{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MAX   A KOON","gend":0,"add":"2347 BOX ELDER ROAD","city":"SUFFOLK","state":"VA","zip":"23437-9998","dob":"1971-09-09","age":"","mstatus":"","insh":"7905661*01","cliId":"","pno":"757\/235-3239","cno":"757\/235-3239","email":"","ename":"","eno":"","pphy":"RAMSTAD, DAVID S MD","ppno":"757\/394-1390","pcpadd":"SUITE 600 1035 CHAMPIONS WAY","pcpcity":"SUFFOLK","pcpstate":"VA","pcpzip":23435,"pcpcounty":"","pcpid":149625,"pcpname":"","plan":"OHP","program":"ACA","lob":"Small Group","region":"TIDEWATER","aligned":"","ano":"757\/771-1858","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/394-1393","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["E23.0","L23.7","Z20.828","K21.9","I10.","N52.8","E79.1","M79.643","G56.00","Z12.11","R79.89","Z12.12","Z12.5","Z00.00","H00.011"],"date":["2020-01-29","2020-05-29","2021-02-28","2020-01-28","2021-08-13","2020-09-29","2020-09-29","2021-07-07","2021-07-07","2021-05-23","2021-08-13","2021-08-13","2021-08-13","2021-08-13","2021-09-28"],"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":[["","00574082001","TESTOST","200MG\/ML","2","Select","Select",""],["","00781207410","TRIAMT\/HCTZ","37.5-25","90","Select","Select",""],["","68180072003","AMLODIPINE","5MG","90","Select","Select",""],["","59746028101","ESCITALOPRAM","20MG","90","Select","Select",""],["","80777027399","MODERNA","COVID-19","0","Select","Select",""],["","00603533831","PREDNISONE","10MG","48","Select","Select",""],["","00574082001","TESTOST ","200MG\/ML","2","Select","Select",""],["","00781207410","TRIAMT\/HCTZ ","37.5-25","90","Select","Select",""],["","68180072003","AMLODIPINE ","5MG","90","Select","Select",""],["","00603533831","PREDNISONE ","10MG","48","Select","Select",""],["","59746028101","ESCITALOPRAM ","20MG","90","Select","Select",""],["","80777027399","MODERNA ","COVID-19","0","Select","Select",""],["","68382009810","PAROXETINE ","20MG","90","Select","Select",""],["","16571020150","DICLOFENAC ","75MG DR","30","Select","Select",""],["","68382009810","PAROXETINE","20MG","-90","Select","Select",""],["","16571020150","DICLOFENAC","75MG DR","90","Select","Select",""],["","57237007710","ONDANSETRON ","TAB 4MG ODT","30","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":""}]}]}