{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MARC   ALLAN GAMBLE","gend":0,"add":"PO BOX 188","city":"PORT HAYWOOD","state":"VA","zip":"23138-9998","dob":"1964-01-09","age":"","mstatus":"","insh":"2008995*01","cliId":"","pno":"303\/917-9816","cno":"303\/917-9816","email":"","ename":"","eno":"","pphy":"ANTHONY, ERVIN MD","ppno":"804\/725-9191","pcpadd":"10980 BUCKLEY HALL RD BLDG #5","pcpcity":"MATHEWS","pcpstate":"VA","pcpzip":23109,"pcpcounty":"","pcpid":116807,"pcpname":"","plan":"OHP","program":"ACA","lob":"Individual","region":"CENTRAL","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"804\/725-9120","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z12.11","J30.9","E78.5","J41.0","F17.210","F32.9","F41.9","Z76.0","M54.2","Z87.448","F17.200","F17.290","F41.1","R73.9","S06.2X0S","Z23."],"date":["2021-06-17","2020-09-10","2021-10-14","2020-11-09","2021-07-15","2021-10-14","2021-07-15","2020-11-30","2021-10-14","2020-03-06","2020-11-30","2020-11-30","2021-11-03","2021-07-15","2021-07-15","2021-10-14"],"priorHcc":["","",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":[["","00093102506","NEFAZODONE","200MG","90","Select","Select",""],["","67877022401","GABAPENTIN","400MG","90","Select","Select",""],["","65862019401","FLUOXETINE","40MG","60","Select","Select",""],["","68180051202","LISINOPRIL","2.5MG","-30","Select","Select",""],["","14539067501","HYDROXYZ","50MG","120","Select","Select",""],["","70436005902","BUPROPION","150MG SR","30","Select","Select",""],["","00093100305","BUSPIRONE","15MG","60","Select","Select",""],["","69315090410","LORAZEPAM","0.5MG","12","Select","Select",""],["","67877022401","GABAPENTIN ","400MG","90","Select","Select",""],["","65862019401","FLUOXETINE ","40MG","60","Select","Select",""],["","00093102506","NEFAZODONE ","200MG","90","Select","Select",""],["","68180051202","LISINOPRIL ","2.5MG","30","Select","Select",""],["","14539067501","HYDROXYZ ","50MG","120","Select","Select",""],["","70436005902","BUPROPION ","150MG SR","60","Select","Select",""],["","23155002405","BUSPIRONE ","10MG","60","Select","Select",""],["","68180031902","BUPROPN ","150MG XL","-60","Select","Select",""],["","69315090410","LORAZEPAM ","0.5MG","12","Select","Select",""],["","65862067705","ALPRAZOLAM ","0.5MG","14","Select","Select",""],["","51672400201","NORTRIPTYLIN ","25MG","60","Select","Select",""],["","50111056003","TRAZODONE ","50MG","30","Select","Select",""],["","65862067705","ALPRAZOLAM","0.5MG","14","Select","Select",""],["","68180031902","BUPROPN","150MG XL","-60","Select","Select",""],["","51672400201","NORTRIPTYLIN","25MG","60","Select","Select",""],["","50111056003","TRAZODONE","50MG","30","Select","Select",""],["","42571017210","ATORVASTATIN","10MG","30","Select","Select",""],["","42571017210","ATORVASTATIN ","TAB 10MG","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":""}]}]}