{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"AYMAN AHMED","gend":0,"add":"11493 ABBOTS CROSS LN APT 8","city":"GLEN ALLEN","state":"VA","zip":"23059-9998","dob":"1963-01-01","age":"","mstatus":"","insh":"1648820*01","cliId":"","pno":"804\/317-3135","cno":"804\/317-3135","email":"","ename":"","eno":"","pphy":"BLEVINS, CAROLINE MD","ppno":"804\/560-0490","pcpadd":"500 HIOAKS ROAD SUITE B","pcpcity":"RICHMOND","pcpstate":"VA","pcpzip":23225,"pcpcounty":"","pcpid":149263,"pcpname":"Primary Health Group - Chippenham","plan":"OHP","program":"MEDICAID","lob":"M4","region":"CENTRAL","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"804\/560-3424","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z20.828","R05."],"date":["2021-06-30","2021-06-30"],"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":[["","67877019910","AMLODIPINE ","10MG","90","Select","Select",""],["","00172208380","HYDROCHLOROT ","25MG","30","Select","Select",""],["","62756014202","METFORMIN ","500MG ER","60","Select","Select",""],["","31722071390","PANTOPRAZOLE ","40MG","30","Select","Select",""],["","43598044774","NICOTINE ","14MG\/24H","28","Select","Select",""],["","55111015810","OMEPRAZOLE ","20MG","30","Select","Select",""],["","00527193206","CLARITHROMYC ","500MG","28","Select","Select",""],["","00093310905","AMOXICILLIN ","500MG","56","Select","Select",""],["","58160088552","FLUARIX ","2020-21","0","Select","Select",""],["","00904673080","ACETAMIN ","500MG","30","Select","Select",""],["","00093720198","PRAVASTATIN ","20MG","90","Select","Select",""],["","00172208380","HYDROCHLOROT","25MG","30","Select","Select",""],["","53746017805","METFORMIN","500MG ER","120","Select","Select",""],["","31722071390","PANTOPRAZOLE","40MG","30","Select","Select",""],["","67877019910","AMLODIPINE","10MG","30","Select","Select",""],["","43598044774","NICOTINE","14MG\/24H","28","Select","Select",""],["","55111015810","OMEPRAZOLE","20MG","30","Select","Select",""],["","00093310905","AMOXICILLIN","500MG","56","Select","Select",""],["","00904673080","ACETAMIN","500MG","30","Select","Select",""],["","00093720198","PRAVASTATIN","20MG","90","Select","Select",""],["","00527193206","CLARITHROMYC","500MG","28","Select","Select",""],["","58160088552","FLUARIX","2020-21","0","Select","Select",""],["","70436005902","BUPROPION ","TAB 150MG SR","120","Select","Select",""],["","70461032103","FLUCLVX ","INJ 2021-22","0","Select","Select",""],["","59267100002","PFIZER ","INJ COVID-19","0","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":""}]}]}