{"version":"0.4","data":[{"t":"Demographics","q":[{"name":" ANTOINETTE VINSTON FRANCIS","gend":1,"add":"305 WEBSTER ST","city":"HAMPTON","state":"VA","zip":"23663-9998","dob":"1961-10-20","age":"","mstatus":"","insh":"1854813*01","cliId":"","pno":"757\/778-7841","cno":"757\/778-7841, 757\/230-7214, ","email":"","ename":"","eno":"","pphy":"BAINES, ROBIN S MD","ppno":"757\/726-5000","pcpadd":"200 EATON ST","pcpcity":"HAMPTON","pcpstate":"VA","pcpzip":"23669-9998","pcpcounty":"","pcpid":101284,"pcpname":"SMG - Sentara Family & Internal Medicine Physicians - Williamsburg","plan":"OHP - OPTIMA","program":"ACA","lob":"Individual","region":"TIDEWATER","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":["Z12.31","Z86.000","D72.819","E55.9","E11.65","Z11.59","E78.2","D05.12","E78.49","I10.","L90.5","Z12.39","Z79.811","Z08.","B35.9","Z85.3","E11.9","Z17.0","Z60.4","Z13.820","Z78.0","M85.80","H25.13","L20.89"],"date":["2021-02-11","2021-02-11","2021-05-04","2021-04-30","2021-04-30","2021-04-30","2021-04-30","2021-06-21","2020-05-19","2020-05-19","2020-02-10","2021-02-11","2021-02-11","2021-02-11","2021-02-11","2021-02-11","2021-06-21","2021-06-21","2021-06-21","2021-02-22","2021-02-22","2021-02-22","2021-05-27","2021-03-07"],"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":[["","16729003410","LETROZOLE","2.5MG","-20","Select","Select",""],["","55111015930","OMEPRAZOLE","40MG","30","Select","Select",""],["","50742061701","METOPROL","100MG ER","30","Select","Select",""],["","64380073706","VITAMIN","50000UNT","4","Select","Select",""],["","68645056854","ATORVASTATIN","40MG","30","Select","Select",""],["","33342004810","IRBESARTAN","150MG","30","Select","Select",""],["","68645058259","METFORMIN","500MG","60","Select","Select",""],["","68645051054","HYDROCHLOROT","25MG","30","Select","Select",""],["","67877022210","GABAPENTIN","100MG","90","Select","Select",""],["","68645057454","GLIPIZIDE","5MG","60","Select","Select",""],["","68645051554","AMLODIPINE","5MG","30","Select","Select",""],["","00904782236","CLOTRIMAZOLE","1%","15","Select","Select",""],["","00574200815","NYSTOP","100000","15","Select","Select",""],["","33332032001","AFLURIA","2020-21","0","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":""}]}]}