{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"WILLIAM   M BOLEAN","gend":0,"add":"4705 RIVER SHORE ROAD","city":"PORTSMOUTH","state":"VA","zip":"23703-9998","dob":"1958-08-14","age":"","mstatus":"","insh":"1978837*01","cliId":"","pno":"757\/406-8630","cno":"757\/406-8630","email":"","ename":"","eno":"","pphy":"WOODS, DAVID W MD","ppno":"757\/363-6800","pcpadd":"#100 816 INDEPENDENCE BLVD","pcpcity":"VIRGINIA BEACH","pcpstate":"VA","pcpzip":23455,"pcpcounty":"","pcpid":101283,"pcpname":"SMG - Sentara Family Medicine Physicians - Independence","plan":"OHP","program":"ACA","lob":"Small Group","region":"TIDEWATER","aligned":"","ano":"757\/904-0884","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/507-9029","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["J20.9","J43.9","Z87.891","R09.89","R07.9","R04.2","E78.5","K21.9","J30.1","R73.9","R79.89","R45.4","E66.01","R03.0","J92.0","G47.33","Z12.11","M65.332","M72.0","Z12.5","E66.9","R07.2","R05.","M47.812","M25.50","K57.30","K64.1","Z68.35","R60.0","Z77.090","R91.8"],"date":["2020-12-10","2021-07-15","2021-07-15","2020-12-10","2020-12-10","2020-12-10","2021-06-30","2020-12-30","2021-06-30","2021-06-30","2020-12-30","2021-06-30","2021-06-30","2021-06-30","2021-07-15","2021-06-30","2021-03-02","2020-01-09","2020-01-09","2021-06-30","2020-06-15","2020-12-09","2020-12-09","2020-06-15","2020-06-15","2021-03-02","2021-03-02","2021-06-30","2021-06-30","2021-07-15","2021-07-15"],"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":[["","65862019301","FLUOXETINE","20MG","-30","Select","Select",""],["","29300012510","MELOXICAM","15MG","90","Select","Select",""],["","16571020150","DICLOFENAC","75MG DR","180","Select","Select",""],["","00781569031","EZETIMIBE","10MG","90","Select","Select",""],["","68382050010","OMEPRAZOLE","40MG","-90","Select","Select",""],["","52268001201","SUPREP","PREP KIT","354","Select","Select",""],["","00173068220","VENTOLIN","","-18","Select","Select",""],["","00597010051","SPIRIVA","2.5MCG","4","Select","Select",""],["","00093317431","ALBUTEROL","HFA","8","Select","Select",""],["","59310057922","PROAIR","","8","Select","Select",""],["","69238110005","DOXYCYCL","100MG","20","Select","Select",""],["","64380071206","BENZONATATE","100MG","30","Select","Select",""],["","50111064801","FLUOXETINE ","20MG","-30","Select","Select",""],["","29300012510","MELOXICAM ","15MG","90","Select","Select",""],["","00781569031","EZETIMIBE ","10MG","90","Select","Select",""],["","16571020150","DICLOFENAC ","75MG DR","180","Select","Select",""],["","68382050010","OMEPRAZOLE ","40MG","-90","Select","Select",""],["","64380071206","BENZONATATE ","100MG","-30","Select","Select",""],["","00173068220","VENTOLIN ","","18","Select","Select",""],["","66993001968","ALBUTEROL ","HFA","18","Select","Select",""],["","52268001201","SUPREP ","PREP KIT","354","Select","Select",""],["","59310057922","PROAIR ","","8","Select","Select",""],["","69238110005","DOXYCYCL ","100MG","20","Select","Select",""],["","00597010051","SPIRIVA ","2.5MCG","4","Select","Select",""],["","58657050508","GG\/DM ","SYP 100-10\/5","100","Select","Select",""],["","00054418625","DEXAMETHASON ","TAB 6MG","7","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":""}]}]}