{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"DONNA   H CLARKE","gend":1,"add":"1020 DITCHLEY RD","city":"VIRGINIA BEACH","state":"VA","zip":"23451-9998","dob":"1961-03-10","age":"","mstatus":"","insh":"1742334*01","cliId":"","pno":"757\/362-4665","cno":"757\/362-4665","email":"","ename":"","eno":"","pphy":"LOCK, RACHEL DO","ppno":"757\/395-2500","pcpadd":"1024 FIRST COLONIAL RD STE 102","pcpcity":"VIRGINIA BEACH","pcpstate":"VA","pcpzip":23454,"pcpcounty":"","pcpid":117368,"pcpname":"SMG - Sentara Family Medicine Physicians - First Colonial","plan":"OHP","program":"ACA","lob":"Small Group","region":"TIDEWATER","aligned":"","ano":"757\/362-4665","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/275-9700","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["G47.33","R32.","Z12.2","F17.211","R91.8","R76.8","Z01.419","R00.2","I10.","E89.0","R79.89","Z12.31","Z79.899","N30.00","R31.9","Z00.00","F98.8","F17.210","E78.2","F32.89","K21.9","J44.9","M54.12","L57.8","L57.0","Z12.83","R06.00","E03.9","E28.39","R30.0","N81.10","N81.9","R39.15","H40.013","H33.321","H33.331","H35.413","H43.811","H43.392","H40.053","Z83.511","F17.200","R07.89","Z23.","M85.89","Z80.3","Z12.11"],"date":["2021-09-17","2020-08-31","2020-12-10","2021-05-06","2020-12-10","2020-08-28","2020-10-21","2021-10-26","2021-10-26","2021-10-26","2020-07-02","2021-09-30","2021-10-26","2020-10-27","2020-10-27","2021-03-30","2021-10-26","2021-03-30","2021-10-26","2021-10-26","2021-03-30","2021-10-26","2021-03-30","2021-04-12","2021-04-12","2021-04-12","2021-10-21","2021-10-21","2020-09-18","2020-10-26","2020-10-26","2020-10-26","2020-10-26","2021-03-25","2021-03-25","2021-03-25","2021-03-25","2021-03-25","2021-03-25","2021-03-25","2021-03-25","2021-10-21","2021-10-21","2021-10-26","2021-10-26","2021-09-30","2021-11-03"],"priorHcc":["","","","","","","",null,null,null,"",null,null,"","","",null,"",null,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":[["","65162098908","DOTTI","0.025MG","-8","Select","Select",""],["","68180096701","LEVOTHYROXIN","75MCG","90","Select","Select",""],["","17478076610","PROGESTERONE","100MG","30","Select","Select",""],["","13107007001","AMPHET\/DEXTR","10MG","30","Select","Select",""],["","57237001830","DULOXETINE","30MG","30","Select","Select",""],["","50742061601","METOPROL","50MG ER","90","Select","Select",""],["","00378427593","VALACYCLOVIR","500MG","30","Select","Select",""],["","00093720198","PRAVASTATIN","20MG","90","Select","Select",""],["","59310057922","PROAIR","","8","Select","Select",""],["","66993001968","ALBUTEROL","HFA","18","Select","Select",""],["","58160088552","FLUARIX","2020-21","0","Select","Select",""],["","55111064501","OMEPRAZOLE","40MG","-90","Select","Select",""],["","59746017506","PREDNISONE","20MG","10","Select","Select",""],["","65862019105","CYCLOBENZAPR","10MG","30","Select","Select",""],["","80777027399","MODERNA","COVID-19","0","Select","Select",""],["","00173068220","VENTOLIN","","-18","Select","Select",""],["","29300012810","HYDROCHLOROT","25MG","90","Select","Select",""],["","65162098908","DOTTI ","0.025MG","8","Select","Select",""],["","68180096701","LEVOTHYROXIN ","75MCG","90","Select","Select",""],["","50742061601","METOPROL ","50MG ER","90","Select","Select",""],["","57237001830","DULOXETINE ","30MG","30","Select","Select",""],["","17478076610","PROGESTERONE ","100MG","30","Select","Select",""],["","13107007001","AMPHET\/DEXTR ","10MG","30","Select","Select",""],["","00093720198","PRAVASTATIN ","20MG","90","Select","Select",""],["","59310057922","PROAIR ","","8","Select","Select",""],["","66993001968","ALBUTEROL ","HFA","18","Select","Select",""],["","00378427593","VALACYCLOVIR ","500MG","30","Select","Select",""],["","58160088552","FLUARIX ","2020-21","0","Select","Select",""],["","55111064501","OMEPRAZOLE ","40MG","90","Select","Select",""],["","59746017506","PREDNISONE ","20MG","10","Select","Select",""],["","65862019105","CYCLOBENZAPR ","10MG","30","Select","Select",""],["","80777027399","MODERNA ","COVID-19","0","Select","Select",""],["","00173068220","VENTOLIN ","","18","Select","Select",""],["","29300012810","HYDROCHLOROT ","25MG","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":""}]}]}