{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MAURICE BARTLEY","gend":0,"add":"790 EARLYSVILLE FOREST DR","city":"EARLYSVILLE","state":"VA","zip":"22936-9998","dob":"1959-07-11","pno":"434\/242-8496","cno":"434\/242-8496","email":"","pphy":"TRIBASTONE, ANDREA DENISE MD","ppno":"","pcpadd":"3263 PROFFIT ROAD SUITE 101","pcpcity":"CHARLOTTESVILLE","pcpstate":"VA","pcpzip":22911,"pcpcounty":"","pcpid":145520,"pcpname":"SMJMG - Sentara Forest Lakes Family Medicine","insh":"2258569*01","cliId":"","plan":"OHP","program":"ACA","lob":"Individual","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"434\/975-1384","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["M54.5","M25.551","S61.318A","Z12.11","B07.9","L56.8","G54.8","L81.4","Z12.83","D22.62","D22.61","D22.72","D22.71","D22.5","L82.1","I10.","Z00.01","G47.33","E78.2","E66.3","M17.11","D22.9","B35.3","J30.1","M25.531","R10.31","U07.1","E11.9","M70.22"],"date":["2021-08-09","2021-08-09","2020-01-27","2021-05-23","2020-03-17","2020-03-17","2020-03-17","2020-03-17","2021-03-31","2020-03-17","2020-03-17","2020-03-17","2020-03-17","2021-03-31","2021-03-31","2020-01-23","2020-01-23","2020-01-23","2021-09-29","2020-01-23","2020-01-23","2020-01-23","2020-01-23","2020-01-23","2021-07-06","2021-07-06","2021-11-04","2021-11-04","2021-10-07"],"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":[["","62175048537","VERAPAMIL","100MG ER","90","Select","Select",""],["","68180098003","LISINOPRIL","10MG","30","Select","Select",""],["","58160081912","SHINGRIX","50\/0.5ML","1","Select","Select",""],["","65162019050","NAPROXEN","500MG","-60","Select","Select",""],["","70377002811","ATORVASTATIN","20MG","-90","Select","Select",""],["","62175048537","VERAPAMIL ","CAP 100MG ER","90","Select","Select",""],["","68180098003","LISINOPRIL ","TAB 10MG","-30","Select","Select",""],["","58160081912","SHINGRIX ","INJ 50\/0.5ML","1","Select","Select",""],["","65162019050","NAPROXEN ","TAB 500MG","60","Select","Select",""],["","70377002811","ATORVASTATIN ","TAB 20MG","90","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":""}]}]}