{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"JASON   L FORREST","gend":0,"add":"944 CHATSWORTH DR","city":"NEWPORT NEWS","state":"VA","zip":"23601-9998","dob":"1979-12-18","age":"","mstatus":"","insh":"2180037*01","cliId":"","pno":"757\/408-6048","cno":"757\/408-6048","email":"","ename":"","eno":"","pphy":"HOLLINGSWORTH, JOHN D MD","ppno":"757\/898-7737","pcpadd":"222 GRAFTON DRIVE","pcpcity":"GRAFTON","pcpstate":"VA","pcpzip":23692,"pcpcounty":"","pcpid":157577,"pcpname":"","plan":"OHP","program":"ACA","lob":"Small Group","region":"TIDEWATER","aligned":"","ano":"757\/846-6346","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/898-8377","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R11.2","E87.6","R10.9","K29.70","K29.80","Z79.899","Z87.891","R11.10","K22.10","K59.00","R93.89","B37.81","K22.8","K21.9","K30.","L03.119","S61.429A","R10.84","N20.0","R10.10","R19.7","R50.9","R06.02","D72.829"],"date":["2021-06-10","2021-01-18","2021-04-02","2021-03-26","2021-03-24","2021-03-24","2021-06-10","2021-04-02","2021-04-02","2021-03-30","2021-03-30","2021-04-02","2021-04-02","2020-08-24","2020-08-24","2020-06-03","2020-06-03","2021-06-10","2021-06-10","2021-06-10","2021-06-10","2021-06-10","2021-06-10","2021-06-10"],"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":[["","00406012301","HYDROCO\/APAP","5-325MG","12","Select","Select",""],["","68645056354","IBUPROFEN","800MG","30","Select","Select",""],["","65162027250","SMZ\/TMP","800-160","20","Select","Select",""],["","00254101196","SUCRALFATE","1GM\/10ML","840","Select","Select",""],["","00378803093","LANSOPRAZOLE","30MG DR","60","Select","Select",""],["","00832532511","POT CL MICRO","20MEQ ER","5","Select","Select",""],["","68382004101","PROMETHAZINE","25MG","-12","Select","Select",""],["","42858010201","OXYCOD\/APAP","5-325MG","18","Select","Select",""],["","59267100002","PFIZER","COVID-19","0","Select","Select",""],["","00093081101","NORTRIPTYLIN","25MG","-30","Select","Select",""],["","57237007710","ONDANSETRON","4MG ODT","12","Select","Select",""],["","65862078430","ESOMEPRA","40MG DR","90","Select","Select",""],["","00143924920","AMOX\/K","875-125","20","Select","Select",""],["","31722071390","PANTOPRAZOLE","40MG","-30","Select","Select",""],["","00378803093","LANSOPRAZOLE ","30MG DR","60","Select","Select",""],["","68645056354","IBUPROFEN ","800MG","30","Select","Select",""],["","00406012301","HYDROCO\/APAP ","5-325MG","12","Select","Select",""],["","00143924920","AMOX\/K ","875-125","20","Select","Select",""],["","65162027250","SMZ\/TMP ","800-160","20","Select","Select",""],["","65862078430","ESOMEPRA ","40MG DR","90","Select","Select",""],["","00254101196","SUCRALFATE ","1GM\/10ML","840","Select","Select",""],["","57237007710","ONDANSETRON ","4MG ODT","30","Select","Select",""],["","00832532511","POT  CL MICRO","20MEQ ER","5","Select","Select",""],["","68382004101","PROMETHAZINE ","25MG","-12","Select","Select",""],["","31722071390","PANTOPRAZOLE ","40MG","-30","Select","Select",""],["","00093081101","NORTRIPTYLIN ","25MG","30","Select","Select",""],["","42858010201","OXYCOD\/APAP ","5-325MG","-18","Select","Select",""],["","59267100002","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":""}]}]}