{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"NANCY   L O'TOOLE","gend":1,"add":"1017 ASSEMBLY DR","city":"VIRGINIA BEACH","state":"VA","zip":"23454-9998","dob":"1960-09-24","age":"","mstatus":"","insh":"2160360*02","cliId":"","pno":"757\/496-9226","cno":"757\/496-9226","email":"","ename":"","eno":"","pphy":"FENDERSON, ALLEN MD","ppno":"757\/499-5550","pcpadd":"351 EDWIN DR #102","pcpcity":"VIRGINIA BEACH","pcpstate":"VA","pcpzip":23462,"pcpcounty":"","pcpid":126202,"pcpname":"","plan":"OHP","program":"ACA","lob":"Small Group","region":"TIDEWATER","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/473-0919","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z01.419","Z12.39","Z12.12","I10.","E11.9","E78.5","R82.81","E78.2","I48.0","Z79.01","Z51.81","E11.65","I49.3","Z12.4","Z12.31","E66.3","E66.9","I82.503","I48.21","I48.91","Z86.718","H81.02","L02.32","Z71.9","Z28.21","Z12.11","Z79.4","Z00.00","E55.9","Z86.79","L73.2","L23.9","R42.","H90.42"],"date":["2020-07-08","2020-07-08","2020-07-08","2021-08-05","2021-08-05","2020-08-13","2020-08-20","2021-08-05","2021-08-05","2021-08-05","2021-07-23","2021-06-11","2020-01-21","2020-07-08","2020-08-28","2021-08-05","2021-02-02","2021-08-05","2021-07-23","2020-04-22","2020-04-22","2021-06-21","2020-07-31","2021-05-24","2020-07-31","2020-08-31","2020-01-06","2020-02-11","2020-02-11","2020-06-03","2021-05-24","2021-05-24","2021-08-05","2021-08-05"],"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":[["","51672402901","WARFARIN ","2.5MG","120","Select","Select",""],["","51991070405","ALPRAZOLAM ","0.25MG","60","Select","Select",""],["","00832532411","POT  CL MICRO","10MEQ ER","-60","Select","Select",""],["","63304007601","POT  CHLORIDE","10MEQ ER","60","Select","Select",""],["","69097094312","GABAPENTIN ","300MG","150","Select","Select",""],["","00054001225","FLECAINIDE ","150MG","-90","Select","Select",""],["","55111046805","METOPROL ","100MG ER","90","Select","Select",""],["","69238199201","DIGOXIN ","0.25MG","90","Select","Select",""],["","67877015905","METFORMIN ","500MG ER","270","Select","Select",""],["","69315011610","FUROSEMIDE ","20MG","180","Select","Select",""],["","68180046403","SIMVASTATIN ","40MG","90","Select","Select",""],["","43975030510","FENOFIBRATE ","134MG","90","Select","Select",""],["","65862042005","SMZ\/TMP ","800-160","14","Select","Select",""],["","65862029630","ROSUVASTATIN ","40MG","90","Select","Select",""],["","49281072010","FLUBLOK ","2020-21","0","Select","Select",""],["","00527133601","DOXYCYCLINE ","20MG","60","Select","Select",""],["","58160082311","SHINGRIX ","50\/0.5ML","-1","Select","Select",""],["","59267100002","PFIZER ","COVID-19","0","Select","Select",""],["","62332054730","CLOBETASOL ","0.05%","60","Select","Select",""],["","16571066101","MECLIZINE ","25MG","30","Select","Select",""],["","00172392570","DIAZEPAM ","2MG","20","Select","Select",""],["","49884072703","DOXYCYC ","100MG","60","Select","Select",""],["","51672402901","WARFARIN","2.5MG","120","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":""}]}]}