{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"FRANCES   G BRISTOW","gend":1,"add":"212 RIDGE ROAD","city":"POQUOSON","state":"VA","zip":"23662-9998","dob":"1956-10-26","age":"","mstatus":"","insh":"2125237*01","cliId":"","pno":"757\/754-5443","cno":"757\/754-5443","email":"","ename":"","eno":"","pphy":"KHANNA, SIDDHARTH MD","ppno":"757\/868-7709","pcpadd":"370A WYTHE CREEK ROAD","pcpcity":"POQUOSON","pcpstate":"VA","pcpzip":23662,"pcpcounty":"","pcpid":168390,"pcpname":"MARYVIEW HOSPITALISTS","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":["R13.14","K22.70","R33.9","N30.00","N39.0","N12.","R10.9","Z00.00","E11.9","Z12.31","R10.84","K76.0","Z90.710","M21.371","S62.354A","I11.0","I50.31","J44.1","B96.20","F41.9","F32.9","E03.9","Z20.822","D64.9","Z79.899","Z79.890","Z79.1","Z79.4","Z88.6","Z88.2","J90.","J44.9","Z14.8","R42.","B96.89","I21.3","I50.9","I21.4","I25.10","I51.81","E87.1","I73.1","I10.","E78.5","E78.00","M15.0","Z68.25","E66.09","R33.8","R07.89","K21.9","M46.1","R06.00","S62.354D","Z13.820","Z87.891","R00.1","Z79.82","M51.16","M48.061","E03.8","M54.5","R07.2","R07.9","I45.10","M16.0","M25.551","M70.61","G89.29","M54.41","Z79.891","Z51.81","Z87.440","R39.14","R06.09","R06.2","R53.1","Z88.8","M79.641","Z09.","Z01.812","Z11.59","R82.90","E11.51","R39.9","N31.9","D72.828","D72.829","M47.817","M47.816","H90.3","M51.36","R20.0","R32.","N13.30","N39.490","K59.00","R20.2","M25.571","M25.572","M54.08","Z68.26","K22.2","M54.16","Z68.22","M54.31","N39.3","F41.8","E87.2","E11.65","R06.02","Z98.84","N39.45","N30.01","Z03.818","Z20.828","H35.3131","H21.233","H52.13","H52.4","S62.324A","R87.619","I73.9","R10.2","R11.2","R19.15","R10.30","R79.1","N10.","N17.9","E86.0","Z88.1","Z23.","Z95.828","I27.20","I36.1","I34.0","I51.7","I77.810","M51.26","I31.3","Z77.122","D48.5","I42.9","I49.8","A41.9","B96.29","I95.9","R74.02","I45.81","A41.51","E83.42","I50.22","I42.8","E83.51","R79.89","I48.91","I24.9","R26.9","C44.301","E66.9","C53.9","E78.2","I49.3","I49.1","R50.9","I70.0","Z86.79","I21.09","I50.32","I47.1","E86.1","I50.23","L57.8","L82.1","L81.4","Z16.12","Z16.19","K59.09","Z66.","R65.21","M19.90"],"date":["2020-09-15","2020-09-15","2021-03-29","2020-09-28","2021-07-22","2021-07-16","2021-06-26","2021-03-10","2021-07-22","2020-12-17","2021-07-16","2021-07-16","2021-07-16","2021-02-01","2021-02-15","2021-07-16","2021-02-28","2021-06-13","2021-07-17","2021-07-14","2021-07-14","2021-07-22","2021-06-13","2021-06-13","2021-05-27","2021-02-28","2021-02-28","2021-06-13","2021-02-28","2021-02-28","2021-03-16","2021-07-18","2021-03-16","2021-05-27","2021-05-27","2021-06-15","2021-07-14","2021-06-14","2021-06-15","2021-06-27","2021-06-27","2021-06-27","2021-07-17","2021-07-22","2020-05-04","2020-03-16","2020-09-11","2020-05-04","2020-05-03","2020-08-25","2021-07-22","2020-11-24","2021-03-10","2021-04-09","2021-04-20","2021-07-14","2021-06-24","2020-03-15","2020-04-23","2020-04-23","2020-05-04","2021-02-01","2020-08-21","2021-06-13","2021-06-30","2020-10-08","2020-10-08","2020-11-05","2020-11-05","2020-11-05","2020-11-05","2020-11-05","2021-07-14","2020-11-23","2021-04-05","2020-12-17","2021-06-26","2021-02-14","2021-02-14","2021-03-09","2021-03-10","2021-05-12","2021-05-27","2021-06-27","2020-09-21","2021-01-05","2021-01-12","2021-07-16","2021-01-28","2021-01-28","2021-05-24","2020-04-23","2020-04-23","2020-04-23","2020-04-23","2020-04-30","2021-07-16","2020-05-05","2020-05-05","2020-05-05","2020-09-11","2021-03-16","2020-09-14","2020-10-08","2021-01-12","2021-02-01","2021-05-03","2021-07-18","2021-06-13","2021-06-13","2021-07-16","2021-07-16","2020-05-07","2021-07-16","2020-11-02","