{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"CYNTHIA   MARIE SULLIVAN","gend":1,"add":"1304 RIVERFRONT COURT APT 301","city":"VIRGINIA BEACH","state":"VA","zip":"23451-9998","dob":"1959-07-10","age":"","mstatus":"","insh":"2239543*01","cliId":"","pno":"757\/434-1000","cno":"757\/434-1000","email":"","ename":"","eno":"","pphy":"BAKHSHI, RAJA M MD","ppno":"757\/395-6900","pcpadd":"984B LASKIN ROAD","pcpcity":"VIRGINIA BEACH","pcpstate":"VA","pcpzip":23451,"pcpcounty":"","pcpid":117346,"pcpname":"SMG - Sentara Primary Care & Therapy Center - Oceanfront","plan":"OHP","program":"ACA","lob":"Individual","region":"TIDEWATER","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/425-7180","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["I10.","E55.9","R73.9","J44.9","Z11.59","Z11.4","Z12.11","Z23.","Z12.39","Z12.4","F17.210","Z00.00","F17.200","H40.013","H04.123","H25.13","L25.9"],"date":["2020-12-03","2020-12-03","2020-12-03","2020-12-03","2020-03-18","2020-03-18","2021-05-23","2020-12-03","2020-12-03","2020-12-03","2020-12-03","2020-03-18","2020-03-18","2021-03-09","2021-03-09","2021-03-09","2021-06-25"],"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":[["","66993001968","ALBUTEROL","HFA","18","Select","Select",""],["","59310057922","PROAIR","","8","Select","Select",""],["","00173068220","VENTOLIN","","18","Select","Select",""],["","00603533715","PREDNISONE","5MG","21","Select","Select",""],["","31722070090","LOSARTAN","25MG","30","Select","Select",""],["","00597007541","SPIRIVA","HANDIHLR","-30","Select","Select",""],["","67877019905","AMLODIPINE","10MG","30","Select","Select",""],["","65862064163","AZITHROMYCIN","250MG","6","Select","Select",""],["","50383008716","GUAIATUSS","100-10\/5","120","Select","Select",""],["","57237002801","AMOXICILLIN","500MG","21","Select","Select",""],["","11822372390","RA","1%","30","Select","Select",""],["","64380073706","VITAMIN","50000UNT","12","Select","Select",""],["","00904685289","LORATADINE","10MG","30","Select","Select",""],["","65862064163","AZITHROMYCIN ","250MG","6","Select","Select",""],["","00603533715","PREDNISONE ","5MG","-21","Select","Select",""],["","66993001968","ALBUTEROL ","HFA","18","Select","Select",""],["","50383008716","GUAIATUSS ","100-10\/5","120","Select","Select",""],["","59310057922","PROAIR ","","8","Select","Select",""],["","00173068220","VENTOLIN ","","18","Select","Select",""],["","67877019905","AMLODIPINE ","10MG","30","Select","Select",""],["","31722070090","LOSARTAN ","25MG","30","Select","Select",""],["","00597007541","SPIRIVA ","HANDIHLR","-30","Select","Select",""],["","57237002801","AMOXICILLIN ","500MG","21","Select","Select",""],["","64380073706","VITAMIN ","50000UNT","12","Select","Select",""],["","00597002402","COMBIVENT ","20-100","4","Select","Select",""],["","11822372390","RA ","1%","30","Select","Select",""],["","00904685289","LORATADINE ","10MG","30","Select","Select",""],["","00597002402","COMBIVENT","20-100","4","Select","Select",""],["","59267100002","PFIZER","COVID-19","0","Select","Select",""],["","59267100002","PFIZER ","INJ 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","",""],["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":""}]}]}