{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"JOHN   R TOLER","gend":0,"add":"3235 ODD FELLOWS RD","city":"LYNCHBURG","state":"VA","zip":"24501-9998","dob":"1963-01-11","age":"","mstatus":"","insh":"1734909*01","cliId":"","pno":"434\/841-5838","cno":"434\/841-5838","email":"","ename":"","eno":"","pphy":"COMBS, KIMBERLY H MD","ppno":"434\/534-6868","pcpadd":"1088 LONDON LINKS RD","pcpcity":"FOREST","pcpstate":"VA","pcpzip":24551,"pcpcounty":"","pcpid":210259,"pcpname":"","plan":"OHP","program":"ACA","lob":"Small Group","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"434\/534-6868","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["H04.123","H43.312","H25.093","Z00.00","F41.1","L57.8","X32.XXXA","D22.5","L57.0","L82.1","S00.81XA","L24.2","L81.4","E29.1","F32.1","Z12.11","J06.9","Z20.828","G47.9","G47.00","F90.2","J01.90","G47.10","G47.33","R06.81","D48.5"],"date":["2021-04-19","2021-04-19","2021-04-19","2021-10-26","2021-11-22","2021-10-04","2021-10-04","2021-10-04","2021-10-04","2021-10-04","2021-02-25","2021-02-25","2021-10-04","2021-03-11","2021-07-19","2021-08-30","2020-12-11","2020-12-11","2021-03-11","2021-07-26","2021-07-19","2021-07-26","2021-07-01","2021-07-01","2021-07-01","2021-10-04"],"priorHcc":["","","",null,null,null,null,null,null,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":[["","00143965901","TESTOST","200MG\/ML","4","Select","Select",""],["","33342032915","TRIAMCINOLON","0.10%","15","Select","Select",""],["","13668013601","ESCITALOPRAM","10MG","90","Select","Select",""],["","45802046611","ECONAZOLE","1%","-30","Select","Select",""],["","00228202950","ALPRAZOLAM","0.5MG","90","Select","Select",""],["","13107008501","LORAZEPAM","2MG","10","Select","Select",""],["","00093117410","PENICILLN","500MG","42","Select","Select",""],["","50111056001","TRAZODONE","50MG","-90","Select","Select",""],["","65862096701","ESZOPICLONE","1MG","60","Select","Select",""],["","00143965901","TESTOST ","200MG\/ML","10","Select","Select",""],["","45802046611","ECONAZOLE ","1%","30","Select","Select",""],["","33342032915","TRIAMCINOLON ","0.10%","-15","Select","Select",""],["","13668013601","ESCITALOPRAM ","10MG","30","Select","Select",""],["","00228202950","ALPRAZOLAM ","0.5MG","90","Select","Select",""],["","00093117410","PENICILLN ","500MG","42","Select","Select",""],["","65862096701","ESZOPICLONE ","1MG","60","Select","Select",""],["","13107008405","LORAZEPAM ","1MG","7","Select","Select",""],["","50111056001","TRAZODONE ","50MG","90","Select","Select",""],["","53489011905","DOXYCYCL ","100MG","14","Select","Select",""],["","80777027399","MODERNA ","COVID-19","0","Select","Select",""],["","53489011905","DOXYCYCL","100MG","14","Select","Select",""],["","80777027399","MODERNA","COVID-19","0","Select","Select",""],["","00228207710","TEMAZEPAM","30MG","-30","Select","Select",""],["","00574222545","TRETINOIN","0.03%","45","Select","Select",""],["","00228306411","AMPHET\/DEXTR","25MG ER","30","Select","Select",""],["","54092038901","ADDERALL","25MG","30","Select","Select",""],["","00228207710","TEMAZEPAM ","CAP 30MG","-30","Select","Select",""],["","00228306411","AMPHET\/DEXTR ","CAP 25MG ER","30","Select","Select",""],["","54092038901","ADDERALL ","CAP 25MG","30","Select","Select",""],["","00574222545","TRETINOIN ","CRE 0.00025","45","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":""}]}]}