{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"HENRY   R STUTZMAN","gend":0,"add":"800 SHETLAND DR","city":"CHESAPEAKE","state":"VA","zip":"23322-9998","dob":"1968-01-02","age":"","mstatus":"","insh":"1320449*01","cliId":"","pno":"757\/418-2475","cno":"757\/418-2475","email":"","ename":"","eno":"","pphy":"PAVER, RICHARD MD","ppno":"804\/968-5700","pcpadd":"5000 COX RD STE 100","pcpcity":"GLEN ALLEN","pcpstate":"VA","pcpzip":23060,"pcpcounty":"","pcpid":125390,"pcpname":"","plan":"OHP","program":"ACA","lob":"Small Group","region":"TIDEWATER","aligned":"","ano":"757\/482-3667","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"804\/968-5739","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F43.10","I48.91","I50.9","R07.9","I10.","I48.19","I48.0","R06.02","R05.","H40.9","I50.31","I50.21","E78.5","S61.012A","Z87.891","Z79.899","M79.646","J01.00","J18.9","R94.31","R03.0","I11.0","I50.30","H40.1133","H47.233","H26.493","Z96.1","R07.89","H43.811","J40.","Z77.22","I50.32","M79.645","S69.92XA","R35.1","Z12.11","R03.1","F40.240","Z68.35","E66.9","Z20.822","H40.1113","F41.9","M19.90","E66.01","Z68.36","Z79.01","Z88.0","Z88.2","Z88.5"],"date":["2021-09-20","2021-07-15","2020-09-15","2020-09-17","2021-07-15","2020-11-25","2020-09-18","2020-09-18","2020-09-18","2020-09-18","2020-09-15","2020-09-17","2020-10-01","2020-01-24","2021-07-15","2021-07-15","2020-01-24","2020-08-08","2020-08-17","2020-09-12","2020-09-12","2020-09-16","2020-09-17","2021-07-13","2021-05-25","2021-06-23","2021-06-23","2020-09-16","2020-04-09","2020-08-17","2020-08-17","2020-11-25","2020-01-24","2020-01-24","2020-05-08","2021-08-30","2020-09-12","2020-09-12","2020-09-12","2020-09-12","2021-07-13","2021-07-15","2021-07-15","2021-07-15","2021-07-15","2021-07-15","2021-07-15","2021-07-15","2021-07-15","2021-07-15"],"priorHcc":["","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","",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":[["","65862052890","VENLAFAXINE","75MG ER","30","Select","Select",""],["","00065027515","AZOPT","1% OP","-15","Select","Select",""],["","60758080105","TIMOLOL","0.5% OP","5","Select","Select",""],["","65162046510","IBUPROFEN","600MG","30","Select","Select",""],["","70727049725","RHOPRESSA","0.02%","2","Select","Select",""],["","00093317431","ALBUTEROL","HFA","8","Select","Select",""],["","65862073260","AMIODARONE","200MG","90","Select","Select",""],["","00003089421","ELIQUIS","5MG","-60","Select","Select",""],["","62037059890","CARTIA","180\/24HR","30","Select","Select",""],["","00054429931","FUROSEMIDE","40MG","30","Select","Select",""],["","61314054701","LATANOPROST","0.01%","2","Select","Select",""],["","57237010299","METOPROL","100MG","120","Select","Select",""],["","60219106901","POT CHLORIDE","20MEQ ER","90","Select","Select",""],["","00591212712","BRINZOLAMIDE","1%","45","Select","Select",""],["","61314014415","BRIMONIDINE","0.15%","15","Select","Select",""],["","63304071990","DILTIAZEM","180MG ER","90","Select","Select",""],["","67877057305","BENZONATATE","100MG","15","Select","Select",""],["","00603533932","PREDNISONE","20MG","21","Select","Select",""],["","69238110005","DOXYCYCL","100MG","20","Select","Select",""],["","31722071390","PANTOPRAZOLE","40MG","30","Select","Select",""],["","65862052890","VENLAFAXINE ","75MG ER","30","Select","Select",""],["","00065027515","AZOPT ","1% OP","15","Select","Select",""],["","70727049725","RHOPRESSA ","0.02%","2","Select","Select",""],["","61314054701","LATANOPROST ","0.01%","-2","Select","Select",""],["","65162046510","IBUPROFEN ","600MG","-30","Select","Select",""],["","60758080105","TIMOLOL ","0.5% OP","5","Select","Select",""],["","69238110005","DOXYCYCL ","100MG","20","Select","Select",""],["","66993001968","ALBUTEROL ","HFA","18","Select","Select",""],["","00603533932","PREDNISONE ","20MG","21","Select","Select",""],["","67877057305","BENZONATATE ","100MG","15","Select","Select",""],["","00003089421","ELIQUIS ","5MG","-60","Select","Select",""],["","60219106901","POT  CHLORIDE","20MEQ ER","30","Select","Select",""],["","16714084401","AMIODARONE ","200MG","90","Select","Select",""],["","00054429931","FUROSEMIDE ","40MG","90","Select","Select",""],["","57237010299","METOPROL ","100MG","180","Select","Select",""],["","31722071390","PANTOPRAZOLE ","40MG","30","Select","Select",""],["","62037059890","CARTIA ","180\/24HR","30","Select","Select",""],["","63304071990","DILTIAZEM ","180MG ER","90","Select","Select",""],["","00591212712","BRINZOLAMIDE ","1%","45","Select","Select",""],["","61314014415","BRIMONIDINE ","0.15%","15","Select","Select",""],["","17478071310","OFLOXACIN ","0.3% OP","5","Select","Select",""],["","61314063136","NEO\/POLY\/DEX ","0.1% OP","4","Select","Select",""],["","60758011905","PREDNISOLONE ","1% OP","5","Select","Select",""],["","57237001830","DULOXETINE ","30MG","30","Select","Select",""],["","17478071310","OFLOXACIN","0.3% OP","5","Select","Select",""],["","61314063136","NEO\/POLY\/DEX","0.1% OP","4","Select","Select",""],["","60758011905","PREDNISOLONE","1% OP","5","Select","Select",""],["","27241009903","DULOXETINE","60MG","90","Select","Select",""],["","88888888887","DMR","","1","Select","Select",""],["","88888888887","DMR ","T ","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","",""],["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":""}]}]}