{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"SANDRA   D MERRITT","gend":1,"add":"100 ATWELL LN","city":"HAMPTON","state":"VA","zip":"23669-9998","dob":"1963-02-26","age":"","mstatus":"","insh":"1861874*01","cliId":"","pno":"757\/927-3908","cno":"757\/927-3908","email":"","ename":"","eno":"","pphy":"WENG, JESSICA MD","ppno":"757\/850-1311","pcpadd":"19D FOX HILL RD","pcpcity":"HAMPTON","pcpstate":"VA","pcpzip":23669,"pcpcounty":"","pcpid":118380,"pcpname":"","plan":"OHP","program":"ACA","lob":"Small Group","region":"TIDEWATER","aligned":"","ano":"000\/000-0000","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":["R05.","E78.1","R09.82","F43.21","R23.2","Z12.11","J34.89","F17.210","Z71.6","J41.0","E55.9","J01.91","M25.512","M25.561","S89.91XA","S80.01XA","K21.9","J45.909","E78.5","Z87.891","Z79.899","Z88.1","Z91.030","S80.812A","R73.09","Z20.828","S89.91XD","R03.0","R06.02","I10.","Z12.2","J44.9","G47.33","E78.2","Z12.31"],"date":["2021-06-14","2021-11-16","2021-11-16","2021-02-25","2021-02-25","2021-11-16","2021-11-16","2021-11-16","2021-11-16","2021-06-14","2021-08-19","2021-02-25","2021-02-25","2021-03-29","2021-03-29","2021-03-29","2021-03-29","2021-03-29","2021-03-29","2021-07-22","2021-03-29","2021-03-29","2021-03-29","2021-03-29","2021-11-16","2021-02-06","2021-05-03","2021-05-03","2021-08-01","2021-11-16","2021-07-22","2021-08-20","2021-08-20","2021-11-16","2021-11-16"],"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":[["","65862052890","VENLAFAXINE","75MG ER","30","Select","Select",""],["","68645048154","ATORVASTATIN","20MG","30","Select","Select",""],["","65862050220","AMOX\/K","500-125","20","Select","Select",""],["","65862042005","SMZ\/TMP","800-160","20","Select","Select",""],["","00781286810","OMEPRAZOLE","20MG","30","Select","Select",""],["","29300022019","MONTELUKAST","10MG","90","Select","Select",""],["","00536589688","NICOTINE","21MG\/24H","-28","Select","Select",""],["","16571040250","CETIRIZINE","10MG","30","Select","Select",""],["","00054327099","FLUTICASONE","50MCG","48","Select","Select",""],["","00093598627","EPINEPHRINE","0.3MG","2","Select","Select",""],["","51663000500","OPTIMAL-D","50000UNT","4","Select","Select",""],["","42806071401","BENZONATATE","100MG","30","Select","Select",""],["","65162083366","DICLOFENAC","1%","100","Select","Select",""],["","59267100001","PFIZER","COVID-19","0","Select","Select",""],["","55111018015","TIZANIDINE","4MG","30","Select","Select",""],["","00143928501","AMOXICILLIN","875MG","20","Select","Select",""],["","53191036201","VITAMIN","50000UNT","4","Select","Select",""],["","68645051554","AMLODIPINE","5MG","30","Select","Select",""],["","65862052890","VENLAFAXINE ","75MG ER","30","Select","Select",""],["","68645048154","ATORVASTATIN ","20MG","30","Select","Select",""],["","65862042005","SMZ\/TMP ","800-160","20","Select","Select",""],["","65862050220","AMOX\/K ","500-125","20","Select","Select",""],["","00781286810","OMEPRAZOLE ","20MG","30","Select","Select",""],["","29300022019","MONTELUKAST ","10MG","90","Select","Select",""],["","00054327099","FLUTICASONE ","50MCG","48","Select","Select",""],["","43598044874","NICOTINE ","21MG\/24H","28","Select","Select",""],["","51663000500","OPTIMAL-D ","50000UNT","4","Select","Select",""],["","00143928501","AMOXICILLIN ","875MG","20","Select","Select",""],["","53191036201","VITAMIN ","50000UNT","4","Select","Select",""],["","65162083366","DICLOFENAC ","1%","100","Select","Select",""],["","00093598627","EPINEPHRINE ","0.3MG","2","Select","Select",""],["","42806071401","BENZONATATE ","100MG","30","Select","Select",""],["","16714079904","CETIRIZINE ","10MG","30","Select","Select",""],["","59267100001","PFIZER ","COVID-19","0","Select","Select",""],["","68645051554","AMLODIPINE ","5MG","30","Select","Select",""],["","55111018015","TIZANIDINE ","4MG","30","Select","Select",""],["","00173088710","TRELEGY ","ELLIPTA","60","Select","Select",""],["","00173088710","TRELEGY","ELLIPTA","60","Select","Select",""],["","19515081852","FLULAVAL ","INJ 2021-22","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":[[["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":""}]}]}