{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"RUFUS GILDER SR","gend":0,"add":"PO BOX 5189","city":"SUFFOLK","state":"VA","zip":"23435-9998","dob":"1971-01-05","age":"","mstatus":"","insh":"2048997*02","cliId":"","pno":"832\/435-1226","cno":"832\/435-1226","email":"","ename":"","eno":"","pphy":"TANNOUS, GEORGE MD","ppno":"757\/673-5890","pcpadd":"SUITE 250 5818 HARBOR VIEW BLVD","pcpcity":"SUFFOLK","pcpstate":"VA","pcpzip":23435,"pcpcounty":"","pcpid":131856,"pcpname":"BON SECOURS MEDICAL ASSOCIATES","plan":"OHP","program":"ACA","lob":"Individual","region":"TIDEWATER","aligned":"","ano":"832\/435-1226","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":["E11.40","E11.65","I10.","E78.2","E55.9","Z79.4","Z68.29","Z68.31","R07.9","Z68.41","E66.01","E11.9"],"date":["2021-11-05","2021-11-05","2021-11-05","2021-11-05","2021-11-05","2021-11-05","2020-07-21","2020-10-26","2020-05-17","2021-11-05","2021-10-06","2021-10-06"],"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":[["","00088221905","LANTUS","100\/ML","18","Select","Select",""],["","27241011403","TADALAFIL","20MG","10","Select","Select",""],["","50458094301","INVOKAMET","150-1000","-60","Select","Select",""],["","00006027754","JANUVIA","100MG","30","Select","Select",""],["","68645057454","GLIPIZIDE","5MG","90","Select","Select",""],["","08290320119","BD PEN NEEDL","31GX5MM","100","Select","Select",""],["","64380073706","VITAMIN","50000UNT","4","Select","Select",""],["","00088221905","LANTUS ","100\/ML","18","Select","Select",""],["","27241011403","TADALAFIL ","20MG","10","Select","Select",""],["","00006027754","JANUVIA ","100MG","30","Select","Select",""],["","50458094301","INVOKAMET ","150-1000","-60","Select","Select",""],["","68645057454","GLIPIZIDE ","5MG","90","Select","Select",""],["","64380073706","VITAMIN ","50000UNT","4","Select","Select",""],["","08290320119","BD  PEN NEEDL","31GX5MM","-100","Select","Select",""],["","59267100003","PFIZER ","COVID-19","0","Select","Select",""],["","59267100003","PFIZER","COVID-19","0","Select","Select",""],["","00310654004","BYDUREON","2\/0.85ML","10","Select","Select",""],["","00597029578","SYNJARDY ","TAB 25-1000","-90","Select","Select",""],["","00310654004","BYDUREON ","INJ 2\/0.85ML","10","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":""}]}]}