":"WAVERLY","pcpstate":"VA","pcpzip":23890,"pcpcounty":"","pcpid":671580,"pcpname":"","plan":"OHP","program":"ACA","lob":"Individual","region":"CENTRAL","aligned":"","ano":"757\/556-7669","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":["Z01.419","B20.","Z11.51","Z12.31","I10.","G62.9","E55.9","E66.9","Z79.899","E87.6","B02.29","Z20.828","R05.","R06.02","J18.9","M79.641","M25.531","Z12.11","Z12.12","B02.23","K04.7","Z23.","D50.9"],"date":["2020-03-24","2021-07-20","2020-03-24","2020-03-24","2021-03-17","2020-11-18","2021-02-23","2020-11-18","2021-07-20","2020-01-31","2021-02-23","2021-03-17","2021-03-17","2021-03-17","2021-03-17","2020-06-30","2020-06-30","2020-11-13","2020-11-13","2020-07-29","2020-11-01","2020-11-01","2021-07-20"],"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":[["","61958250101","BIKTARVY","","30","Select","Select",""],["","65162010250","GABAPENTIN","300MG","90","Select","Select",""],["","00642747001","SLYND","4MG","28","Select","Select",""],["","68180072103","AMLODIPINE","10MG","30","Select","Select",""],["","16571040250","CETIRIZINE","10MG","30","Select","Select",""],["","69452015120","VITAMIN","50000UNT","12","Select","Select",""],["","00603533932","PREDNISONE","20MG","-21","Select","Select",""],["","50383077504","LIDOCAINE","2% VISC","100","Select","Select",""],["","11917009588","CAPSAICIN","0.10%","42","Select","Select",""],["","42571016242","AMOX\/K","875-125","20","Select","Select",""],["","50111033402","METRONIDAZOL","500MG","14","Select","Select",""],["","50580072636","ZYRTEC","10MG","30","Select","Select",""],["","67877057305","BENZONATATE","100MG","-15","Select","Select",""],["","00093317431","ALBUTEROL","HFA","8","Select","Select",""],["","69238110005","DOXYCYCL","100MG","20","Select","Select",""],["","61958250101","BIKTARVY ","","-30","Select","Select",""],["","43598081115","CETIRIZINE ","10MG","30","Select","Select",""],["","65162010250","GABAPENTIN ","300MG","90","Select","Select",""],["","68180072103","AMLODIPINE ","10MG","30","Select","Select",""],["","50111033402","METRONIDAZOL ","500MG","14","Select","Select",""],["","00642747001","SLYND ","4MG","28","Select","Select",""],["","69452015120","VITAMIN ","50000UNT","12","Select","Select",""],["","50580072636","ZYRTEC ","10MG","30","Select","Select",""],["","11917009588","CAPSAICIN ","0.10%","42","Select","Select",""],["","42571016242","AMOX\/K ","875-125","20","Select","Select",""],["","50383077504","LIDOCAINE ","2% VISC","100","Select","Select",""],["","67877057305","BENZONATATE ","100MG","15","Select","Select",""],["","69238110005","DOXYCYCL ","100MG","20","Select","Select",""],["","00093317431","ALBUTEROL ","HFA","8","Select","Select",""],["","00603533932","PREDNISONE ","20MG","-21","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","",""],["N\/A","Select","","","","","Select","",""],["Yes","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["N\/A","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":""}]}]}