{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"LUCIAN   F MONTAGNA JR","gend":0,"add":"5520 JANET DR","city":"NORFOLK","state":"VA","zip":"23513-9998","dob":"1959-12-10","pno":"757\/535-6868","cno":"757\/535-6868","email":"","pphy":"","ppno":"","pcpadd":"","pcpcity":"","pcpstate":"","pcpzip":"","pcpcounty":"","pcpid":"","pcpname":"","insh":"6489427*01","cliId":"","plan":"OHP","program":"ACA","lob":"Small Group","region":"TIDEWATER","aligned":"","ano":"490-2034","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":["Z20.828","R97.20","J20.9","N28.89","Z87.891","R10.32","R11.0","J18.9","K21.9","Z87.09","N40.1","N13.8","G51.4","M54.2","M79.601","M54.5","M79.605","G43.109","G89.29","M79.602","J06.9","Z88.1","Z88.8","Z80.0","D12.5","D12.8","K64.1","K57.30","M50.122","U07.1","J12.89","C64.9","E78.5","Z79.899","Z80.3","Z82.5","Z82.61","J31.0","F41.9","E66.9","Z68.32","E78.00","E55.9","D30.02","D41.02","Z00.00","R79.89","E66.01","R73.9","Z68.35","Z12.11","R05.","Z12.5","E29.1","F43.23","F43.12","R68.82","K57.90","Z86.010","J01.00","J47.9","Z86.16","R06.00","M54.12","M25.552","M65.321","M25.531","M25.532","M25.78","M48.02","R06.02","Z23.","K57.32","R10.9","R30.0","R35.0","E66.09","K27.9","D12.6","J38.3","R51.9","R91.8","C64.2","G47.30","H53.2","N18.31","G89.18","Z20.822","R73.01","R52.","R06.09","Z09.","Z86.018","Z90.5","Z98.890"],"date":["2020-12-13","2021-04-15","2020-12-09","2021-03-15","2021-08-25","2020-12-09","2020-12-09","2020-12-16","2021-03-12","2020-12-16","2021-01-06","2021-01-06","2020-10-14","2020-02-12","2020-01-17","2021-08-18","2020-01-17","2020-01-17","2021-08-18","2020-01-17","2020-12-04","2020-12-09","2020-12-09","2021-02-23","2021-02-23","2021-02-23","2021-02-23","2021-02-23","2020-11-12","2020-12-21","2020-12-13","2020-12-13","2021-08-18","2021-03-12","2020-12-13","2020-12-13","2020-12-13","2020-12-13","2021-03-12","2021-08-18","2020-12-13","2020-12-13","2020-12-13","2021-10-05","2021-03-12","2021-04-15","2021-04-15","2021-04-14","2021-04-15","2021-04-14","2020-02-12","2021-01-13","2020-02-12","2020-02-12","2020-08-12","2020-08-12","2020-09-24","2020-11-25","2020-11-25","2020-12-05","2021-08-25","2021-08-25","2021-08-25","2020-11-12","2020-02-26","2021-06-21","2020-11-03","2020-11-03","2020-11-12","2020-11-12","2020-12-13","2020-11-19","2020-11-19","2021-03-15","2020-11-19","2020-11-19","2020-12-13","2020-12-13","2020-10-14","2020-09-16","2020-10-14","2020-12-13","2021-03-12","2021-08-18","2021-03-12","2021-03-12","2021-03-15","2021-03-12","2021-08-25","2020-11-03","2021-08-25","2021-10-01","2021-10-01","2021-10-01","2021-10-01"],"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":[["","68382013814","TOPIRAMATE","25MG","60","Select","Select",""],["","00378623201","CITALOPRAM","20MG","30","Select","Select",""],["","68001036103","MONTELUKAST","10MG","30","Select","Select",""],["","00378647097","SCOPOLAMINE","1MG\/3DAY","-10","Select","Select",""],["","55111015905","OMEPRAZOLE","40MG","-90","Select","Select",""],["","69452014420","BENZONATATE","200MG","60","Select","Select",""],["","65862053750","LEVOFLOXACIN","500MG","10","Select","Select",""],["","69452015120","VITAMIN","50000UNT","12","Select","Select",""],["","00172392760","DIAZEPAM","10MG","-1","Select","Select",""],["","63304082805","ATORVASTATIN","20MG","90","Select","Select",""],["","68382013201","TAMSULOSIN","0.4MG","90","Select","Select",""],["","57237023305","SMZ-TMP","800-160","1","Select","Select",""],["","66993001968","ALBUTEROL","HFA","18","Select","Select",""],["","52268001201","SUPREP","PREP