{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"CALLIE SEALEY","gend":1,"add":"649 ABERDEEN ROAD APT R1","city":"HAMPTON","state":"VA","zip":"23661-9998","dob":"1986-08-08","age":"","mstatus":"","insh":"2047430*01","cliId":"","pno":"757\/825-8811","cno":"757\/825-8811","email":"","ename":"","eno":"","pphy":"BAINES, ROBIN S MD","ppno":"757\/726-5000","pcpadd":"200 EATON ST","pcpcity":"HAMPTON","pcpstate":"VA","pcpzip":23669,"pcpcounty":"","pcpid":101284,"pcpname":"SMG - Sentara Family & Internal Medicine Physicians - Williamsburg","plan":"OHP","program":"ACA","lob":"Individual","region":"TIDEWATER","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/726-5001","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["E66.01","M62.838","R69.","Z09.","M54.5","L40.9","Z68.44","M79.18","R23.8","M25.552","M79.10","E11.9","J45.909","K21.9","Z79.899","Z82.61","Z82.62","Z88.7","R25.2","M79.661","M79.662"],"date":["2021-07-02","2021-06-28","2021-06-28","2021-07-02","2021-07-02","2021-07-02","2021-07-02","2021-06-28","2021-06-28","2021-06-28","2021-06-28","2021-06-28","2021-06-28","2021-06-28","2021-06-28","2021-06-28","2021-06-28","2021-06-28","2021-06-28","2021-06-28","2021-06-28"],"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":[["","50742061510","METOPROL","25MG ER","-30","Select","Select",""],["","68382000514","TOPIRAMATE","25MG","180","Select","Select",""],["","65862023060","LAMOTRIGINE","200MG","-15","Select","Select",""],["","00591565810","CYCLOBENZAPR","10MG","12","Select","Select",""],["","80777027399","MODERNA","COVID-19","0","Select","Select",""],["","68180012202","CEPHALEXIN","500MG","28","Select","Select",""],["","69097015907","MELOXICAM","15MG","30","Select","Select",""],["","68382000514","TOPIRAMATE ","25MG","180","Select","Select",""],["","65862023060","LAMOTRIGINE ","200MG","-15","Select","Select",""],["","50742061510","METOPROL ","25MG ER","30","Select","Select",""],["","80777027399","MODERNA ","COVID-19","0","Select","Select",""],["","69097015907","MELOXICAM ","15MG","30","Select","Select",""],["","68180012202","CEPHALEXIN ","500MG","28","Select","Select",""],["","00591565810","CYCLOBENZAPR ","10MG","12","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","",""],["No","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":""}]}]}