{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"TINA WELLS","gend":1,"add":"PO BOX 6405","city":"CHARLOTTESVILLE","state":"VA","zip":"22906-9998","dob":"1964-12-04","age":"","mstatus":"","insh":"2040931*01","cliId":"","pno":"434\/971-1702","cno":"434\/971-1702","email":"","ename":"","eno":"","pphy":"SANUSI, H AUGUST MD","ppno":"434\/973-4040","pcpadd":"535 WESTFIELD RD #200","pcpcity":"CHARLOTTESVILLE","pcpstate":"VA","pcpzip":22901,"pcpcounty":"","pcpid":210188,"pcpname":"","plan":"OHP","program":"ACA","lob":"Individual","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"434\/971-1702","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"434\/974-1780","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R94.5","I10.","G25.81","E11.65","Z68.38","E66.9","R35.0","Z12.31","E11.69","F41.9","K64.9","R94.6","K64.8","K64.3","K62.6","E11.9","K21.9","E78.00","Z79.84","Z79.899","Z88.8","Z90.49","Z82.49","Z01.810","Z91.89","G62.9","Z00.00","Z23.","R82.90"],"date":["2020-01-14","2021-08-18","2020-09-17","2021-11-08","2020-01-29","2021-11-08","2020-09-17","2021-10-08","2021-11-08","2021-11-08","2021-08-11","2021-02-02","2021-08-18","2021-08-18","2021-08-18","2021-08-18","2021-11-08","2021-08-18","2021-08-18","2021-08-18","2021-08-18","2021-08-18","2021-08-18","2021-08-04","2021-11-08","2021-11-08","2021-11-08","2021-11-08","2021-11-08"],"priorHcc":["","","",null,"",null,"",null,null,null,"","","","","","",null,"","","","","","","",null,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":[["","43547026850","ROPINIROLE","0.25MG","30","Select","Select",""],["","16729000316","GLIMEPIRIDE","4MG","30","Select","Select",""],["","00054025522","IRBESAR\/HCTZ","300-12.5","30","Select","Select",""],["","51991081701","PROPRANOLOL","60MG ER","60","Select","Select",""],["","67877019905","AMLODIPINE","10MG","30","Select","Select",""],["","13668008190","MONTELUKAST","10MG","30","Select","Select",""],["","59746032530","VALACYCLOVIR","1GM","12","Select","Select",""],["","65162027250","SMZ\/TMP","800-160","14","Select","Select",""],["","24979003901","METOPROL","100MG ER","30","Select","Select",""],["","66993001968","ALBUTEROL","HFA","18","Select","Select",""],["","67877049030","EZETIMIBE","10MG","30","Select","Select",""],["","00143992801","CIPROFLOXACN","500MG","14","Select","Select",""],["","51991000633","DESVENLAFAX","25MG ER","30","Select","Select",""],["","00173068220","VENTOLIN","","18","Select","Select",""],["","00169406012","VICTOZA","18MG\/3ML","-3","Select","Select",""],["","59676058015","JANSSEN","COVID-19","0","Select","Select",""],["","08290320119","BD PEN NEEDL","31GX5MM","100","Select","Select",""],["","51991081701","PROPRANOLOL ","60MG ER","60","Select","Select",""],["","43547026850","ROPINIROLE ","0.25MG","30","Select","Select",""],["","16729000316","GLIMEPIRIDE ","4MG","30","Select","Select",""],["","13668008190","MONTELUKAST ","10MG","30","Select","Select",""],["","67877019905","AMLODIPINE ","10MG","30","Select","Select",""],["","00054025522","IRBESAR\/HCTZ ","300-12.5","-30","Select","Select",""],["","24979003901","METOPROL ","100MG ER","30","Select","Select",""],["","59746032530","VALACYCLOVIR ","1GM","12","Select","Select",""],["","65162027250","SMZ\/TMP ","800-160","-14","Select","Select",""],["","00173068220","VENTOLIN ","","18","Select","Select",""],["","66993001968","ALBUTEROL ","HFA","18","Select","Select",""],["","00143992801","CIPROFLOXACN ","500MG","14","Select","Select",""],["","67877049030","EZETIMIBE ","10MG","30","Select","Select",""],["","51991000633","DESVENLAFAX ","25MG ER","30","Select","Select",""],["","59676058015","JANSSEN ","COVID-19","0","Select","Select",""],["","08290320119","BD  PEN NEEDL","31GX5MM","100","Select","Select",""],["","00169406012","VICTOZA ","18MG\/3ML","6","Select","Select",""],["","42858000101","OXYCODONE ","5MG","20","Select","Select",""],["","42858000101","OXYCODONE","5MG","20","Select","Select",""],["","49281042150","FLUZONE","2021-22","0","Select","Select",""],["","67877021905","CEPHALEXIN ","CAP 500MG","14","Select","Select",""],["","49281042150","FLUZONE ","INJ 2021-22","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":""}]}]}