{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"LORENA SANCHEZ","gend":1,"add":"37 TRINITY CHURCH ROAD","city":"ROCKINGHAM","state":"VA","zip":"22802-9998","dob":"1959-03-20","age":"","mstatus":"","insh":"2009691*01","cliId":"","pno":"540\/282-8343","cno":"540\/282-8343","email":"","ename":"","eno":"","pphy":"PERKINS, JASON F DO","ppno":"540\/298-1200","pcpadd":"13737 SPOTSWOOD TRAIL","pcpcity":"ELKTON","pcpstate":"VA","pcpzip":22827,"pcpcounty":"","pcpid":188285,"pcpname":"SRMHMG - East Rockingham Health Center","plan":"OHP","program":"ACA","lob":"Individual","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/579-8587","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["N95.0","Z11.59","N84.0","Z11.52","R10.31","R10.9","N93.9","R31.9","Z00.00"],"date":["2021-05-26","2021-03-25","2021-05-26","2021-05-26","2021-03-19","2021-03-19","2021-03-19","2021-03-19","2021-05-21"],"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":[["","29300022019","MONTELUKAST","10MG","30","Select","Select",""],["","42806071401","BENZONATATE","100MG","30","Select","Select",""],["","00037682210","PROCTOFOAM","HC 1%","-10","Select","Select",""],["","00406012301","HYDROCO\/APAP","5-325MG","12","Select","Select",""],["","00574402435","ERYTHROMYCIN","5MG\/GM","4","Select","Select",""],["","29300022019","MONTELUKAST ","10MG","30","Select","Select",""],["","42806071401","BENZONATATE ","100MG","30","Select","Select",""],["","00574402435","ERYTHROMYCIN ","5MG\/GM","4","Select","Select",""],["","00406012301","HYDROCO\/APAP ","5-325MG","12","Select","Select",""],["","00037682210","PROCTOFOAM ","HC 1%","10","Select","Select",""],["","59267100002","PFIZER","COVID-19","0","Select","Select",""],["","59267100002","PFIZER ","INJ COVID-19","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":[[["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":""}]}]}