{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"ARIANNA   R GILLIS","gend":1,"add":"1516 PICASSO CT","city":"VIRGINIA BEACH","state":"VA","zip":"23456-9998","dob":"2003-06-25","age":"","mstatus":"","insh":"1456669*01","cliId":"","pno":"757\/636-4391","cno":"757\/636-4391","email":"","ename":"","eno":"","pphy":"CHILDS, MARCELLA MD","ppno":"757\/499-7442","pcpadd":"SUITE 250 4505 COLUMBUS STREET","pcpcity":"VIRGINIA BEACH","pcpstate":"VA","pcpzip":23462,"pcpcounty":"","pcpid":102433,"pcpname":"CMG - Children's Hospital of The King's Daughters - Town Center Pediatrics at Columbus","plan":"OHP","program":"MEDICAID","lob":"M4","region":"TIDEWATER","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/490-3638","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["N91.1","E66.3","K21.9","F41.1","Z71.1","E28.2","Z30.011","Z00.129","Z68.52","Z23.","Z30.41"],"date":["2021-04-26","2021-08-25","2020-10-19","2020-10-19","2020-10-19","2021-08-25","2021-04-26","2020-08-10","2020-08-10","2020-08-10","2021-08-25"],"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":[["","68382050010","OMEPRAZOLE ","40MG","30","Select","Select",""],["","70710122700","AMITRIPTYLIN ","50MG","30","Select","Select",""],["","70700011385","ISIBLOOM ","","84","Select","Select",""],["","59762005601","MEDROXYPR ","10MG","10","Select","Select",""],["","57237000511","FLUCONAZOLE ","150MG","2","Select","Select",""],["","68382050010","OMEPRAZOLE","40MG","30","Select","Select",""],["","59762005601","MEDROXYPR","10MG","10","Select","Select",""],["","57237000511","FLUCONAZOLE","150MG","2","Select","Select",""],["","70700011385","ISIBLOOM","","84","Select","Select",""],["","70710122700","AMITRIPTYLIN","50MG","30","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","",""],["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":""}]}]}