{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"ALLAN WEINTRAUT","gend":0,"add":"629 SEDGEFIELD CT","city":"CHESAPEAKE","state":"VA","zip":"23322-9998","dob":"1961-03-06","age":"","mstatus":"","insh":"1320460*01","cliId":"","pno":"757\/687-9595","cno":"757\/687-9595","email":"","ename":"","eno":"","pphy":"BROOKS, BONNIE J MD","ppno":"757\/594-1803","pcpadd":"SUITE 140 1183 JEFFERSON AVE","pcpcity":"NEWPORT NEWS","pcpstate":"VA","pcpzip":23606,"pcpcounty":"","pcpid":119865,"pcpname":"SMG - Sentara Internal Medicine Physicians - Port Warwick","plan":"OHP","program":"ACA","lob":"Small Group","region":"TIDEWATER","aligned":"","ano":"757\/482-3667","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":["E11.65","E78.2","E78.1","N52.9","I73.9","F17.200","Z01.818","R03.0","Z12.11","E87.5","E11.51","I70.301","E78.00","Z95.828","Z79.82","Z79.02","Z79.84","Z79.899","M54.2","I77.1","T82.858A","I70.201","R79.89"],"date":["2021-08-03","2021-08-03","2021-08-03","2020-06-23","2021-05-21","2020-06-23","2020-09-04","2021-07-28","2021-08-30","2020-03-13","2021-05-28","2021-05-28","2021-05-28","2021-05-28","2021-05-28","2021-05-28","2021-05-28","2021-05-28","2020-01-02","2020-09-11","2020-09-11","2020-09-11","2021-08-03"],"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":[["","64980028005","GLIPIZIDE ","5MG","90","Select","Select",""],["","65862035790","CLOPIDOGREL ","75MG","90","Select","Select",""],["","72205002790","ROSUVASTATIN ","5MG","90","Select","Select",""],["","65162017810","METFORMIN ","500MG ER","-360","Select","Select",""],["","31722070930","SILDENAFIL ","25MG","30","Select","Select",""],["","59676058015","JANSSEN ","COVID-19","0","Select","Select",""],["","64980028010","GLIPIZIDE","5MG","90","Select","Select",""],["","65862035790","CLOPIDOGREL","75MG","90","Select","Select",""],["","72205002790","ROSUVASTATIN","5MG","90","Select","Select",""],["","65162017810","METFORMIN","500MG ER","-360","Select","Select",""],["","31722070930","SILDENAFIL","25MG","30","Select","Select",""],["","59676058015","JANSSEN","COVID-19","0","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","",""],["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":""}]}]}