{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"SELENA   D PASZKIEWICZ","gend":1,"add":"8048 EAST GLEN RD","city":"NORFOLK","state":"VA","zip":"23505-9998","dob":"1986-06-27","age":"","mstatus":"","insh":"1898887*01","cliId":"","pno":"757\/615-7863","cno":"757\/615-7863","email":"","ename":"","eno":"","pphy":"DONALDSON, NICOLE MD","ppno":"757\/227-6866","pcpadd":"SUITE 504 301 RIVERVIEW AVENUE","pcpcity":"NORFOLK","pcpstate":"VA","pcpzip":23510,"pcpcounty":"","pcpid":161071,"pcpname":"Fort Norfolk Plaza Primary Care","plan":"OHP","program":"ACA","lob":"Small Group","region":"TIDEWATER","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/277-0298","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z03.818","Z11.59","Z12.4","Z11.3","R87.613","Z32.02","R87.611","Z13.1","Z13.220","Z13.21","R87.610","F41.9","Z13.29","R87.619","Z01.419","D64.9","E55.9","Z79.3","B37.3","Z12.31","R92.8","Z80.3","R51.9"],"date":["2020-07-27","2020-07-27","2021-07-19","2021-07-19","2020-11-11","2020-10-23","2021-02-11","2021-04-05","2021-04-05","2021-04-05","2021-07-19","2021-04-05","2021-04-05","2020-11-11","2021-07-19","2021-07-19","2021-07-19","2020-10-01","2021-02-11","2021-07-27","2021-08-13","2021-07-19","2021-10-04"],"priorHcc":["","","","","","","","","","","","","","","","","","","","","","",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":[["","00591024105","LORAZEPAM","1MG","60","Select","Select",""],["","00555901658","SPRINTEC","28 DAY","28","Select","Select",""],["","57237000430","FLUCONAZOLE","100MG","5","Select","Select",""],["","65862077685","MILI","0.25\/35","84","Select","Select",""],["","59267100002","PFIZER","COVID-19","0","Select","Select",""],["","69097084805","ESCITALOPRAM","10MG","30","Select","Select",""],["","11917013956","FOLIC","400MCG","90","Select","Select",""],["","11845009661","VITAMIN","1000MCG","30","Select","Select",""],["","00555901658","SPRINTEC ","28 DAY","28","Select","Select",""],["","00591024105","LORAZEPAM ","1MG","60","Select","Select",""],["","57237000430","FLUCONAZOLE ","100MG","5","Select","Select",""],["","65862077685","MILI ","0.25\/35","84","Select","Select",""],["","59267100002","PFIZER ","COVID-19","0","Select","Select",""],["","69097084805","ESCITALOPRAM ","10MG","30","Select","Select",""],["","11917013956","FOLIC ","400MCG","-90","Select","Select",""],["","11845009661","VITAMIN ","1000MCG","30","Select","Select",""],["","68462030929","NORGEST\/ETHI","0.25\/35","84","Select","Select",""],["","68462030929","NORGEST\/ETHI ","TAB 0.25\/35","84","Select","Select",""],["","70010075401","METHOCARBAM ","TAB 500MG","30","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","",""],["No","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":""}]}]}