{"version":"0.4","data":[{"t":"Demographics","q":[{"name":" JEANETTE W MCCLOUD","gend":1,"add":"PO BOX 172","city":"PALMYRA","state":"VA","zip":"22963-9998","dob":"1958-05-17","age":"","mstatus":"","insh":"1383087*01","cliId":"","pno":"434\/390-2149","cno":"434\/390-2149, 434\/390-2149","email":"","ename":"","eno":"","pphy":"SANTULLI, MICHAEL E MD","ppno":"434\/295-5155","pcpadd":"SUITE 201 1405 ROLKIN ROAD","pcpcity":"CHARLOTTESVILLE","pcpstate":"VA","pcpzip":"22911-9998","pcpcounty":"","pcpid":102328,"pcpname":"","plan":"OHP - OPTIMA","program":"ACA","lob":"Small Group","region":"WESTERN\/ CHARLOTTESVILLE","aligned":"","ano":"","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":["R79.9","E89.0","Z11.59","Z20.828","E11.65","C73.","E78.2","K90.0","G43.009","J30.2","E55.9","R73.01","G47.31","Z23.","H04.123","Z96.1","H43.811","H52.4","J11.1","G47.33","Z12.31","Z01.411","N95.2","J01.90","Z00.01"],"date":["2020-04-07","2021-06-16","2020-08-01","2020-08-01","2021-06-16","2021-06-16","2021-06-16","2021-06-16","2021-06-16","2021-06-16","2021-06-16","2020-10-19","2021-06-16","2020-10-19","2020-01-02","2020-01-02","2020-01-02","2020-01-02","2020-02-06","2021-01-29","2020-09-09","2020-09-16","2020-09-16","2020-02-23","2020-12-09"],"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":[["","53746017805","METFORMIN","500MG ER","90","Select","Select",""],["","00074662490","SYNTHROID","100MCG","90","Select","Select",""],["","00093227534","AMOX\/K","875-125","20","Select","Select",""],["","69097084615","CYCLOBENZAPR","10MG","30","Select","Select",""],["","13668008105","MONTELUKAST","10MG","30","Select","Select",""],["","70710101002","OSELTAMIVIR","75MG","10","Select","Select",""],["","65862014736","SUMATRIPTAN","50MG","-9","Select","Select",""],["","53885027210","ONETOUCH","VERIO","100","Select","Select",""],["","70377000812","ROSUVASTATIN","20MG","90","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":""}]}]}