{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"TAMARA   A SHIFFLETT","gend":1,"add":"PO BOX 314","city":"EARLYSVILLE","state":"VA","zip":"22936-9998","dob":"1965-02-28","age":"","mstatus":"","insh":"6803008*01","cliId":"","pno":"434\/990-1215","cno":"434\/990-1215","email":"","ename":"","eno":"","pphy":"CAMPBELL JR, BRUCE D MD","ppno":"434\/978-1691","pcpadd":"4304 FREE UNION RD","pcpcity":"FREE UNION","pcpstate":"VA","pcpzip":22940,"pcpcounty":"","pcpid":101654,"pcpname":"","plan":"OHP","program":"ACA","lob":"Small Group","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"434\/825-6839","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"434\/973-0876","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R07.2","I25.10","I10.","R53.83","R05.","J45.30","Z96.651","M25.561","F34.1","R07.89","Z47.1","I11.9","E78.5","F41.9","G43.909","H91.93","K21.9","E66.9","Z68.36","Z03.818","J45.20","F41.1","M25.50","R06.02","R06.00","M17.11","Z12.11","R07.9","M79.669","Z95.5","Z88.1","Z88.5","Z79.82","Z79.899","Z88.0","Z88.2","Z88.8","Z82.49","Z01.818","M17.12","M25.562","J45.909","M19.90","Z00.00","G89.18"],"date":["2020-04-21","2020-08-11","2020-07-17","2020-05-20","2020-06-23","2020-09-03","2020-10-22","2020-10-22","2021-04-05","2020-03-04","2020-08-11","2020-08-11","2020-08-11","2020-08-11","2020-08-11","2020-08-11","2020-08-11","2020-08-11","2020-08-11","2020-12-29","2021-04-14","2020-06-09","2020-06-09","2020-06-23","2020-07-01","2020-08-03","2021-08-30","2020-03-04","2020-05-20","2020-04-02","2020-03-04","2020-03-04","2020-04-02","2020-04-02","2020-04-02","2020-04-02","2020-04-02","2020-04-02","2020-07-17","2020-06-09","2020-06-09","2020-07-17","2020-07-17","2020-07-17","2020-08-03"],"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":[["","00173089310","TRELEGY ","ELLIPTA","60","Select","Select",""],["","24979010107","BUPROPN ","150MG XL","30","Select","Select",""],["","00173088210","BREO ","200-25","60","Select","Select",""],["","55111029336","SUMATRIPTAN ","100MG","6","Select","Select",""],["","67877019805","AMLODIPINE ","5MG","90","Select","Select",""],["","00591354060","BUPROPION ","100MG SR","60","Select","Select",""],["","10702001801","OXYCODONE ","5MG","75","Select","Select",""],["","57896055501","SENNA-PLUS ","8.6-50MG","30","Select","Select",""],["","58160082311","SHINGRIX ","50\/0.5ML","1","Select","Select",""],["","33342010215","MONTELUKAST ","10MG","30","Select","Select",""],["","68462018022","MUPIROCIN ","2%","22","Select","Select",""],["","00126007061","PREVDNT ","1.1-5%","100","Select","Select",""],["","66993001968","ALBUTEROL ","HFA","54","Select","Select",""],["","00173068220","VENTOLIN ","","54","Select","Select",""],["","64980032005","TRIAMCINOLON ","DEN 0.1%","15","Select","Select",""],["","57896092110","ASPIRIN ","325MG EC","28","Select","Select",""],["","53489011905","DOXYCYCL ","100MG","14","Select","Select",""],["","70461032003","FLUCLVX ","2020-21","0","Select","Select",""],["","00126007061","PREVDNT","1.1-5%","100","Select","Select",""],["","67877019805","AMLODIPINE","5MG","90","Select","Select",""],["","68462018022","MUPIROCIN","2%","22","Select","Select",""],["","00591354060","BUPROPION","100MG SR","60","Select","Select",""],["","00173088210","BREO","200-25","60","Select","Select",""],["","65862014836","SUMATRIPTAN","100MG","6","Select","Select",""],["","00406055201","OXYCODONE","5MG","60","Select","Select",""],["","64980032005","TRIAMCINOLON","DEN 0.1%","15","Select","Select",""],["","57896055501","SENNA-PLUS","8.6-50MG","30","Select","Select",""],["","33342010215","MONTELUKAST","10MG","30","Select","Select",""],["","00591333130","BUPROPN","150MG XL","30","Select","Select",""],["","57896092110","ASPIRIN","325MG EC","28","Select","Select",""],["","70461032003","FLUCLVX","2020-21","0","Select","Select",""],["","58160082311","SHINGRIX","50\/0.5ML","1","Select","Select",""],["","00173089310","TRELEGY","ELLIPTA","-60","Select","Select",""],["","53489011905","DOXYCYCL","100MG","14","Select","Select",""],["","66993001968","ALBUTEROL","HFA","54","Select","Select",""],["","00173068220","VENTOLIN","","54","Select","Select",""],["","59267100001","PFIZER","COVID-19","0","Select","Select",""],["","59267100001","PFIZER ","INJ COVID-19","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":""}]}]}