{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MARK   R GOLDNER","gend":0,"add":"1532 WOLFSNARE ROAD","city":"VIRGINIA BEACH","state":"VA","zip":"23451-9998","dob":"1964-01-31","age":"","mstatus":"","insh":"2057612*01","cliId":"","pno":"757\/422-3029","cno":"757\/422-3029","email":"","ename":"","eno":"","pphy":"ALBALA, NATALIE L MD","ppno":"757\/395-6630","pcpadd":"1080 FIRST COLONIAL RD STE 200","pcpcity":"VIRGINIA BEACH","pcpstate":"VA","pcpzip":23454,"pcpcounty":"","pcpid":117381,"pcpname":"SMG - Sentara Family Medicine Physicians - 1080 Bldg","plan":"OHP","program":"ACA","lob":"Small Group","region":"TIDEWATER","aligned":"","ano":"757\/472-9118","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":["E78.2","Z12.5","I30.1","I48.0","R74.8","D75.1","Z00.00","Z12.11","Z23.","K76.0","J90.","R50.9","Z98.890","Z86.79","E78.5","K21.9","A41.9","R79.89","I31.3","I51.9","I21.3","I51.7","E66.9","D48.5","L82.1"],"date":["2021-10-20","2020-11-09","2021-06-07","2021-06-30","2021-02-18","2021-02-15","2020-11-16","2020-11-16","2021-06-30","2021-02-18","2021-05-11","2021-05-11","2021-05-11","2021-05-11","2021-05-11","2021-05-11","2021-05-11","2021-05-11","2021-05-11","2021-05-11","2021-05-11","2021-06-16","2021-06-30","2021-11-08","2021-11-08"],"priorHcc":[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":[["","68645056854","ATORVASTATIN","40MG","90","Select","Select",""],["","63304090090","FENOFIBRATE","54MG","90","Select","Select",""],["","58160082311","SHINGRIX","50\/0.5ML","1","Select","Select",""],["","63304090090","FENOFIBRATE ","54MG","90","Select","Select",""],["","68645056854","ATORVASTATIN ","40MG","90","Select","Select",""],["","58160082311","SHINGRIX ","50\/0.5ML","-1","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":""}]}]}