{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"RICK   V CHAPPLE","gend":0,"add":"6401 YORKSHIRE DR","city":"SUFFOLK","state":"VA","zip":"23435-9998","dob":"1983-06-02","age":"","mstatus":"","insh":"7783426*01","cliId":"","pno":"757\/619-3430","cno":"757\/619-3430","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":["R10.32","R19.7","R11.2","K42.9","R91.1","N28.9","M75.81","J45.991","J45.50","J30.1","E66.01","K21.9","Z20.828","R11.11","R10.9","R10.13","T15.91XA","T15.01XA","Z23.","Z91.048"],"date":["2020-10-22","2020-10-22","2020-10-22","2020-10-22","2020-10-22","2020-10-22","2020-11-03","2020-01-21","2020-01-21","2020-01-21","2020-01-21","2020-01-21","2020-10-19","2020-10-19","2020-10-19","2020-10-21","2021-10-20","2021-10-20","2021-10-20","2021-10-20"],"priorHcc":["","","","","","","","","","","","","","","","",null,null,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":[["","00597016061","SPIRIVA","1.25MCG","12","Select","Select",""],["","16714065202","CIPROFLOXACN","500MG","-14","Select","Select",""],["","65862039010","ONDANSETRON","4MG ODT","10","Select","Select",""],["","00143312610","DICYCLOMINE","10MG","-28","Select","Select",""],["","00597016061","SPIRIVA ","1.25MCG","-12","Select","Select",""],["","00143312610","DICYCLOMINE ","10MG","-28","Select","Select",""],["","16714065202","CIPROFLOXACN ","500MG","-14","Select","Select",""],["","65862039010","ONDANSETRON ","4MG ODT","-10","Select","Select",""],["","17478007035","ERYTHROMYCIN","5MG\/GM","4","Select","Select",""],["","17478007035","ERYTHROMYCIN ","OIN 5MG\/GM","-4","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","",""],["No","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":""}]}]}