{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MARJORIE NANCE","gend":1,"add":"300 SIERRA DR","city":"CHESAPEAKE","state":"VA","zip":"23322-9998","dob":"1958-04-25","age":"","mstatus":"","insh":"2044742*01","cliId":"","pno":"757\/477-4845","cno":"757\/477-4845","email":"","ename":"","eno":"","pphy":"SMITH GRIFFIN, KIMBERLY ANN MD","ppno":"757\/983-5100","pcpadd":"UNIT 100 4214 CHESAPK SQ BLVD","pcpcity":"CHESAPEAKE","pcpstate":"VA","pcpzip":23321,"pcpcounty":"","pcpid":101283,"pcpname":"SMG - Sentara Family & Internal Medicine Physicians - Chesapeake Square","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":["I47.1","I34.0","I51.89","R00.1","I10.","E78.5","Z86.010","D12.6","E78.2","Z86.79","R42.","T78.40XA","R00.2","R20.2","M54.30","R07.89","F17.200","Z79.899","T50.995A","H01.005","H00.15"],"date":["2020-08-27","2020-08-12","2020-07-15","2021-05-10","2020-08-27","2020-07-15","2020-12-07","2020-12-07","2020-08-27","2020-08-27","2021-05-10","2021-05-10","2021-05-10","2021-05-10","2021-05-10","2021-05-10","2021-05-10","2021-05-10","2021-05-10","2020-11-25","2020-11-25"],"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":[["","47781065990","LEVOTHYROXIN","137MCG","-90","Select","Select",""],["","52268001201","SUPREP","PREP KIT","354","Select","Select",""],["","72305015030","EUTHYROX","150MCG","-90","Select","Select",""],["","52268001201","SUPREP ","PREP KIT","354","Select","Select",""],["","47781065990","LEVOTHYROXIN ","137MCG","-90","Select","Select",""],["","72305015030","EUTHYROX ","150MCG","-90","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":""}]}]}