{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"TIFFANY BOLDEN-LEWIS","gend":1,"add":"9232 ATWOOD AVE","city":"NORFOLK","state":"VA","zip":"23503-9998","dob":"1981-09-14","age":"","mstatus":"","insh":"1253245*01","cliId":"","pno":"757\/355-3319","cno":"757\/355-3319","email":"","ename":"","eno":"","pphy":"MANDELL JR, M STEPHEN MD","ppno":"804\/633-5840","pcpadd":"121 COURTHOUSE LN","pcpcity":"BOWLING GREEN","pcpstate":"VA","pcpzip":22427,"pcpcounty":"","pcpid":195552,"pcpname":"SMG - Sentara Internal Medicine Physicians - Wards Corner","plan":"OHP","program":"ACA","lob":"Individual","region":"TIDEWATER","aligned":"","ano":"757\/652-8559","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":["Z12.4","Z11.51","Z20.828","Z01.419","Z30.41","E66.01","Z68.35","J30.89","Z00.00","S05.10XS","G43.909","I10.","E66.9","E78.5"],"date":["2021-02-18","2021-02-18","2021-03-08","2021-02-18","2021-02-18","2020-02-27","2020-02-27","2021-02-24","2020-02-27","2020-02-27","2020-02-27","2021-02-24","2021-02-24","2021-02-24"],"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":[["","16714069301","FLUCONAZOLE","200MG","3","Select","Select",""],["","68462056529","NORGEST\/ETHI","ESTRADIO","28","Select","Select",""],["","60432026415","FLUTICASONE","50MCG","16","Select","Select",""],["","64380071206","BENZONATATE","100MG","30","Select","Select",""],["","68462056529","NORGEST\/ETHI ","ESTRADIO","28","Select","Select",""],["","64380071206","BENZONATATE ","100MG","30","Select","Select",""],["","60432026415","FLUTICASONE ","50MCG","16","Select","Select",""],["","16714069301","FLUCONAZOLE ","200MG","3","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":""}]}]}