{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MARK FERGUSON","gend":0,"add":"PO BOX 493","city":"COBBS CREEK","state":"VA","zip":"23035-9998","dob":"1967-03-29","age":"","mstatus":"","insh":"2004714*02","cliId":"","pno":"703\/909-6834","cno":"703\/909-6834","email":"","ename":"","eno":"","pphy":"REYNOLDS, WAYNE J DO","ppno":"804\/210-1025","pcpadd":"SUITE 210 5659 PARKWAY DR","pcpcity":"GLOUCESTER","pcpstate":"VA","pcpzip":23061,"pcpcounty":"","pcpid":127045,"pcpname":"SMG - Sentara Family Medicine Physicians - Gloucester","plan":"OHP","program":"ACA","lob":"Individual","region":"CENTRAL","aligned":"","ano":"703\/909-6834","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/510-9062","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z00.00","E78.2","R73.09","I20.8","Z12.11","R07.9","Z20.822","D12.6","D12.8","R52.","G89.4","K21.9","M15.3"],"date":["2021-02-15","2021-10-11","2021-10-11","2021-03-31","2021-02-15","2021-03-24","2021-02-15","2020-03-09","2020-03-09","2021-02-02","2021-02-02","2021-10-11","2021-10-11"],"priorHcc":["",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":[["","16729000617","SIMVASTATIN","40MG","90","Select","Select",""],["","16729000617","SIMVASTATIN ","40MG","90","Select","Select",""],["","67877032105","IBUPROFEN","800MG","30","Select","Select",""],["","67877032105","IBUPROFEN ","TAB 800MG","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","",""],["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":""}]}]}