{"version":"0.4","data":[{"t":"Demographics","q":[{"name":" TERESA A SMITH","gend":1,"add":"2453 LEYTONSTONE DR","city":"CHESAPEAKE","state":"VA","zip":"23321-9998","dob":"1964-09-25","age":"","mstatus":"","insh":"5604397*01","cliId":"","pno":"757\/335-2867","cno":"757\/335-2867, 757\/942-2162","email":"","ename":"","eno":"","pphy":"MADREN, ERIC M MD","ppno":"757\/548-0076","pcpadd":"SUITE 100 725 VOLVO PKWY","pcpcity":"CHESAPEAKE","pcpstate":"VA","pcpzip":"23320-9998","pcpcounty":"","pcpid":129852,"pcpname":"Volvo Medical Associates","plan":"OHP - OPTIMA","program":"ACA","lob":"Small Group","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":["R05.","R51.","R50.9","R31.21","Z20.828","N20.0","K57.90","M47.26","R52.","R68.89","L60.0","M79.674","R09.89","Z71.89","Z87.891","Z88.1","Z88.5","Z88.8","R10.32","K29.70","F33.1","F41.9","F51.01","Z85.820","K57.30","R31.29","M13.0","M35.9","G57.92","M76.822","M79.672","J20.9","R07.9","R31.9","G50.0","G47.33","I10."],"date":["2020-05-09","2020-08-06","2020-08-06","2020-05-09","2020-05-09","2020-09-15","2020-08-06","2020-08-06","2020-08-06","2020-05-21","2020-12-21","2020-12-21","2020-05-09","2020-05-09","2020-07-27","2020-05-09","2020-05-09","2020-05-09","2020-02-06","2020-02-06","2021-06-03","2021-06-03","2021-06-03","2020-07-27","2020-08-06","2020-09-15","2020-10-12","2020-10-12","2020-03-30","2020-03-30","2020-03-30","2020-05-03","2020-05-09","2020-06-05","2020-07-01","2021-02-22","2020-04-03"],"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":[["","67877021901","CEPHALEXIN","500MG","9","Select","Select",""],["","69238131509","PREGABALIN","200MG","90","Select","Select",""],["","42858010201","OXYCOD\/APAP","5-325MG","20","Select","Select",""],["","00591079501","DICYCLOMINE","20MG","100","Select","Select",""],["","55111015901","OMEPRAZOLE","40MG","30","Select","Select",""],["","00378400305","ALPRAZOLAM","0.5MG","90","Select","Select",""],["","68382004101","PROMETHAZINE","25MG","6","Select","Select",""],["","65862064163","AZITHROMYCIN","250MG","6","Select","Select",""],["","00832107230","TOPIRAMATE","ER 50MG","30","Select","Select",""],["","65862016001","ZOLPIDEM","10MG","-30","Select","Select",""],["","64380073706","VITAMIN","50000UNT","12","Select","Select",""],["","65862037401","ESCITALOPRAM","10MG","30","Select","Select",""],["","65862001230","SERTRALINE","50MG","30","Select","Select",""],["","67877014601","TEMAZEPAM","15MG","30","Select","Select",""],["","68382080501","TRAZODONE","50MG","30","Select","Select",""],["","61314062810","POLYMYXIN","TRIMETHP","10","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":""}]}]}