{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MICHAEL ELSWICK","gend":0,"add":"101 SHAWNEE CT","city":"CHARLOTTESVILLE","state":"VA","zip":"22901-9998","dob":"1958-07-25","age":"","mstatus":"","insh":"2025296*01","cliId":"","pno":"434\/973-4299","cno":"434\/973-4299","email":"","ename":"","eno":"","pphy":"POEHAILOS, KAREN MD","ppno":"434\/962-6234","pcpadd":"1885 SEMINOLE TRAIL","pcpcity":"CHARLOTTESVILLE","pcpstate":"VA","pcpzip":22901,"pcpcounty":"","pcpid":210647,"pcpname":"Privia - Well Family Medicine, Inc","plan":"OHP","program":"ACA","lob":"Individual","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"844\/297-9925","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["G81.94","G83.81","J30.2","H43.812","Z20.828","L82.0","L82.1","D48.5","Z12.83","D22.5","Z12.11","M25.561"],"date":["2020-06-25","2020-06-25","2020-06-25","2020-09-22","2020-12-09","2021-07-19","2021-07-19","2021-08-12","2021-07-19","2021-08-12","2021-05-23","2021-11-22"],"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":[["","52817031910","BACLOFEN","5MG","30","Select","Select",""],["","00093310905","AMOXICILLIN","500MG","28","Select","Select",""],["","00173068220","VENTOLIN","","18","Select","Select",""],["","67877032005","IBUPROFEN","600MG","24","Select","Select",""],["","00093005805","TRAMADOL","50MG","10","Select","Select",""],["","69097094312","GABAPENTIN","300MG","90","Select","Select",""],["","66993001968","ALBUTEROL","HFA","18","Select","Select",""],["","33332032001","AFLURIA","2020-21","0","Select","Select",""],["","52817031910","BACLOFEN ","5MG","30","Select","Select",""],["","00173068220","VENTOLIN ","","18","Select","Select",""],["","69097094312","GABAPENTIN ","300MG","90","Select","Select",""],["","66993001968","ALBUTEROL ","HFA","18","Select","Select",""],["","00093310905","AMOXICILLIN ","500MG","28","Select","Select",""],["","00093005805","TRAMADOL ","50MG","10","Select","Select",""],["","67877032005","IBUPROFEN ","600MG","24","Select","Select",""],["","33332032001","AFLURIA ","2020-21","0","Select","Select",""],["","59310057922","PROAIR ","","8","Select","Select",""],["","59310057922","PROAIR","","8","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":""}]}]}