KIT","354","Select","Select",""],["","59762307002","AZITHROMYCIN","500MG","-1","Select","Select",""],["","00781185220","AMOX\/K","875-125","20","Select","Select",""],["","67877021660","CEFUROXIME","500MG","-14","Select","Select",""],["","65162062750","TRAMADOL","50MG","30","Select","Select",""],["","65862039010","ONDANSETRON","4MG ODT","10","Select","Select",""],["","00173068220","VENTOLIN","","18","Select","Select",""],["","69543025216","VIRTUSSIN","100-10\/5","240","Select","Select",""],["","00173071920","FLOVENT","110MCG","12","Select","Select",""],["","29300028713","TADALAFIL","5MG","90","Select","Select",""],["","59267100002","PFIZER","COVID-19","0","Select","Select",""],["","52817031910","BACLOFEN","5MG","15","Select","Select",""],["","67877022310","GABAPENTIN","300MG","40","Select","Select",""],["","64764008060","AMITIZA","8MCG","180","Select","Select",""],["","00054418625","DEXAMETHASON","6MG","7","Select","Select",""],["","00536124710","SENEXON-S","8.6-50MG","30","Select","Select",""],["","68382013814","TOPIRAMATE ","TAB 25MG","60","Select","Select",""],["","00378623201","CITALOPRAM ","TAB 20MG","30","Select","Select",""],["","68001036103","MONTELUKAST ","TAB 10MG","30","Select","Select",""],["","69452014420","BENZONATATE ","CAP 200MG","60","Select","Select",""],["","55111015905","OMEPRAZOLE ","CAP 40MG","90","Select","Select",""],["","00378647044","SCOPOLAMINE ","DIS 1MG\/3DAY","-10","Select","Select",""],["","65862053750","LEVOFLOXACIN ","TAB 500MG","10","Select","Select",""],["","00172392760","DIAZEPAM ","TAB 10MG","1","Select","Select",""],["","68382013201","TAMSULOSIN ","CAP 0.4MG","90","Select","Select",""],["","29300028713","TADALAFIL ","TAB 5MG","90","Select","Select",""],["","69452015120","VITAMIN ","CAP 50000UNT","12","Select","Select",""],["","00781185220","AMOX\/K ","TAB 875-125","20","Select","Select",""],["","52268001201","SUPREP ","SOL PREP KIT","-354","Select","Select",""],["","63304082805","ATORVASTATIN ","TAB 20MG","90","Select","Select",""],["","59762307002","AZITHROMYCIN ","TAB 500MG","1","Select","Select",""],["","57237023305","SMZ-TMP ","TAB 800-160","1","Select","Select",""],["","67877021660","CEFUROXIME ","TAB 500MG","14","Select","Select",""],["","64764008060","AMITIZA ","CAP 8MCG","180","Select","Select",""],["","00054418625","DEXAMETHASON ","TAB 6MG","7","Select","Select",""],["","66993001968","ALBUTEROL ","AER HFA","18","Select","Select",""],["","52817031910","BACLOFEN ","TAB 5MG","15","Select","Select",""],["","65162062750","TRAMADOL ","TAB 50MG","7","Select","Select",""],["","00173071920","FLOVENT ","AER 110MCG","12","Select","Select",""],["","59267100002","PFIZER ","INJ COVID-19","0","Select","Select",""],["","67877022310","GABAPENTIN ","CAP 300MG","40","Select","Select",""],["","00536124710","SENEXON-S ","TAB 8.6-50MG","30","Select","Select",""],["","00173068220","VENTOLIN ","AER ","18","Select","Select",""],["","69543025216","VIRTUSSIN ","SOL 100-10\/5","240","Select","Select",""],["","65862039010","ONDANSETRON ","TAB 4MG ODT","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":""}]}]}