{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"SARAH KIRVEN","gend":1,"add":"4137 COUNTRY CLUB CIR","city":"VIRGINIA BEACH","state":"VA","zip":"23455-9998","dob":"2000-07-14","age":"","mstatus":"","insh":"1059216*03","cliId":"","pno":"460-0452","cno":"460-0452","email":"","ename":"","eno":"","pphy":"PHYSICIAN, PRIMARY CARE (MISC)","ppno":"","pcpadd":"4417 CORPORATION LN","pcpcity":"VIRGINIA BEACH","pcpstate":"VA","pcpzip":23462,"pcpcounty":"","pcpid":799999,"pcpname":"","plan":"OHP","program":"ACA","lob":"Small Group","region":"TIDEWATER","aligned":"","ano":"757\/652-0228","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":["F41.1","Z11.3","R53.83","N94.819","Z20.828","Z00.00","N92.6","F43.22","N91.4","N91.2","Z03.818","N94.810","R10.2","N90.89","J35.8","Z20.822","J01.90","J02.9","R05.","Z01.818"],"date":["2020-12-16","2020-10-13","2021-02-19","2020-11-17","2020-07-08","2021-03-05","2021-03-05","2021-03-05","2021-03-10","2021-03-10","2020-09-08","2020-11-02","2020-11-05","2020-11-17","2021-01-05","2021-01-07","2020-02-29","2020-02-29","2020-02-29","2020-11-05"],"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":[["","17478071110","LIDOCAINE","2% JELLY","30","Select","Select",""],["","00093081001","NORTRIPTYLIN","10MG","90","Select","Select",""],["","80777027399","MODERNA","COVID-19","0","Select","Select",""],["","68462029817","CLOTRIM\/BETA","DIPROP","-15","Select","Select",""],["","65862067699","ALPRAZOLAM","0.25MG","10","Select","Select",""],["","65862037401","ESCITALOPRAM","10MG","30","Select","Select",""],["","50111078710","AZITHROMYCIN","250MG","6","Select","Select",""],["","50111078710","AZITHROMYCIN ","250MG","6","Select","Select",""],["","68462029817","CLOTRIM\/BETA ","DIPROP","-15","Select","Select",""],["","17478071110","LIDOCAINE ","2% JELLY","30","Select","Select",""],["","00093081001","NORTRIPTYLIN ","10MG","-180","Select","Select",""],["","80777027399","MODERNA ","COVID-19","0","Select","Select",""],["","65862067699","ALPRAZOLAM ","0.25MG","10","Select","Select",""],["","65862037401","ESCITALOPRAM ","10MG","30","Select","Select",""],["","65862000505","CITALOPRAM ","TAB 10MG","-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","",""],["N\/A","Select","","","","","Select","",""],["No","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":""}]}]}