2020-11-02","2020-11-19","2020-11-19","2020-11-19","2020-11-19","2021-02-14","2021-04-14","2021-07-14","2020-05-23","2020-05-23","2020-05-23","2020-05-03","2021-02-28","2021-07-22","2020-11-10","2020-11-10","2020-11-10","2020-11-10","2021-01-07","2021-06-14","2021-06-14","2021-06-14","2021-06-14","2021-06-14","2021-02-01","2021-06-13","2021-05-24","2021-06-23","2021-06-15","2021-06-15","2021-07-18","2021-06-26","2021-06-26","2021-06-26","2021-06-26","2021-07-22","2021-06-30","2021-06-30","2021-07-17","2021-07-16","2021-07-16","2021-07-17","2021-06-13","2021-06-30","2021-07-14","2021-07-14","2021-07-14","2021-06-24","2021-06-22","2021-06-22","2021-06-26","2021-07-16","2021-07-16","2021-06-13","2021-06-13","2021-06-13","2021-06-13","2021-07-16","2021-06-23","2021-06-23","2021-06-23","2021-06-27","2021-06-27","2021-06-27","2021-06-27","2021-07-22","2021-07-22"],"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":[["","00173088710","TRELEGY","ELLIPTA","60","Select","Select",""],["","00046110281","PREMARIN","0.625MG","30","Select","Select",""],["","67877019705","AMLODIPINE","2.5MG","30","Select","Select",""],["","68180096801","LEVOTHYROXIN","88MCG","30","Select","Select",""],["","60505265401","TRAZODONE","100MG","30","Select","Select",""],["","16571020110","DICLOFENAC","75MG DR","60","Select","Select",""],["","65162063609","PANTOPRAZOLE","20MG","60","Select","Select",""],["","31722082730","ARIPIPRAZOLE","10MG","30","Select","Select",""],["","00088221905","LANTUS","100\/ML","3","Select","Select",""],["","00378400305","ALPRAZOLAM","0.5MG","90","Select","Select",""],["","55111034001","AMLOD\/BENAZP","5-20MG","30","Select","Select",""],["","67877021901","CEPHALEXIN","500MG","40","Select","Select",""],["","65862019401","FLUOXETINE","40MG","180","Select","Select",""],["","60505083001","MOMETASONE","50MCG","17","Select","Select",""],["","00456430001","MONUROL","GRANULES","3","Select","Select",""],["","45802086801","POLYETH","3350 NF","119","Select","Select",""],["","68382004101","PROMETHAZINE","25MG","15","Select","Select",""],["","00093310953","AMOXICILLIN","500MG","21","Select","Select",""],["","51224022060","METFORMIN","1000MG","30","Select","Select",""],["","67877058450","CEFIXIME","400MG","10","Select","Select",""],["","11822393560","RA","","119","Select","Select",""],["","47781030301","NITROFURANTN","100MG","90","Select","Select",""],["","72205002290","ATORVASTATIN","10MG","30","Select","Select",""],["","68462010340","FLUCONAZOLE","150MG","1","Select","Select",""],["","59746017306","PREDNISONE","10MG","30","Select","Select",""],["","67877032105","IBUPROFEN","800MG","20","Select","Select",""],["","16714039401","CEFPODOXIME","100MG","-14","Select","Select",""],["","55111028130","LEVOFLOXACIN","750MG","-4","Select","Select",""],["","59267100001","PFIZER","COVID-19","0","Select","Select",""],["","76204020025","ALBUTEROL","0.08%","-2700","Select","Select",""],["","42858010201","OXYCOD\/APAP","5-325MG","10","Select","Select",""],["","70700026894","FOSFOMYCIN","3GM","1","Select","Select",""],["","00904759060","FEROSUL","325MG","30","Select","Select",""],["","69238110005","DOXYCYCL","100MG","14","Select","Select",""],["","31722070090","LOSARTAN","25MG","90","Select","Select",""],["","68382009201","CARVEDILOL","3.125MG","180","Select","Select",""],["","65162062710","TRAMADOL","50MG","30","Select","Select",""],["","29033000301","SUCRALFATE","1GM","120","Select","Select",""],["","70710112307","DOXYCYC","100MG","14","Select","Select",""],["","59310057922","PROAIR","","8","Select","Select",""],["","00054429931","FUROSEMIDE","40MG","90","Select","Select",""],["","50111078710","AZITHROMYCIN","250MG","6","Select","Select",""],["","31722099601","HYDROCO\/APAP","5-325MG","20","Select","Select",""],["","57896070310","IRON","325MG","30","Select","Select",""],["","00078065920","ENTRESTO","24-26MG","60","Select","Select",""],["","67877019705","AMLODIPINE ","2.5MG","30","Select","Select",""],["","00046110281","PREMARIN ","0.625MG","30","Select","Select",""],["","00173088710","TRELEGY ","ELLIPTA","60","Select","Select",""],["","00088221905","LANTUS ","100\/ML","3","Select","Select",""],["","16571020110","DICLOFENAC ","75MG DR","60","Select","Select",""],["","65162063609","PANTOPRAZOLE ","20MG","60","Select","Select",""],["","65862019430","FLUOXETINE ","40MG","60","Select","Select",""],["","31722082730","ARIPIPRAZOLE ","10MG","30","Select","Select",""],["","60505265401","TRAZODONE ","100MG","30","Select","Select",""],["","68180096801","LEVOTHYROXIN ","88MCG","30","Select","Select",""],["","60505083001","MOMETASONE ","50MCG","17","Select","Select",""],["","00378400305","ALPRAZOLAM ","0.5MG","90","Select","Select",""],["","60505257809","ATORVASTATIN ","10MG","30","Select","Select",""],["","55111034001","AMLOD\/BENAZP ","5-20MG","-30","Select","Select",""],["","68382004101","PROMETHAZINE ","25MG","15","Select","Select",""],["","11822393560","RA ","","119","Select","Select",""],["","00456430001","MONUROL ","GRANULES","3","Select","Select",""],["","67877021901","CEPHALEXIN ","500MG","40","Select","Select",""],["","68462010340","FLUCONAZOLE ","150MG","2","Select","Select",""],["","45802086801","POLYETH ","3350 NF","119","Select","Select",""],["","67877058450","CEFIXIME ","400MG","10","Select","Select",""],["","67877032105","IBUPROFEN ","800MG","20","Select","Select",""],["","51224022060","METFORMIN ","1000MG","30","Select","Select",""],["","69238110005","DOXYCYCL ","100MG","14","Select","Select",""],["","00093317431","ALBUTEROL ","HFA","8","Select","Select",""],["","29033000301","SUCRALFATE ","1GM","120","Select","Select",""],["","47781030301","NITROFURANTN ","100MG","30","Select","Select",""],["","00093310953","AMOXICILLIN ","500MG","21","Select","Select",""],["","70710112307","DOXYCYC ","100MG","14","Select","Select",""],["","16714039401","CEFPODOXIME ","100MG","14","Select","Select",""],["","65162062710","TRAMADOL ","50MG","20","Select","Select",""],["","59310057922","PROAIR ","","8","Select","Select",""],["","59746017306","PREDNISONE ","10MG","30","Select","Select",""],["","50111078710","AZITHROMYCIN ","250MG","6","Select","Select",""],["","43547040211","FUROSEMIDE ","40MG","30","Select","Select",""],["","31722099601","HYDROCO\/APAP ","5-325MG","20","Select","Select",""],["","00378363201","CARVEDILOL ","6.25MG","60","Select","Select",""],["","57896070310","IRON ","325MG","30","Select","Select",""],["","59267100001","PFIZER ","COVID-19","0","Select","Select",""],["","00904759060","FEROSUL ","325MG","30","Select","Select",""],["","55111028130","LEVOFLOXACIN ","750MG","-4","Select","Select",""],["","42858010201","OXYCOD\/APAP ","5-325MG","10","Select","Select",""],["","70700026894","FOSFOMYCIN ","3GM","1","Select","Select",""],["","31722070090","LOSARTAN ","25MG","90","Select","Select",""],["","00078065920","ENTRESTO ","24-26MG","60","Select","Select",""],["","68382039801","POT  CHLORIDE","20MEQ ER","90","Select","Select",""],["","58657012012","MAG ","400MG","30","Select","Select",""],["","50383070016","FLUTICASONE ","50MCG","16","Select","Select",""],["","65162067684","AZELASTINE ","0.10%","30","Select","Select",""],["","00005446381","CENTRUM ","SILVER","80","Select","Select",""],["","65162018810","NAPROXEN ","250MG","60","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":""}]}]}