{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"EMILY   D CHANEY","gend":1,"add":"4424 DEBORAH CT APT 4","city":"CHESAPEAKE","state":"VA","zip":23321,"dob":"2002-05-28","age":"","mstatus":"","insh":"1576187*01","cliId":"","pno":"757\/215-6195","cno":"757\/215-6195","email":"","ename":"","eno":"","pphy":"DORBAD, DAVID G MD","ppno":"757\/488-2223","pcpadd":"SUITE 200A 4012 RAINTREE ROAD","pcpcity":"CHESAPEAKE","pcpstate":"VA","pcpzip":23321,"pcpcounty":"","pcpid":200329,"pcpname":"Renaissance Pediatrics","plan":"OHP","program":"MEDICAID","lob":"M4","region":"TIDEWATER","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/488-0890","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F39.","Z00.01","F32.9","Z68.37","Z72.821","Z13.31","Z71.3","E66.8","Z71.82","N30.01","Z30.09","Z11.3","F33.1","F41.9","R10.32","S20.461A","L70.0"],"date":["2020-09-29","2020-08-14","2020-08-14","2020-08-14","2020-08-14","2020-08-14","2020-08-14","2020-08-14","2020-08-14","2020-01-31","2020-02-06","2020-02-06","2021-09-24","2020-04-21","2020-08-05","2020-07-14","2021-06-10"],"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":[["","00555901858","TRI-SPRINTEC","","28","Select","Select",""],["","00555901858","TRI-SPRINTEC ","","28","Select","Select",""],["","65862050220","AMOX\/K ","500-125","14","Select","Select",""],["","42192080201","PHENAZOPYRID ","200MG","9","Select","Select",""],["","53746027205","SMZ\/TMP ","800-160","6","Select","Select",""],["","65862001205","SERTRALINE ","50MG","30","Select","Select",""],["","00093506110","HYDROXYZ ","25MG","28","Select","Select",""],["","67877025115","TRIAMCINOLON ","0.10%","15","Select","Select",""],["","59746000103","METHYLPRED ","4MG","21","Select","Select",""],["","00143312610","DICYCLOMINE ","10MG","28","Select","Select",""],["","53746027205","SMZ\/TMP","800-160","6","Select","Select",""],["","65862050220","AMOX\/K","500-125","14","Select","Select",""],["","42192080201","PHENAZOPYRID","200MG","9","Select","Select",""],["","65862001205","SERTRALINE","50MG","30","Select","Select",""],["","67877025115","TRIAMCINOLON","0.10%","15","Select","Select",""],["","59746000103","METHYLPRED","4MG","21","Select","Select",""],["","00143312610","DICYCLOMINE","10MG","28","Select","Select",""],["","00093506110","HYDROXYZ","25MG","28","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":""}]}]}