{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"SARAH   C DONAHUE","gend":1,"add":"1119 LITTLE NECK RD","city":"VIRGINIA BEACH","state":"VA","zip":"23452-9998","dob":"2003-09-15","age":"","mstatus":"","insh":"1494949*03","cliId":"","pno":"757\/701-5315","cno":"757\/701-5315","email":"","ename":"","eno":"","pphy":"HOLLAND, DEBORAH C MD","ppno":"","pcpadd":"STE 200 1800 CAMELOT DR","pcpcity":"VIRGINIA BEACH","pcpstate":"VA","pcpzip":23454,"pcpcounty":"","pcpid":117350,"pcpname":"SMG - Sentara Pediatric Physicians - Camelot","plan":"OHP","program":"ACA","lob":"Small Group","region":"TIDEWATER","aligned":"","ano":"757\/425-0351","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/351-2905","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F32.89","F32.9","N92.5","Z11.3","F12.90","Z23.","Z00.129","Z68.52","Z71.3","Z71.82","F41.9","Z51.81","U07.1","F17.290","R50.9","R30.0","Z01.419","Z30.011","N92.6","Z80.3","Z72.51","N39.0"],"date":["2021-11-22","2021-08-12","2021-04-15","2021-04-15","2020-11-30","2021-07-20","2020-11-16","2020-11-16","2020-11-16","2020-11-16","2021-01-25","2020-11-16","2021-09-10","2021-09-10","2021-09-10","2021-09-22","2021-04-15","2021-04-15","2021-04-15","2021-04-15","2021-09-22","2021-09-01"],"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":[["","65862019401","FLUOXETINE","40MG","30","Select","Select",""],["","68382000801","LAMOTRIGINE","100MG","30","Select","Select",""],["","68180086573","BLISOVI","Jan-20","84","Select","Select",""],["","13668013501","ESCITALOPRAM","5MG","30","Select","Select",""],["","23155050110","HYDROXYZ","25MG","30","Select","Select",""],["","00603548232","PROPRANOLOL","10MG","30","Select","Select",""],["","68180012202","CEPHALEXIN","500MG","20","Select","Select",""],["","47781030301","NITROFURANTN","100MG","14","Select","Select",""],["","75826011510","PHENAZOPYRID","200MG","6","Select","Select",""],["","47781030801","NITROFUR","100MG","14","Select","Select",""],["","00555902658","JUNEL","Jan-20","28","Select","Select",""],["","65862019401","FLUOXETINE ","CAP 40MG","30","Select","Select",""],["","68382000801","LAMOTRIGINE ","TAB 100MG","30","Select","Select",""],["","68180086573","BLISOVI ","TAB 43831","84","Select","Select",""],["","13668013501","ESCITALOPRAM ","TAB 5MG","30","Select","Select",""],["","23155050110","HYDROXYZ ","TAB 25MG","30","Select","Select",""],["","00603548232","PROPRANOLOL ","TAB 10MG","30","Select","Select",""],["","68180012202","CEPHALEXIN ","CAP 500MG","20","Select","Select",""],["","47781030301","NITROFURANTN ","CAP 100MG","14","Select","Select",""],["","00555902658","JUNEL ","TAB 43831","28","Select","Select",""],["","68180016111","AZITHROMYCIN ","TAB 500MG","-2","Select","Select",""],["","75826011510","PHENAZOPYRID ","TAB 200MG","6","Select","Select",""],["","47781030801","NITROFUR ","CAP 100MG","14","Select","Select",""],["","67877054360","CEFDINIR ","CAP 300MG","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":[[["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":""}]}]}