{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"AUSTA   LEE MIDGETT","gend":1,"add":"314 PENNINGTON BLVD","city":"PORTSMOUTH","state":"VA","zip":"23701-9998","dob":"1974-08-30","age":"","mstatus":"","insh":"3325199*01","cliId":"","pno":"757\/617-9901","cno":"757\/617-9901","email":"","ename":"","eno":"","pphy":"ZEV, ZAHAN MD","ppno":"757\/484-0500","pcpadd":"2994 CHURCHLAND BLVD","pcpcity":"CHESAPEAKE","pcpstate":"VA","pcpzip":23321,"pcpcounty":"","pcpid":101382,"pcpname":"","plan":"OHP","program":"ACA","lob":"Small Group","region":"TIDEWATER","aligned":"","ano":"757\/465-1235","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/686-2805","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["E11.65","I10.","E78.5","Z20.89","Z20.828","H04.123","H04.121","H04.122","Z00.00","E55.9","Z12.11","Z12.12"],"date":["2021-07-12","2021-07-12","2020-12-03","2020-11-13","2021-09-15","2020-12-03","2020-12-03","2020-12-03","2021-07-12","2021-07-01","2021-07-01","2021-07-01"],"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":[["","00002143480","TRULICITY","1.5\/0.5","2","Select","Select",""],["","29300018801","BISOPRL\/HCTZ","5-6.25MG","-90","Select","Select",""],["","59267100002","PFIZER","COVID-19","0","Select","Select",""],["","00002143480","TRULICITY ","1.5\/0.5","2","Select","Select",""],["","29300018801","BISOPRL\/HCTZ ","5-6.25MG","90","Select","Select",""],["","59267100002","PFIZER ","COVID-19","0","Select","Select",""],["","42806054701","VITAMIN ","1.25MG","12","Select","Select",""],["","42806054701","VITAMIN","1.25MG","12","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","",""],["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":""}]}]}