{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MARGARET   M CULVER","gend":1,"add":"7 LOUISE DR","city":"BRIDGEWATER","state":"VA","zip":"22812-9998","dob":"1956-10-17","age":"","mstatus":"","insh":"2238881*01","cliId":"","pno":"540\/820-0418","cno":"540\/820-0418","email":"","ename":"","eno":"","pphy":"MOSS, JONATHAN D MD","ppno":"540\/828-2634","pcpadd":"200 HIGH ST","pcpcity":"BRIDGEWATER","pcpstate":"VA","pcpzip":22812,"pcpcounty":"","pcpid":147705,"pcpname":"","plan":"OHP","program":"ACA","lob":"Individual","region":"WESTERN\/ CHARLOTTESVILLE","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":["E11.9","Z23.","I10.","H61.21","H61.20","R68.84","H93.8X3","H93.8X1","M79.672","S90.32XA","E03.9","M81.0","Z12.31","E78.2","M71.341","L21.8","M77.32","Z12.11","E55.9"],"date":["2021-06-21","2020-12-21","2020-12-21","2020-12-21","2021-06-16","2021-06-16","2021-06-16","2021-06-16","2021-07-21","2021-07-21","2021-06-21","2020-06-15","2021-01-11","2020-06-16","2020-06-29","2020-06-29","2021-07-21","2020-08-31","2021-06-21"],"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":[["","00193709750","CONTOUR ","IPS (STP)","100","Select","Select",""],["","00781518192","LEVOTHYROXIN ","50MCG","30","Select","Select",""],["","68645057390","GLIMEPIRIDE ","4MG","30","Select","Select",""],["","65862046990","LOSARTAN\/HCT ","100-12.5","90","Select","Select",""],["","13668000701","ZOLPIDEM ","5MG","30","Select","Select",""],["","43547028111","ESCITALOPRAM ","10MG","90","Select","Select",""],["","72205002790","ROSUVASTATIN ","5MG","30","Select","Select",""],["","72305005030","EUTHYROX ","50MCG","-90","Select","Select",""],["","68645051554","AMLODIPINE ","5MG","90","Select","Select",""],["","00116200116","CHLORHEX ","0.12%","473","Select","Select",""],["","65162017810","METFORMIN ","500MG ER","360","Select","Select",""],["","57237002801","AMOXICILLIN ","500MG","21","Select","Select",""],["","00228202750","ALPRAZOLAM ","0.25MG","2","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":""}]}]}