{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"ELEANOR BINION","gend":1,"add":"4615 JURLANDO LN APT 201","city":"CHARLOTTESVILLE","state":"VA","zip":"22911-9998","dob":"1987-02-09","age":"","mstatus":"","insh":"1164914*01","cliId":"","pno":"434\/760-1451","cno":"434\/760-1451","email":"","ename":"","eno":"","pphy":"MURRAY, WILLIAM H MD","ppno":"434\/923-4600","pcpadd":"3263 PROFFIT ROAD SUITE 101","pcpcity":"CHARLOTTESVILLE","pcpstate":"VA","pcpzip":22911,"pcpcounty":"","pcpid":145520,"pcpname":"SMJMG - Sentara Forest Lakes Family Medicine","plan":"OHP","program":"MEDICAID","lob":"M4","region":"WESTERN\/ CHARLOTTESVILLE","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R00.2","I49.9","R11.0","O62.0","F41.9","G43.101","E66.01","M54.5","G47.33","F32.9","Z68.41","G89.29","E66.09","F33.41","F95.9","O99.810","Z30.430","O24.425","O62.1","Z3A.39","Z37.0","Z79.84","V23.89","N91.0","Z3A.34","O24.419","G43.709","R07.2","R55.","Z36.9"],"date":["2020-07-23","2020-07-10","2020-09-10","2021-05-05","2021-07-06","2020-06-30","2020-03-18","2020-03-18","2020-03-18","2021-07-06","2020-03-18","2020-03-18","2021-07-06","2020-06-30","2020-06-30","2021-04-15","2021-06-24","2021-05-04","2021-05-05","2021-05-05","2021-05-05","2021-05-04","2021-05-04","2020-10-01","2021-04-01","2021-07-06","2020-04-29","2020-07-23","2020-07-23","2020-10-01"],"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":[]},{"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","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["Yes","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":""}]}]}