{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"NOELE   A C POE","gend":1,"add":"1732 GARDEN DR","city":"VIRGINIA BEACH","state":"VA","zip":"23454-9998","dob":"1997-12-12","age":"","mstatus":"","insh":"2179755*01","cliId":"","pno":"757\/685-2897","cno":"757\/685-2897","email":"","ename":"","eno":"","pphy":"SAMARAS, THOMAS A MD","ppno":"757\/481-2333","pcpadd":"1120 FIRST COLONIAL RD STE 101","pcpcity":"VIRGINIA BEACH","pcpstate":"VA","pcpzip":23454,"pcpcounty":"","pcpid":210216,"pcpname":"Privia - First Colonial Family Practice","plan":"OHP","program":"ACA","lob":"Small Group","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":["R51.","S09.90XA","L70.0","L81.4","D22.9","Z12.83","Z71.9","Z28.21","Z20.828","Z01.419","Z30.09","Z71.89","E66.3","N76.0","B37.3","Z20.822"],"date":["2020-05-15","2020-05-15","2020-01-20","2020-01-20","2020-01-20","2020-01-20","2020-01-20","2020-01-20","2021-01-05","2020-01-07","2020-01-07","2020-01-07","2020-01-07","2020-01-07","2020-01-07","2021-01-07"],"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":[["","50111033402","METRONIDAZOL","500MG","14","Select","Select",""],["","51672530703","DAPSONE","7.50%","180","Select","Select",""],["","14290035297","TRETIN-X","0.03%","90","Select","Select",""],["","57237000511","FLUCONAZOLE","150MG","1","Select","Select",""],["","57237002801","AMOXICILLIN","500MG","21","Select","Select",""],["","50111033402","METRONIDAZOL ","500MG","14","Select","Select",""],["","57237000511","FLUCONAZOLE ","150MG","1","Select","Select",""],["","51672530703","DAPSONE ","7.50%","180","Select","Select",""],["","14290035297","TRETIN-X ","0.03%","90","Select","Select",""],["","57237002801","AMOXICILLIN ","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":""}]}]}