{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"DINH PHAN","gend":0,"add":"4010 APPALOOSA CT","city":"SUFFOLK","state":"VA","zip":"23434-9998","dob":"1966-08-20","age":"","mstatus":"","insh":"2026119*01","cliId":"","pno":"757\/582-4364","cno":"757\/582-4364","email":"","ename":"","eno":"","pphy":"GOINS, BENJAMIN M MD","ppno":"757\/923-9660","pcpadd":"3060 GODWIN BLVD","pcpcity":"SUFFOLK","pcpstate":"VA","pcpzip":23434,"pcpcounty":"","pcpid":122066,"pcpname":"Lakeview Pediatrics & Family Medicine","plan":"OHP","program":"ACA","lob":"Individual","region":"TIDEWATER","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["M17.11","M76.61","E11.65","Z00.01","M54.5","F17.200","M77.02"],"date":["2020-02-13","2020-02-13","2020-02-13","2021-07-15","2021-05-24","2021-05-24","2021-05-24"],"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":[["","51224000760","METFORMIN ","500MG ER","60","Select","Select",""],["","16729013516","ALLOPURINOL ","300MG","30","Select","Select",""],["","68180051303","LISINOPRIL ","5MG","30","Select","Select",""],["","00591544305","PREDNISONE ","20MG","10","Select","Select",""],["","68180031909","BUPROPN ","150MG XL","30","Select","Select",""],["","23155014201","DOXYCYCL ","100MG DR","20","Select","Select",""],["","55111012105","ATORVASTATIN ","10MG","90","Select","Select",""],["","31722071030","SILDENAFIL ","50MG","10","Select","Select",""],["","52817033010","CYCLOBENZAPR ","5MG","-30","Select","Select",""],["","70461032003","FLUCLVX ","2020-21","0","Select","Select",""],["","65862085901","FAMOTIDINE ","20MG","60","Select","Select",""],["","80777027399","MODERNA ","COVID-19","0","Select","Select",""],["","68462018905","NAPROXEN ","375MG","60","Select","Select",""],["","16729013516","ALLOPURINOL","300MG","30","Select","Select",""],["","51224000760","METFORMIN","500MG ER","60","Select","Select",""],["","68180051303","LISINOPRIL","5MG","30","Select","Select",""],["","00591544305","PREDNISONE","20MG","10","Select","Select",""],["","68180031909","BUPROPN","150MG XL","30","Select","Select",""],["","23155014201","DOXYCYCL","100MG DR","20","Select","Select",""],["","55111012105","ATORVASTATIN","10MG","90","Select","Select",""],["","31722071030","SILDENAFIL","50MG","10","Select","Select",""],["","65862085901","FAMOTIDINE","20MG","60","Select","Select",""],["","68462019005","NAPROXEN","500MG","60","Select","Select",""],["","52817033010","CYCLOBENZAPR","5MG","30","Select","Select",""],["","70461032003","FLUCLVX","2020-21","0","Select","Select",""],["","80777027399","MODERNA","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":[[["Yes","Select","","","","","Select","",""],["Yes","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":""}]}]}