{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"EDWIN   V CALANDRIA","gend":0,"add":"1233 WESTOVER AVE APT A4","city":"NORFOLK","state":"VA","zip":"23507-9998","dob":"1965-11-22","age":"","mstatus":"","insh":"5920817*01","cliId":"","pno":"757\/288-7688","cno":"757\/288-7688","email":"","ename":"","eno":"","pphy":"KIRKLAND, C STOKES MD","ppno":"757\/622-6520","pcpadd":"STE 1 425 W 20TH ST","pcpcity":"NORFOLK","pcpstate":"VA","pcpzip":23517,"pcpcounty":"","pcpid":110772,"pcpname":"","plan":"OHP","program":"ACA","lob":"Small Group","region":"TIDEWATER","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/622-7205","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["M17.11","R07.89","R07.9","F33.1","F41.1","F10.129","M10.9","M25.561","R97.20","E55.9","D51.0","N40.0","F14.10","Z12.11","Z00.00"],"date":["2020-07-13","2020-07-31","2020-07-31","2021-09-27","2021-09-27","2021-09-27","2020-06-22","2020-06-22","2020-06-22","2020-06-03","2020-06-03","2020-06-03","2021-09-27","2021-08-30","2021-11-15"],"priorHcc":["","","","","","","","","","","","","",null,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":[["","59148003813","REXULTI","2MG","15","Select","Select",""],["","68180032002","BUPROPN","300MG XL","30","Select","Select",""],["","67877058901","COLCHICINE","0.6MG","30","Select","Select",""],["","00378064110","PREDNISONE","10MG","30","Select","Select",""],["","68462010960","TOPIRAMATE","100MG","60","Select","Select",""],["","70710121001","ALLOPURINOL","300MG","-90","Select","Select",""],["","51991031290","DESVENLAFAX","100MG ER","30","Select","Select",""],["","00378392593","FEBUXOSTAT","40MG","30","Select","Select",""],["","59746000103","METHYLPRED","4MG","-21","Select","Select",""],["","55111028050","LEVOFLOXACIN","500MG","14","Select","Select",""],["","59148003813","REXULTI ","2MG","-15","Select","Select",""],["","68462010960","TOPIRAMATE ","100MG","60","Select","Select",""],["","68180032009","BUPROPN ","300MG XL","30","Select","Select",""],["","51991031290","DESVENLAFAX ","100MG ER","30","Select","Select",""],["","00378064110","PREDNISONE ","10MG","-30","Select","Select",""],["","00254200801","COLCHICINE ","0.6MG","30","Select","Select",""],["","55111028050","LEVOFLOXACIN ","500MG","14","Select","Select",""],["","70710121001","ALLOPURINOL ","300MG","-90","Select","Select",""],["","00378392593","FEBUXOSTAT ","40MG","30","Select","Select",""],["","59746000103","METHYLPRED ","4MG","21","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":""}]}]}