{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"CHARLES   O BAILEY","gend":0,"add":"3803 GREY FOX CIR APT A","city":"WILLIAMSBURG","state":"VA","zip":"23188-9998","dob":"1960-11-10","age":"","mstatus":"","insh":"2325272*01","cliId":"","pno":"571\/361-0411","cno":"571\/361-0411","email":"","ename":"","eno":"","pphy":"LARRAZABAL, JOHANNA MD","ppno":"757\/220-8300","pcpadd":"5231 JOHN TYLER HIGHWAY","pcpcity":"WILLIAMSBURG","pcpstate":"VA","pcpzip":23185,"pcpcounty":"","pcpid":118380,"pcpname":"Riverside Internal Medicine & Family Care","plan":"OHP","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":["R51.9","G95.9","M48.02","Z86.73","L72.0","E78.2","M47.12","H25.11","L72.3","Z96.1","I71.4","I65.23","F17.200","Z12.11","J02.9"],"date":["2020-10-30","2020-10-30","2020-10-30","2020-11-18","2021-04-29","2021-06-11","2020-09-30","2020-11-18","2021-04-01","2020-11-18","2020-11-30","2020-11-30","2020-11-30","2021-05-23","2021-09-21"],"priorHcc":["","","","","","","","","","","","","","",null]}},{"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":[["","80777027399","MODERNA","COVID-19","0","Select","Select",""],["","65862035705","CLOPIDOGREL","75MG","90","Select","Select",""],["","70461032003","FLUCLVX","2020-21","0","Select","Select",""],["","63304082705","ATORVASTATIN","10MG","90","Select","Select",""],["","70461032003","FLUCLVX ","2020-21","0","Select","Select",""],["","63304082705","ATORVASTATIN ","10MG","90","Select","Select",""],["","65862035705","CLOPIDOGREL ","75MG","90","Select","Select",""],["","80777027399","MODERNA ","COVID-19","0","Select","Select",""],["","69452017173","AZITHROMYCIN","250MG","6","Select","Select",""],["","58160082311","SHINGRIX ","INJ 50\/0.5ML","1","Select","Select",""],["","69452017173","AZITHROMYCIN ","TAB 250MG","6","Select","Select",""],["","49281042150","FLUZONE ","INJ 2021-22","0","Select","Select",""],["","00006483703","PNEUMOVAX ","INJ 25\/0.5","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":""}]}]}