{"version":"0.4","data":[{"t":"Demographics","q":[{"name":" MARY BETH LOUGEN","gend":1,"add":"605 FORT RALEIGH DR","city":"VIRGINIA BEACH","state":"VA","zip":"23451-9998","dob":"1959-11-21","age":"","mstatus":"","insh":"2038848*02","cliId":"","pno":"757\/749-3088","cno":"757\/749-3088, ","email":"","ename":"","eno":"","pphy":"DERBER, PAUL MD","ppno":"757\/481-1113","pcpadd":"SUITE 201 1168 FIRST COLONIAL R","pcpcity":"VIRGINIA BEACH","pcpstate":"VA","pcpzip":"23454-9998","pcpcounty":"","pcpid":113694,"pcpname":"First Colonial Medical Associates","plan":"OHP - OPTIMA","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":["J45.40","I51.89","I10.","Z23.","E78.2","R91.8","R91.1","Z68.41","R05.","L30.9","J98.4","J98.11","E07.9","E04.1","H93.13","Z00.00","E55.9","Z12.31","E04.9","R73.01","R06.00","E78.5","E04.2","R06.02","R01.1","R93.89"],"date":["2021-04-19","2021-06-17","2021-06-17","2021-06-17","2021-06-17","2021-06-17","2021-06-17","2021-06-17","2021-06-17","2021-06-17","2020-03-20","2020-03-20","2020-09-24","2020-09-24","2021-01-07","2020-12-17","2020-12-17","2020-12-29","2020-02-12","2020-12-17","2021-02-08","2021-01-28","2020-09-24","2020-10-22","2020-10-22","2020-03-25"],"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":[["","29300012810","HYDROCHLOROT","25MG","30","Select","Select",""],["","00093092610","LOVASTATIN","10MG","90","Select","Select",""],["","70710145602","CLOBETASOL","0.05%","-30","Select","Select",""],["","68180072103","AMLODIPINE","10MG","90","Select","Select",""],["","33332032001","AFLURIA","2020-21","0","Select","Select",""],["","00173068220","VENTOLIN","","18","Select","Select",""],["","80777027399","MODERNA","COVID-19","0","Select","Select",""],["","00173071620","ADVAIR","115\/21","-12","Select","Select",""],["","00054429731","FUROSEMIDE","20MG","-90","Select","Select",""],["","66993001968","ALBUTEROL","HFA","18","Select","Select",""],["","65862020299","LOSARTAN","50MG","-90","Select","Select",""],["","64380071206","BENZONATATE","100MG","-30","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":""}]}]}