{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"TARA POLK","gend":1,"add":"327 WOODSIDE DR","city":"HAMPTON","state":"VA","zip":"23669-9998","dob":"1983-02-12","age":"","mstatus":"","insh":"2257685*02","cliId":"","pno":"480\/238-5947","cno":"480\/238-5947","email":"","ename":"","eno":"","pphy":"GATA JR, RENATO G MD","ppno":"757\/850-1311","pcpadd":"191 FOX HILL ROAD STE D","pcpcity":"HAMPTON","pcpstate":"VA","pcpzip":23669,"pcpcounty":"","pcpid":118380,"pcpname":"SMG - Sentara Family Medicine Physicians - Wesleyan","plan":"OHP","program":"ACA","lob":"Individual","region":"TIDEWATER","aligned":"","ano":"480\/238-5947","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":["G40.909","O09.93","Z3A.36","O32.1XX9","O32.1XX0","Z37.0","G89.18","Z79.899","Z3A.29","Z36.89","G40.802","Z23.","O62.2","Z3A.37","Z36.4","Z3A.34","O41.03X0","O99.354","O34.211","O09.893","Z13.31","Z36.85","O34.29","Z39.2","Z30.41","Z12.4"],"date":["2020-02-27","2020-02-19","2020-02-19","2020-02-26","2020-02-27","2020-02-27","2020-02-27","2021-08-11","2020-01-03","2021-06-29","2020-01-03","2020-01-03","2020-02-26","2020-02-27","2020-02-07","2020-02-07","2020-02-27","2020-02-27","2020-02-27","2020-02-06","2020-03-17","2020-02-06","2020-10-06","2020-03-17","2020-03-17","2021-06-29"],"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":[["","65862024608","LEVETIRACETA","500MG","60","Select","Select",""],["","68462030529","NORETHINDRON","0.35MG","28","Select","Select",""],["","65862024608","LEVETIRACETA ","500MG","180","Select","Select",""],["","68462030529","NORETHINDRON ","0.35MG","28","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":""}]}]}