{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"CYNTHIA   A FORD","gend":1,"add":"301 WESTWOOD CIR","city":"VIRGINIA BEACH","state":"VA","zip":"23454-9998","dob":"1959-01-17","age":"","mstatus":"","insh":"1758012*01","cliId":"","pno":"757\/631-2809","cno":"757\/631-2809","email":"","ename":"","eno":"","pphy":"GEORGE, LINDA J MD","ppno":"757\/962-6262","pcpadd":"STE A 1856 COLONIAL MED CT","pcpcity":"VIRGINIA BEACH","pcpstate":"VA","pcpzip":23454,"pcpcounty":"","pcpid":135761,"pcpname":"Trinity Medical Care PC","plan":"OHP","program":"ACA","lob":"Small Group","region":"TIDEWATER","aligned":"","ano":"631-9773","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/962-1185","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z12.2","F17.210","D07.1","S76.301D","Z20.822","Z12.11","K63.5","K57.30","K64.8","F41.9","Z13.89","Z12.31","Z00.01","Z68.32","E11.9","I25.10","Z00.00","E78.5","R20.2","M79.10","E55.9","M54.5","R10.31","R93.89","Z01.419","R10.2","J44.1","Z01.812","Z01.810","C54.1","D25.9","K21.9","E78.00","J44.9","E66.9","Z87.42","Z87.891","Z79.899","Z79.84","Z79.82","G56.00","Z23.","M25.561","M17.11","M23.41"],"date":["2020-11-17","2020-11-17","2021-02-10","2020-02-03","2021-01-15","2021-04-29","2021-04-29","2021-04-29","2021-04-29","2020-02-19","2020-02-19","2021-11-16","2021-01-22","2021-01-22","2021-10-01","2021-03-31","2021-01-11","2021-10-01","2020-02-14","2020-02-14","2020-02-14","2020-11-24","2021-02-10","2021-01-20","2020-11-20","2021-01-19","2020-03-17","2021-01-11","2021-01-11","2021-01-11","2021-01-19","2021-03-04","2021-01-19","2021-01-19","2021-01-19","2021-01-19","2021-01-19","2021-01-19","2021-01-19","2021-01-19","2020-11-24","2021-10-01","2021-11-08","2021-11-08","2021-11-08"],"priorHcc":["","","","","","","","","","","",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":[["","55111015901","OMEPRAZOLE","40MG","30","Select","Select",""],["","70010049101","METFORMIN","500MG ER","60","Select","Select",""],["","00781106101","ALPRAZOLAM","0.25MG","60","Select","Select",""],["","27808015601","ROSUVASTATIN","10MG","90","Select","Select",""],["","66869020490","LIVALO","2MG","30","Select","Select",""],["","57237001830","DULOXETINE","30MG","30","Select","Select",""],["","62542030104","HYD","10-8\/5ML","60","Select","Select",""],["","00006483703","PNEUMOVAX","25\/0.5","0","Select","Select",""],["","65862064163","AZITHROMYCIN","250MG","6","Select","Select",""],["","55566670001","CLENPIQ","","320","Select","Select",""],["","70461032003","FLUCLVX","2020-21","0","Select","Select",""],["","58160082311","SHINGRIX","50\/0.5ML","-1","Select","Select",""],["","00093117401","PENICILLN","500MG","28","Select","Select",""],["","31722099601","HYDROCO\/APAP","5-325MG","10","Select","Select",""],["","55111015901","OMEPRAZOLE ","40MG","30","Select","Select",""],["","70010049101","METFORMIN ","500MG ER","60","Select","Select",""],["","00781106101","ALPRAZOLAM ","0.25MG","60","Select","Select",""],["","27808015601","ROSUVASTATIN ","10MG","90","Select","Select",""],["","00006483703","PNEUMOVAX ","25\/0.5","0","Select","Select",""],["","65862064163","AZITHROMYCIN ","250MG","6","Select","Select",""],["","62542030104","HYD ","10-8\/5ML","60","Select","Select",""],["","57237001830","DULOXETINE ","30MG","30","Select","Select",""],["","70461032003","FLUCLVX ","2020-21","0","Select","Select",""],["","58160082311","SHINGRIX ","50\/0.5ML","1","Select","Select",""],["","66869020490","LIVALO ","2MG","30","Select","Select",""],["","55566670001","CLENPIQ ","","320","Select","Select",""],["","31722099601","HYDROCO\/APAP ","5-325MG","10","Select","Select",""],["","00093117401","PENICILLN ","500MG","28","Select","Select",""],["","00173085910","BREO","100-25","60","Select","Select",""],["","31722070090","LOSARTAN","25MG","90","Select","Select",""],["","99073012101","FREESTYLE TES","","100","Select","Select",""],["","99073013001","FREESTYLE MIS LANCETS","LANCETS","100","Select","Select",""],["","99073070805","FREESTYLE KIT LITE","LITE","1","Select","Select",""],["","00173085910","BREO ","INH 100-25","60","Select","Select",""],["","31722070090","LOSARTAN ","TAB 25MG","90","Select","Select",""],["","99073012101","FREESTYLE    TES","TES ","100","Select","Select",""],["","99073013001","FREESTYLE    MIS LANCETS","MIS LANCETS","100","Select","Select",""],["","99073070805","FREESTYLE    KIT LITE","KIT LITE","1","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":""}]}]}