{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"CHANEL PENDLETON","gend":1,"add":"2319 GILLS ST","city":"LYNCHBURG","state":"VA","zip":"24501-9998","dob":"2000-12-23","age":"","mstatus":"","insh":"1198247*01","cliId":"","pno":"434\/945-0563","cno":"434\/945-0563","email":"","ename":"","eno":"","pphy":"BROWN, BENJAMIN T MD","ppno":"434\/263-4000","pcpadd":"4038 THOMAS NELSON HIGHWAY","pcpcity":"ARRINGTON","pcpstate":"VA","pcpzip":22922,"pcpcounty":"","pcpid":671660,"pcpname":"","plan":"OHP","program":"MEDICAID","lob":"M4","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"434\/946-9062","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":["N94.6","Z88.0","O21.0","Z3A.15","Z03.71","Z3A.33","O99.513","R06.02","O36.8131","O80.","Z3A.00","Z37.0","Z39.2","F32.1","Z00.01","F12.10","Z34.92","P03.810","Z3A.39","Z39.1","Z34.82","Z34.83","Z36.89","Z34.93","Z3A.29","O77.0","O72.1","O69.81X0","Z3A.41","O70.1","G50.1","O46.91","E87.6","D64.9","Z34.90"],"date":["2020-11-14","2020-11-14","2020-01-18","2020-01-18","2020-05-20","2020-05-20","2020-06-22","2020-06-22","2020-06-22","2020-07-13","2021-07-06","2020-07-13","2020-07-14","2020-11-30","2020-08-06","2020-09-17","2020-01-31","2020-06-26","2020-06-26","2020-05-27","2020-05-27","2020-05-27","2020-06-26","2020-06-22","2020-04-20","2020-07-13","2020-07-13","2020-07-13","2020-07-13","2020-07-13","2021-03-08","2021-07-06","2021-07-06","2021-07-06","2021-07-06"],"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":[["","68180012202","CEPHALEXIN ","500MG","28","Select","Select",""],["","00536100931","","","30","Select","Select",""],["","68180016106","AZITHROMYCIN ","500MG","2","Select","Select",""],["","47781030301","NITROFURANTN ","100MG","14","Select","Select",""],["","65162019050","NAPROXEN ","500MG","30","Select","Select",""],["","00574050810","FERROUS ","324MG","90","Select","Select",""],["","63304069301","CLINDAMYCIN ","300MG","21","Select","Select",""],["","59267100001","PFIZER ","COVID-19","0","Select","Select",""],["","65862042005","SMZ\/TMP ","800-160","6","Select","Select",""],["","68180012202","CEPHALEXIN","500MG","28","Select","Select",""],["","47781030301","NITROFURANTN","100MG","14","Select","Select",""],["","00574050801","FERROUS","324MG","90","Select","Select",""],["","65162019050","NAPROXEN","500MG","30","Select","Select",""],["","63304069301","CLINDAMYCIN","300MG","21","Select","Select",""],["","59267100001","PFIZER","COVID-19","0","Select","Select",""],["","65862042005","SMZ\/TMP","800-160","6","Select","Select",""],["","68180016106","AZITHROMYCIN","500MG","2","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","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["No","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":""}]}]}