{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MEGAN BANCROFT","gend":1,"add":"112 DEHAVEN CT APT L","city":"WILLIAMSBURG","state":"VA","zip":"23188-9998","dob":"1993-08-30","age":"","mstatus":"","insh":"2008361*01","cliId":"","pno":"757\/968-6956","cno":"757\/968-6956","email":"","ename":"","eno":"","pphy":"KHANNA, SIDDHARTH MD","ppno":"757\/868-7709","pcpadd":"370A WYTHE CREEK ROAD","pcpcity":"POQUOSON","pcpstate":"VA","pcpzip":23662,"pcpcounty":"","pcpid":168390,"pcpname":"MARYVIEW HOSPITALISTS","plan":"OHP","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":["Z00.00","E55.9","F32.9","F41.9","E16.2","E88.81","R79.89","M25.551","M77.8","M20.012","D58.2"],"date":["2021-03-05","2021-03-05","2021-03-05","2021-03-05","2021-03-05","2021-03-05","2021-03-05","2021-05-11","2021-08-10","2021-10-11","2021-05-11"],"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":[["","58160089652","FLUARIX","2019-20","0","Select","Select",""],["","16714036004","MONO-LINYAH","0.25-35","-28","Select","Select",""],["","00603020922","MAG","400MG","60","Select","Select",""],["","00591352530","LIDOCAINE","5%","4","Select","Select",""],["","59676058015","JANSSEN","COVID-19","0","Select","Select",""],["","64380073706","VITAMIN","50000UNT","12","Select","Select",""],["","00093317431","ALBUTEROL","HFA","8","Select","Select",""],["","33332042010","AFLURIA","2020-21","0","Select","Select",""],["","59310057922","PROAIR","","8","Select","Select",""],["","16714036004","MONO-LINYAH ","0.25-35","28","Select","Select",""],["","58160089652","FLUARIX ","2019-20","0","Select","Select",""],["","00093317431","ALBUTEROL ","HFA","8","Select","Select",""],["","33332042010","AFLURIA ","2020-21","0","Select","Select",""],["","64380073706","VITAMIN ","50000UNT","12","Select","Select",""],["","00603020922","MAG ","400MG","60","Select","Select",""],["","59310057922","PROAIR ","","8","Select","Select",""],["","00591352530","LIDOCAINE ","5%","4","Select","Select",""],["","59676058015","JANSSEN ","COVID-19","0","Select","Select",""],["","59746017306","PREDNISONE ","10MG","-42","Select","Select",""],["","59746017306","PREDNISONE","10MG","-42","Select","Select",""],["","70461032103","FLUCLVX","2021-22","0","Select","Select",""],["","70461032103","FLUCLVX ","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":[[["Yes","Select","","","","","Select","",""],["Yes","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":""}]}]}