{"version":"0.4","data":[{"t":"Demographics","q":[{"name":" CHRISTINA SNOWBERGER","gend":1,"add":"803 ARONDALE CRES","city":"CHESAPEAKE","state":"VA","zip":"23320-9998","dob":"1970-12-27","age":"","mstatus":"","insh":"2239545*01","cliId":"","pno":"717\/387-1991","cno":"717\/387-1991, ","email":"","ename":"","eno":"","pphy":"PAULSEN, MICHELLE DO","ppno":"757\/495-0606","pcpadd":"SUITE 103 516 INNOVATION DRIVE","pcpcity":"CHESAPEAKE","pcpstate":"VA","pcpzip":"23320-9998","pcpcounty":"","pcpid":131473,"pcpname":"","plan":"OHP - OPTIMA","program":"ACA","lob":"Individual","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":["E03.9","K21.9","E66.9","K44.9","J30.9","J45.909","R73.9","N30.90","Z00.00","H04.123","H01.001","H01.004","H25.13","H35.069","Z01.419","Z11.51","N39.0","Z12.31","E66.3","Z12.11","D22.9","L81.4","Z12.83","Z71.9","Z28.21","Z12.39","R03.0"],"date":["2021-06-10","2021-06-10","2021-06-10","2020-03-04","2021-06-10","2021-06-10","2021-06-10","2021-02-12","2021-02-16","2020-02-06","2020-02-06","2020-02-06","2020-02-06","2020-02-06","2020-11-17","2020-11-17","2020-03-30","2020-09-21","2020-02-25","2020-02-25","2020-09-18","2020-09-18","2020-09-18","2020-09-18","2020-09-18","2020-09-21","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":[["","42806008701","ESTRADIOL","0.5MG","30","Select","Select",""],["","55111015901","OMEPRAZOLE","40MG","30","Select","Select",""],["","31722071390","PANTOPRAZOLE","40MG","30","Select","Select",""],["","16714065202","CIPROFLOXACN","500MG","6","Select","Select",""],["","65862057490","MONTELUKAST","10MG","30","Select","Select",""],["","59310057922","PROAIR","","8","Select","Select",""],["","69238183501","LEVOTHYROXIN","112MCG","30","Select","Select",""],["","00173068220","VENTOLIN","","36","Select","Select",""],["","00093317431","ALBUTEROL","HFA","8","Select","Select",""],["","16729017101","AMITRIPTYLIN","10MG","180","Select","Select",""],["","47781030301","NITROFURANTN","100MG","10","Select","Select",""],["","00172572860","FAMOTIDINE","20MG","60","Select","Select",""],["","67877021901","CEPHALEXIN","500MG","14","Select","Select",""],["","65162068210","PHENAZOPYRID","200MG","6","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":""}]}]}