{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MICHAEL   T FOUTS","gend":0,"add":"4501 PINEBROOK CT","city":"VIRGINIA BEACH","state":"VA","zip":"23462-9998","dob":"1979-11-25","age":"","mstatus":"","insh":"2164160*01","cliId":"","pno":"757\/635-7078","cno":"757\/635-7078","email":"","ename":"","eno":"","pphy":"RICASA, JOCELYN MD","ppno":"757\/305-1797","pcpadd":"STE 220 828 HEALTHY WAY","pcpcity":"VIRGINIA BEACH","pcpstate":"VA","pcpzip":23462,"pcpcounty":"","pcpid":143824,"pcpname":"BON SECOURS MEDICAL ASSOCIATES","plan":"OHP","program":"ACA","lob":"Small Group","region":"TIDEWATER","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/309-4715","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z11.4","Z13.220","Z00.00","E78.2","Z11.59","Z23.","J45.40","I49.9","E66.09","Z68.32","M54.5","J02.9","Z20.828","J00.","L20.84","D22.9","L30.9","R04.0"],"date":["2020-03-06","2020-03-06","2021-03-08","2021-03-08","2021-03-08","2020-03-06","2020-07-15","2020-07-15","2020-07-15","2020-07-15","2021-06-07","2020-07-30","2020-10-26","2020-01-27","2020-11-23","2021-06-14","2021-06-14","2021-10-11"],"priorHcc":["","","","","","","","","","","","","","","","","",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":[["","0","","","-300","Select","Select",""],["","59779082589","CVS ","60-600MG","18","Select","Select",""],["","45802049537","DESOXIMETAS ","0.25%","60","Select","Select",""],["","66993001968","ALBUTEROL ","HFA","18","Select","Select",""],["","51862049460","FLUOCINONIDE ","0.05%","60","Select","Select",""],["","00173068220","VENTOLIN ","","18","Select","Select",""],["","50383077504","LIDOCAINE ","2% VISC","100","Select","Select",""],["","49483060450","IBUPROFEN ","800MG","90","Select","Select",""],["","59310057922","PROAIR ","","8","Select","Select",""],["","69097084507","CYCLOBENZAPR ","5MG","30","Select","Select",""],["","59267100003","PFIZER ","COVID-19","0","Select","Select",""],["","59779082589","CVS","60-600MG","18","Select","Select",""],["","51862049460","FLUOCINONIDE","0.05%","60","Select","Select",""],["","45802049537","DESOXIMETAS","0.25%","60","Select","Select",""],["","66993001968","ALBUTEROL","HFA","18","Select","Select",""],["","00173068220","VENTOLIN","","18","Select","Select",""],["","50383077504","LIDOCAINE","2% VISC","100","Select","Select",""],["","59310057922","PROAIR","","8","Select","Select",""],["","69097084507","CYCLOBENZAPR","5MG","30","Select","Select",""],["","49483060450","IBUPROFEN","800MG","90","Select","Select",""],["","59267100003","PFIZER","COVID-19","0","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":""}]}]}