{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"ANDREA   D COPELAND-WHITSETT","gend":1,"add":"575 DAVID ROAD","city":"CHARLOTTESVILLE","state":"VA","zip":"22902-9998","dob":"1972-06-19","pno":"434\/996-1665","cno":"434\/996-1665","email":"","pphy":"LEHTINEN, SIMON J MD","ppno":"","pcpadd":"415 RAY C HUNT DRIVE STE 2100","pcpcity":"CHARLOTTESVILLE","pcpstate":"VA","pcpzip":22903,"pcpcounty":"","pcpid":100619,"pcpname":"","insh":"2061292*01","cliId":"","plan":"OHP","program":"ACA","lob":"Small Group","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"434\/202-0222","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"434\/924-1138","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z12.31","E55.9","T78.3XXA","I10.","D50.9","Z12.39","D25.9","R10.2","Q24.2","Q24.9","R00.2","R94.31","R22.0","Z82.49","N83.291","I31.3","Z00.00","R05.9","Z53.21","Z20.822","U07.1","R05.8"],"date":["2021-06-21","2021-07-06","2021-01-23","2021-10-26","2021-07-06","2020-03-02","2020-03-18","2020-03-02","2021-09-28","2020-10-19","2021-10-24","2020-09-02","2021-01-26","2021-09-28","2020-03-18","2020-10-19","2021-01-06","2021-10-24","2021-10-24","2021-10-26","2021-11-05","2021-10-26"],"priorHcc":["","","",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":[]},{"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","",""],["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":""}]}]}