{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"LARA BALOVICH","gend":1,"add":"912 GENERAL JACKSON DR","city":"VIRGINIA BEACH","state":"VA","zip":"23454-9998","dob":"1968-02-26","age":"","mstatus":"","insh":"9880615*01","cliId":"","pno":"757\/619-9642","cno":"757\/619-9642","email":"","ename":"","eno":"","pphy":"BAKHSHI, ELIZABETH MD","ppno":"757\/481-3770","pcpadd":"1821 OLD DONATION PKWY SUITE #4","pcpcity":"VIRGINIA BEACH","pcpstate":"VA","pcpzip":23454,"pcpcounty":"","pcpid":120796,"pcpname":"","plan":"OHP","program":"ACA","lob":"Individual","region":"TIDEWATER","aligned":"","ano":"","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":["Z00.00","D64.9","I10.","E66.9","N60.11","N63.10","M79.671","M79.672","D51.9","E55.9","Z13.1","Z13.21","Z13.220","Z12.31","N60.01","N95.0","R63.5","H35.711","H35.712","H25.12","E66.3","Z78.0","R73.09","E78.5","N95.1"],"date":["2020-08-05","2021-07-22","2021-08-27","2021-02-23","2020-09-08","2020-09-08","2021-05-25","2021-05-25","2021-02-23","2021-07-22","2021-02-23","2021-02-23","2021-02-23","2021-09-08","2020-09-08","2021-05-28","2021-05-28","2020-03-06","2020-03-06","2020-03-06","2021-07-22","2021-07-22","2021-07-22","2021-08-27","2021-08-27"],"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":[["","00378464126","ESTRADIOL","0.075MG","8","Select","Select",""],["","64380080707","IBUPROFEN","800MG","30","Select","Select",""],["","69452023420","PROGESTERONE","200MG","90","Select","Select",""],["","00172208380","HYDROCHLOROT","25MG","90","Select","Select",""],["","69452023420","PROGESTERONE ","200MG","30","Select","Select",""],["","64380080707","IBUPROFEN ","800MG","30","Select","Select",""],["","00378464226","ESTRADIOL ","0.05MG","8","Select","Select",""],["","00172208380","HYDROCHLOROT ","25MG","90","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":""}]}]}