{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"BETTY   JEAN HENSLEY","gend":1,"add":"3394 GEORGIA LN","city":"EARLYSVILLE","state":"VA","zip":"22936-9998","dob":"1960-07-06","age":"","mstatus":"","insh":"2011484*01","cliId":"","pno":"434\/295-5934","cno":"434\/295-5934","email":"","ename":"","eno":"","pphy":"CAMPBELL, AMY MD","ppno":"757\/838-6335","pcpadd":"9 MANHATTAN SQUARE STE A","pcpcity":"HAMPTON","pcpstate":"VA","pcpzip":23666,"pcpcounty":"","pcpid":410067,"pcpname":"Hampton Family Practice, PLLC","plan":"OHP","program":"ACA","lob":"Individual","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/838-0612","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F32.1","Z87.891","Z23.","E66.09","G89.29","Z68.34","Z00.00","M54.5","R91.1","E78.00","E03.9","K63.5","Z12.11","Z12.39","Z12.4","M25.532","M65.832","Z12.31","S52.502A","Z12.2","E07.9","S52.552A","Z11.59","F17.210"],"date":["2021-02-15","2021-02-15","2021-02-15","2021-02-15","2021-02-15","2021-02-15","2021-02-15","2021-02-15","2021-03-01","2021-02-15","2021-02-15","2021-02-15","2021-05-23","2021-02-15","2021-02-15","2020-12-28","2020-12-07","2021-03-02","2020-07-17","2020-02-27","2020-03-09","2020-07-21","2020-01-09","2021-03-01"],"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":[["","13668013701","ESCITALOPRAM","20MG","30","Select","Select",""],["","00378181110","LEVOTHYROXIN","112MCG","60","Select","Select",""],["","45802006435","TRIAMCINOLON","0.10%","15","Select","Select",""],["","69097094312","GABAPENTIN","300MG","90","Select","Select",""],["","00591565810","CYCLOBENZAPR","10MG","90","Select","Select",""],["","00006483703","PNEUMOVAX","25\/0.5","0","Select","Select",""],["","70377002811","ATORVASTATIN","20MG","30","Select","Select",""],["","10370010150","BUPROPN","150MG XL","30","Select","Select",""],["","00378020810","FUROSEMIDE","20MG","30","Select","Select",""],["","58160082311","SHINGRIX","50\/0.5ML","1","Select","Select",""],["","49281042050","FLUZONE","2020-21","0","Select","Select",""],["","00536340401","NICOTINE","2MG CINN","-100","Select","Select",""],["","70436005901","BUPROPION","150MG SR","60","Select","Select",""],["","10370010150","BUPROPN ","150MG XL","30","Select","Select",""],["","13668013701","ESCITALOPRAM ","20MG","30","Select","Select",""],["","00378181110","LEVOTHYROXIN ","112MCG","30","Select","Select",""],["","00006483703","PNEUMOVAX ","25\/0.5","0","Select","Select",""],["","70377002811","ATORVASTATIN ","20MG","30","Select","Select",""],["","45802006435","TRIAMCINOLON ","0.10%","15","Select","Select",""],["","00591565810","CYCLOBENZAPR ","10MG","90","Select","Select",""],["","69097094312","GABAPENTIN ","300MG","90","Select","Select",""],["","58160081912","SHINGRIX ","50\/0.5ML","1","Select","Select",""],["","00378020810","FUROSEMIDE ","20MG","30","Select","Select",""],["","49281042050","FLUZONE ","2020-21","0","Select","Select",""],["","00536340401","NICOTINE ","2MG CINN","100","Select","Select",""],["","70436005901","BUPROPION ","150MG SR","60","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":""}]}]}