{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"IYAD   N SHAWAR","gend":0,"add":"23099 HARBOR TOWNE DR","city":"CARROLLTON","state":"VA","zip":"23314-9998","dob":"1990-02-05","age":"","mstatus":"","insh":"2136977*01","cliId":"","pno":"937\/604-4479","cno":"937\/604-4479","email":"","ename":"","eno":"","pphy":"STONE, KIMBERLY J MD","ppno":"757\/238-8751","pcpadd":"SUITE 11 13609 CARROLLTON BLVD","pcpcity":"CARROLLTON","pcpstate":"VA","pcpzip":23314,"pcpcounty":"","pcpid":169839,"pcpname":"EAGLE HARBOR MEDICAL ASSOCIATES","plan":"OHP","program":"ACA","lob":"Small Group","region":"TIDEWATER","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/238-8750","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z32.01","Z3A.01","Z11.4","Z13.1","Z13.220","M43.6","E66.09","Z68.32","J00.","R79.89","Z68.33","R25.2","R73.01","M71.572","M72.2","M79.609","R74.8","Z00.00","H00.014","K76.0","M25.561","H02.824","M23.92","M25.562","Z38.30","P59.9","Z00.111","Z71.3","M25.662","J01.90","R05.9","Z00.110","Q82.6","Z23.","J06.9"],"date":["2020-08-10","2020-08-10","2020-06-08","2020-06-08","2020-06-08","2020-02-04","2021-06-10","2021-08-11","2020-09-02","2021-06-10","2021-06-10","2021-06-10","2021-06-10","2020-01-07","2020-01-07","2020-01-07","2021-09-23","2021-06-10","2021-06-10","2021-06-10","2021-07-27","2021-07-02","2021-07-27","2021-11-09","2021-09-06","2021-09-06","2021-09-21","2021-09-21","2021-11-09","2021-11-18","2021-11-18","2021-09-09","2021-09-09","2021-09-09","2021-09-26"],"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":[["","68382005101","MELOXICAM","15MG","21","Select","Select",""],["","65162046510","IBUPROFEN","600MG","45","Select","Select",""],["","64380071206","BENZONATATE","100MG","30","Select","Select",""],["","59746021106","CYCLOBENZAPR","5MG","30","Select","Select",""],["","60432060416","PROMETHAZINE","DM","118","Select","Select",""],["","62332025118","AZITHROMYCIN","250MG","6","Select","Select",""],["","68382005101","MELOXICAM ","15MG","21","Select","Select",""],["","65162046510","IBUPROFEN ","600MG","45","Select","Select",""],["","59746021106","CYCLOBENZAPR ","5MG","30","Select","Select",""],["","60432060416","PROMETHAZINE ","DM","118","Select","Select",""],["","64380071206","BENZONATATE ","100MG","30","Select","Select",""],["","62332025118","AZITHROMYCIN ","250MG","6","Select","Select",""],["","65162003310","APAP\/CODEINE","300-30MG","10","Select","Select",""],["","57237002801","AMOXICILLIN","500MG","21","Select","Select",""],["","69238110005","DOXYCYCL ","CAP 100MG","20","Select","Select",""],["","65162003310","APAP\/CODEINE ","TAB 300-30MG","10","Select","Select",""],["","57237002801","AMOXICILLIN ","TAB 500MG","21","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","",""],["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":""}]}]}