{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"JOHN   A POLENSKY","gend":0,"add":"2716 N NANSEMOND DR","city":"SUFFOLK","state":"VA","zip":"23435-9998","dob":"1964-11-08","age":"","mstatus":"","insh":"8183848*01","cliId":"","pno":"757\/484-2042","cno":"757\/484-2042","email":"","ename":"","eno":"","pphy":"BIKOWSKI, RICHARD M MD","ppno":"757\/397-6344","pcpadd":"3640 HIGH STREET SUITE 3B","pcpcity":"PORTSMOUTH","pcpstate":"VA","pcpzip":23707,"pcpcounty":"","pcpid":100340,"pcpname":"EVMS Portsmouth Family Medicine","plan":"OHP","program":"ACA","lob":"Small Group","region":"TIDEWATER","aligned":"","ano":"757\/934-8101","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/606-1185","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R73.9","B18.1","K74.60","Z12.5","K76.0","N18.1","Z13.31","Z23.","Z86.010","D12.6","Z00.00","J30.9","K44.9","Z80.9","K57.30","K63.5","R93.89","B19.10","L02.91","Z71.9","L03.317","K74.69"],"date":["2020-01-31","2021-06-25","2021-06-25","2021-05-05","2021-06-23","2020-12-07","2020-01-22","2021-05-12","2021-01-07","2021-01-07","2021-05-12","2021-05-12","2021-01-07","2021-01-07","2021-01-07","2021-01-07","2021-06-23","2021-06-23","2021-07-12","2021-07-12","2021-07-09","2021-07-09"],"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":[["","61958230101","VEMLIDY","25MG","30","Select","Select",""],["","61958230101","VEMLIDY ","25MG","30","Select","Select",""],["","65862042005","SMZ\/TMP ","800-160","14","Select","Select",""],["","31722072320","LEVOFLOXACIN ","750MG","7","Select","Select",""],["","65862042005","SMZ\/TMP","800-160","14","Select","Select",""],["","31722072320","LEVOFLOXACIN","750MG","7","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":""}]}]}