{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"TAMMY BLACKMAN OWENS","gend":1,"add":"5234 ROCKPORT LNDG","city":"SUFFOLK","state":"VA","zip":"23435-9998","dob":"1964-12-19","age":"","mstatus":"","insh":"7776160*01","cliId":"","pno":"757\/651-2325","cno":"757\/651-2325","email":"","ename":"","eno":"","pphy":"FORMATO, ERICA L MD","ppno":"757\/983-8650","pcpadd":"STE 100 2760 GODWIN BLVD","pcpcity":"SUFFOLK","pcpstate":"VA","pcpzip":23434,"pcpcounty":"","pcpid":177933,"pcpname":"SMG - Sentara Family Medicine & Walk-In - Suffolk","plan":"OHP","program":"ACA","lob":"Small Group","region":"TIDEWATER","aligned":"","ano":"757\/651-2325","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":["M25.50","Z23.","E83.42","M89.9","M85.80","E87.6","M94.9","H00.015","F41.9","M54.5","K29.00","G89.29","R07.89","R79.89","C50.919","E78.00","K21.9","E03.9","M24.559","E55.9","C50.912","Z00.00","R00.0","I49.1","I49.3","M25.551","L71.0","L82.1","Z83.71","D05.10","Z85.3","Z20.828","I47.2","Z79.899","Z82.49"],"date":["2020-09-01","2021-02-27","2021-08-24","2020-09-04","2021-08-19","2021-08-24","2020-09-04","2020-02-25","2020-04-03","2020-09-04","2020-04-03","2020-09-04","2021-01-08","2021-01-08","2021-08-19","2021-08-19","2021-05-06","2021-08-24","2021-05-06","2021-08-19","2020-06-24","2020-09-04","2021-02-08","2020-10-08","2020-10-08","2021-08-19","2021-08-19","2021-08-19","2021-08-19","2021-04-22","2021-04-22","2020-11-12","2020-11-19","2020-11-19","2020-11-19"],"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":[["","53746054205","POT CHLORIDE","10MEQ ER","360","Select","Select",""],["","00781518392","LEVOTHYROXIN","88MCG","-90","Select","Select",""],["","00093720210","PRAVASTATIN","40MG","90","Select","Select",""],["","64380073706","VITAMIN","50000UNT","12","Select","Select",""],["","00574029201","AMILORIDE","5MG","-540","Select","Select",""],["","62332014231","CELECOXIB","200MG","30","Select","Select",""],["","55111065001","METAXALONE","800MG","30","Select","Select",""],["","00574402435","ERYTHROMYCIN","5MG\/GM","4","Select","Select",""],["","65862007701","CIPROFLOXACN","500MG","10","Select","Select",""],["","31722094201","HYDROCO\/APAP","7.5-325","15","Select","Select",""],["","72305008830","EUTHYROX","88MCG","90","Select","Select",""],["","67877021905","CEPHALEXIN","500MG","-14","Select","Select",""],["","53746054205","POT  CHLORIDE","10MEQ ER","360","Select","Select",""],["","00781518392","LEVOTHYROXIN ","88MCG","-90","Select","Select",""],["","00093720210","PRAVASTATIN ","40MG","90","Select","Select",""],["","64380073706","VITAMIN ","50000UNT","12","Select","Select",""],["","00574029201","AMILORIDE ","5MG","540","Select","Select",""],["","42571014401","CELECOXIB ","200MG","30","Select","Select",""],["","00574402435","ERYTHROMYCIN ","5MG\/GM","4","Select","Select",""],["","65862007701","CIPROFLOXACN ","500MG","10","Select","Select",""],["","55111065001","METAXALONE ","800MG","30","Select","Select",""],["","72305008830","EUTHYROX ","88MCG","90","Select","Select",""],["","67877021905","CEPHALEXIN ","500MG","-14","Select","Select",""],["","31722094201","HYDROCO\/APAP ","7.5-325","15","Select","Select",""],["","80777027398","MODERNA ","COVID-19","0","Select","Select",""],["","80777027398","MODERNA","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":""}]}]}