{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"WILLIAM   T DIXON III","gend":0,"add":"409 DECLARATION RD","city":"VIRGINIA BEACH","state":"VA","zip":"23462-9998","dob":"1964-03-25","pno":"757\/687-6627","cno":"757\/687-6627","email":"","pphy":"PALTING, JOHN KENNETH MD","ppno":"","pcpadd":"2859 VIRGINIA BEACH","pcpcity":"VIRGINIA BEACH","pcpstate":"VA","pcpzip":23452,"pcpcounty":"","pcpid":310023,"pcpname":"SMG - Sentara Family Medicine Physicians - Little Neck","insh":"1337196*01","cliId":"","plan":"OHP","program":"ACA","lob":"Small Group","region":"TIDEWATER","aligned":"","ano":"757\/536-2066","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/510-9171","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R43.2","Z20.828","M79.89","M79.642","S69.92XA","R05.","R06.02","Z86.16","R51.9","U07.1","L03.011","S69.91XA","E11.40","Z23.","E11.65","E78.00","M1A.9XX0","K21.9","R45.4","F41.9","Z12.5","Z11.4","Z79.84","Z86.14","Z88.8","R42.","R55.","I95.9","L60.3","R53.1","B94.8","E11.9","L03.012","Z86.31","B35.1","Z11.59","W29.8XXA","I95.1","G54.2","L97.521","E11.42","L03.116","Z12.11"],"date":["2021-01-24","2021-01-24","2021-04-07","2021-04-07","2021-04-07","2021-07-29","2021-08-06","2021-08-06","2021-08-06","2021-01-16","2021-04-07","2021-04-07","2021-07-28","2021-04-07","2021-08-05","2021-08-05","2021-04-28","2021-04-28","2021-04-28","2021-04-28","2021-04-28","2021-04-28","2021-07-28","2021-07-28","2021-08-06","2021-08-06","2021-07-29","2021-08-05","2021-07-29","2021-08-06","2021-08-06","2021-08-06","2021-04-23","2020-10-26","2020-10-26","2020-10-26","2021-04-23","2021-08-05","2021-08-05","2021-11-01","2021-11-01","2021-11-01","2021-08-30"],"priorHcc":["","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","",null,null,null,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":[["","65162027210","SMZ\/TMP","800-160","14","Select","Select",""],["","80777027315","MODERNA","COVID-19","0","Select","Select",""],["","11822046713","PAIN","325MG","30","Select","Select",""],["","51224022060","METFORMIN","1000MG","180","Select","Select",""],["","65162019010","NAPROXEN","500MG","20","Select","Select",""],["","67877021901","CEPHALEXIN","500MG","28","Select","Select",""],["","00006027731","JANUVIA","100MG","-90","Select","Select",""],["","65862019301","FLUOXETINE","20MG","90","Select","Select",""],["","16729000515","SIMVASTATIN","20MG","90","Select","Select",""],["","16729000201","GLIMEPIRIDE","2MG","30","Select","Select",""],["","65862019105","CYCLOBENZAPR","10MG","40","Select","Select",""],["","00143924920","AMOX\/K","875-125","20","Select","Select",""],["","11822046713","PAIN ","TAB 325MG","30","Select","Select",""],["","51224022060","METFORMIN ","TAB 1000MG","180","Select","Select",""],["","67877021901","CEPHALEXIN ","CAP 500MG","28","Select","Select",""],["","00006027731","JANUVIA ","TAB 100MG","-90","Select","Select",""],["","65862019301","FLUOXETINE ","CAP 20MG","90","Select","Select",""],["","65862019105","CYCLOBENZAPR ","TAB 10MG","40","Select","Select",""],["","55111032101","GLIMEPIRIDE ","TAB 2MG","30","Select","Select",""],["","00143924920","AMOX\/K ","TAB 875-125","20","Select","Select",""],["","80777027315","MODERNA ","INJ COVID-19","0","Select","Select",""],["","65162027210","SMZ\/TMP ","TAB 800-160","14","Select","Select",""],["","16729000515","SIMVASTATIN ","TAB 20MG","-90","Select","Select",""],["","65162019010","NAPROXEN ","TAB 500MG","20","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":""}]}]}