{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"ELIZABETH   H SMALLWOOD","gend":1,"add":"933 RUGBY RD","city":"CHARLOTTESVILLE","state":"VA","zip":"22903-9998","dob":"1960-06-04","age":"","mstatus":"","insh":"2037561*01","cliId":"","pno":"804\/840-2665","cno":"804\/840-2665","email":"","ename":"","eno":"","pphy":"FISCHER, RENEE L MD","ppno":"434\/284-7650","pcpadd":"1410 INCARNACION DRIVE SUITE 205A","pcpcity":"CHARLOTTESVILLE","pcpstate":"VA","pcpzip":22901,"pcpcounty":"","pcpid":209138,"pcpname":"AHG - Charlottesville Internal Medicine","plan":"OHP","program":"ACA","lob":"Individual","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"434\/293-2555","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"434\/956-4818","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["N64.89","R92.8","Z01.810","Z01.812","Z86.010","L97.511","K63.5","B07.0","Z12.31","B35.3","B35.1","D12.2","Z01.818","I10.","K58.9","F41.9","E78.5","J30.2","Z90.49","Z91.048","Z79.82","R23.4","L60.3","Z76.89","N64.59","Z00.00","R63.4","F41.8"],"date":["2021-06-28","2021-07-06","2020-07-10","2020-07-10","2020-07-22","2020-12-09","2020-01-17","2020-09-16","2020-11-18","2020-12-02","2021-02-24","2020-07-22","2020-07-19","2021-10-13","2020-01-17","2020-01-17","2020-01-17","2020-01-17","2020-01-17","2020-01-17","2020-01-17","2021-02-24","2021-02-24","2020-10-07","2021-07-06","2021-10-13","2021-10-13","2021-10-13"],"priorHcc":["","","","","","","","","","","","","",null,"","","","","","","","","","","",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":[["","68382003516","VENLAFAXINE","75MG ER","30","Select","Select",""],["","59746011506","PROCHLORPER","10MG","30","Select","Select",""],["","68180012202","CEPHALEXIN","500MG","30","Select","Select",""],["","59267100002","PFIZER","COVID-19","0","Select","Select",""],["","49281042050","FLUZONE","2020-21","0","Select","Select",""],["","65862052890","VENLAFAXINE ","75MG ER","-30","Select","Select",""],["","49281042050","FLUZONE ","2020-21","0","Select","Select",""],["","59746011506","PROCHLORPER ","10MG","-30","Select","Select",""],["","68180012202","CEPHALEXIN ","500MG","30","Select","Select",""],["","59267100002","PFIZER ","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":""}]}]}