{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"SARAH BEIN","gend":1,"add":"10756 NEW ROAD","city":"VIRGINIA BEACH","state":"VA","zip":23452,"dob":"1987-07-31","age":"","mstatus":"","insh":"1672597*01","cliId":"","pno":"757\/559-8808","cno":"757\/559-8808","email":"","ename":"","eno":"","pphy":"CHARLES, MICHAEL G MD","ppno":"757\/395-1700","pcpadd":"3745 HOLLAND RD","pcpcity":"VIRGINIA BEACH","pcpstate":"VA","pcpzip":23452,"pcpcounty":"","pcpid":700505,"pcpname":"SMG - Sentara Family Medicine Physicians - Chimney Hill","plan":"OHP","program":"MEDICAID","lob":"M4","region":"CENTRAL","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/507-9004","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R10.13","R10.32","K21.9","F25.0","F12.20","H53.132","S09.93XS","G43.719","R51.","T81.33XA","V58.89","Z86.010","K58.0","K62.5","Z72.0","D22.30","L98.9"],"date":["2020-03-02","2020-03-02","2021-08-30","2020-07-14","2020-07-14","2020-07-14","2020-07-14","2020-07-14","2020-03-02","2021-08-11","2021-08-14","2021-08-30","2021-08-30","2021-08-30","2021-08-30","2021-08-24","2021-08-24"],"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":[["","31722071390","PANTOPRAZOLE ","40MG","30","Select","Select",""],["","00406048410","APAP\/CODEINE ","300-30MG","12","Select","Select",""],["","49035030603","EQ ","","510","Select","Select",""],["","00527058601","DICYCLOMINE ","10MG","60","Select","Select",""],["","70710122500","AMITRIPTYLIN ","10MG","60","Select","Select",""],["","42571025101","CLINDAMYCIN ","150MG","30","Select","Select",""],["","68645056354","IBUPROFEN ","800MG","30","Select","Select",""],["","31722099601","HYDROCO\/APAP ","5-325MG","12","Select","Select",""],["","70710122500","AMITRIPTYLIN","10MG","60","Select","Select",""],["","31722071390","PANTOPRAZOLE","40MG","30","Select","Select",""],["","00527058601","DICYCLOMINE","10MG","60","Select","Select",""],["","00406048410","APAP\/CODEINE","300-30MG","12","Select","Select",""],["","42571025101","CLINDAMYCIN","150MG","30","Select","Select",""],["","31722099601","HYDROCO\/APAP","5-325MG","12","Select","Select",""],["","49035030603","EQ","","510","Select","Select",""],["","68645056354","IBUPROFEN","800MG","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","",""],["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":""}]}]}