{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"DON   D SMART","gend":0,"add":"641 MILBY DR","city":"CHESAPEAKE","state":"VA","zip":"23325-9998","dob":"1960-06-28","age":"","mstatus":"","insh":"9856447*01","cliId":"","pno":"757\/523-1078","cno":"757\/523-1078","email":"","ename":"","eno":"","pphy":"PAVER, RICHARD MD","ppno":"804\/968-5700","pcpadd":"5000 COX RD STE 100","pcpcity":"GLEN ALLEN","pcpstate":"VA","pcpzip":23060,"pcpcounty":"","pcpid":125390,"pcpname":"","plan":"OHP","program":"ACA","lob":"Small Group","region":"TIDEWATER","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"804\/968-5739","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["H10.021","R06.02","I25.10","E78.00","K40.90","L73.8","R07.9","K21.9","I10.","E78.5","I20.0","I25.110","Z95.1","R07.2","N50.82","E87.5","E83.39","R91.8","Z20.828","R11.11","R19.7","R88.8","S01.01XA","Z12.11"],"date":["2020-03-25","2020-09-16","2021-10-20","2021-10-20","2020-03-06","2020-09-29","2021-01-04","2021-01-04","2021-10-20","2021-01-04","2021-01-03","2021-01-03","2021-01-03","2021-01-03","2020-02-08","2020-02-08","2020-02-08","2021-01-01","2021-01-29","2021-01-29","2021-01-29","2020-02-08","2021-04-02","2021-08-30"],"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":[["","68180098103","LISINOPRIL","20MG","-90","Select","Select",""],["","68180072003","AMLODIPINE","5MG","90","Select","Select",""],["","31722088530","ROSUVASTATIN","40MG","90","Select","Select",""],["","61314062810","POLYMYXIN","TRIMETHP","10","Select","Select",""],["","16729027310","PRASUGREL","10MG","30","Select","Select",""],["","49348081709","ACID","20MG","60","Select","Select",""],["","70010075401","METHOCARBAM","500MG","-16","Select","Select",""],["","68462016205","CARVEDILOL","3.125MG","180","Select","Select",""],["","59267100002","PFIZER","COVID-19","0","Select","Select",""],["","43598043611","NITROGLYCERN","0.4MG","25","Select","Select",""],["","68462018905","NAPROXEN","375MG","-14","Select","Select",""],["","00143980305","DOXYCYCL","100MG","20","Select","Select",""],["","68180098103","LISINOPRIL ","20MG","90","Select","Select",""],["","31722088530","ROSUVASTATIN ","40MG","90","Select","Select",""],["","61314062810","POLYMYXIN ","TRIMETHP","10","Select","Select",""],["","43598043611","NITROGLYCERN ","0.4MG","25","Select","Select",""],["","68180072003","AMLODIPINE ","5MG","90","Select","Select",""],["","69238110005","DOXYCYCL ","100MG","-20","Select","Select",""],["","49348081709","ACID ","20MG","60","Select","Select",""],["","65862083030","PRASUGREL ","10MG","30","Select","Select",""],["","00093005105","CARVEDILOL ","3.125MG","60","Select","Select",""],["","68462018905","NAPROXEN ","375MG","-14","Select","Select",""],["","70010075401","METHOCARBAM ","500MG","16","Select","Select",""],["","59267100002","PFIZER ","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":""}]}]}