{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"CHARLES   A STEINMAN","gend":0,"add":"105 EDGEWARE CT","city":"CHESAPEAKE","state":"VA","zip":"23322-9998","dob":"1983-05-30","age":"","mstatus":"","insh":"1144984*01","cliId":"","pno":"757\/282-8996","cno":"757\/282-8996","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":"ACA","lob":"Small Group","region":"TIDEWATER","aligned":"","ano":"757\/282-9262","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":["J10.1","E11.65","S05.01XA","H04.123","H16.143"],"date":["2020-02-29","2020-09-29","2021-07-02","2021-07-02","2021-07-02"],"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":[["","69452015120","VITAMIN","50000UNT","4","Select","Select",""],["","53885001110","ONETOUCH","PLUS 30G","200","Select","Select",""],["","23155010305","METFORMIN","850MG","90","Select","Select",""],["","67877057305","BENZONATATE","100MG","15","Select","Select",""],["","68180067711","OSELTAMIVIR","75MG","10","Select","Select",""],["","69452015120","VITAMIN ","50000UNT","4","Select","Select",""],["","53885001110","ONETOUCH ","PLUS 30G","-200","Select","Select",""],["","23155010305","METFORMIN ","850MG","90","Select","Select",""],["","67877057305","BENZONATATE ","100MG","15","Select","Select",""],["","68180067711","OSELTAMIVIR ","75MG","10","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":[[["Yes","Select","","","","","Select","",""],["Yes","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":""}]}]}