{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"DEBRA BLOODWORTH","gend":1,"add":"3364 LYNNHURST BLVD","city":"CHESAPEAKE","state":"VA","zip":"23321-9998","dob":"1956-10-05","age":"","mstatus":"","insh":"2293753*01","cliId":"","pno":"757\/749-2009","cno":"757\/749-2009","email":"","ename":"","eno":"","pphy":"MASON, JESSICA A MD","ppno":"757\/484-5828","pcpadd":"7185 HARBOUR TOWNE PKWY SUITE 206","pcpcity":"SUFFOLK","pcpstate":"VA","pcpzip":23435,"pcpcounty":"","pcpid":174757,"pcpname":"INTERNISTS OF CHURCHLAND","plan":"OHP","program":"ACA","lob":"Individual","region":"TIDEWATER","aligned":"","ano":"757\/749-1804","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/484-4933","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F33.1","F34.1","K64.0","Z86.010","Z95.0","G40.909","Z79.899","K63.5","R73.01","G47.33","E78.5","F31.9","H40.1114","H40.1121","R55.","G40.309","G47.12","Z00.00","Z23.","Z68.24","Z11.59"],"date":["2021-03-09","2021-08-05","2020-06-15","2020-06-15","2021-08-16","2021-08-02","2020-06-15","2021-08-02","2021-08-02","2021-08-02","2021-08-04","2021-08-02","2021-06-21","2021-06-21","2021-08-04","2021-04-14","2021-04-14","2021-08-02","2021-08-02","2021-08-02","2021-08-02"],"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":[["","69097083412","SERTRALINE","50MG","30","Select","Select",""],["","70377002711","ATORVASTATIN","10MG","90","Select","Select",""],["","00023921105","COMBIGAN","0.2\/0.5%","5","Select","Select",""],["","00023320503","LUMIGAN","0.01%","-8","Select","Select",""],["","52268001201","SUPREP","PREP KIT","-354","Select","Select",""],["","45963030409","DEXTROAMPHET","10MG ER","30","Select","Select",""],["","31722053812","LEVETIRACETA","750MG","360","Select","Select",""],["","69097012403","TOPIRAMATE","100MG","90","Select","Select",""],["","49281072010","FLUBLOK","2020-21","0","Select","Select",""],["","58160082311","SHINGRIX","50\/0.5ML","-1","Select","Select",""],["","65862039010","ONDANSETRON","4MG ODT","3","Select","Select",""],["","65862060130","MODAFINIL","100MG","30","Select","Select",""],["","70377002711","ATORVASTATIN ","10MG","30","Select","Select",""],["","00023921105","COMBIGAN ","0.2\/0.5%","-5","Select","Select",""],["","69097012403","TOPIRAMATE ","100MG","30","Select","Select",""],["","69097083412","SERTRALINE ","50MG","30","Select","Select",""],["","65862024708","LEVETIRACETA ","750MG","120","Select","Select",""],["","00023320503","LUMIGAN ","0.01%","2","Select","Select",""],["","52268001201","SUPREP ","PREP KIT","354","Select","Select",""],["","65862039010","ONDANSETRON ","4MG ODT","3","Select","Select",""],["","65862060130","MODAFINIL ","100MG","30","Select","Select",""],["","45963030409","DEXTROAMPHET ","10MG ER","30","Select","Select",""],["","49281072010","FLUBLOK ","2020-21","0","Select","Select",""],["","58160082311","SHINGRIX ","50\/0.5ML","-1","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":""}]}]}