{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"PAULINE   MARGARET BURRUSS","gend":1,"add":"168 WESTHAMPTON CT","city":"HARRISONBURG","state":"VA","zip":"22801-9998","dob":"1969-03-02","age":"","mstatus":"","insh":"2012921*01","cliId":"","pno":"540\/578-0410","cno":"540\/578-0410","email":"","ename":"","eno":"","pphy":"LEPLEY, SHAWN M MD","ppno":"540\/564-7300","pcpadd":"1661 S MAIN ST","pcpcity":"HARRISONBURG","pcpstate":"VA","pcpzip":22801,"pcpcounty":"","pcpid":188285,"pcpname":"SRMHMG - Sentara South Main Health Center","plan":"OHP","program":"ACA","lob":"Individual","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"540\/421-1087","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/431-7100","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z12.31","Z01.419","M79.662","M79.89","M54.16","R35.0","M48.061","M51.36","M47.816","R22.42","B02.9","F41.9","Z23.","J45.20"],"date":["2021-06-02","2021-06-02","2020-08-25","2020-08-25","2020-10-14","2021-06-02","2020-08-25","2020-08-25","2020-08-25","2020-08-25","2020-10-05","2021-11-19","2021-11-19","2021-11-19"],"priorHcc":["","","","","","","","","","","",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":[["","00228202996","ALPRAZOLAM","0.5MG","-15","Select","Select",""],["","00173068220","VENTOLIN","","18","Select","Select",""],["","65862044990","VALACYCLOVIR","1GM","21","Select","Select",""],["","66993001968","ALBUTEROL","HFA","18","Select","Select",""],["","64380080707","IBUPROFEN","800MG","60","Select","Select",""],["","57237000511","FLUCONAZOLE","150MG","-2","Select","Select",""],["","69097081312","GABAPENTIN","100MG","30","Select","Select",""],["","13811071910","NITROFURANTN","100MG","14","Select","Select",""],["","00173068220","VENTOLIN ","","18","Select","Select",""],["","00228202996","ALPRAZOLAM ","0.5MG","-15","Select","Select",""],["","66993001968","ALBUTEROL ","HFA","18","Select","Select",""],["","64380080707","IBUPROFEN ","800MG","60","Select","Select",""],["","65862044990","VALACYCLOVIR ","1GM","21","Select","Select",""],["","69097081312","GABAPENTIN ","100MG","30","Select","Select",""],["","57237000511","FLUCONAZOLE ","150MG","2","Select","Select",""],["","13811071910","NITROFURANTN ","100MG","-14","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":""}]}]}