{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"EDDIE   L CLYBURN","gend":0,"add":"170 MOTOKA DR APT 9","city":"HAMPTON","state":"VA","zip":23666,"dob":"1969-11-14","age":"","mstatus":"","insh":"1683919*01","cliId":"","pno":"757\/696-1389","cno":"757\/696-1389","email":"","ename":"","eno":"","pphy":"FRANCIS, ALBERT H MD","ppno":"757\/736-3700","pcpadd":"2104 EXECUTIVE DRIVE","pcpcity":"HAMPTON","pcpstate":"VA","pcpzip":23666,"pcpcounty":"","pcpid":149598,"pcpname":"SMG - Sentara Family Medicine Physicians - Peninsula Towne","plan":"OHP","program":"MEDICAID","lob":"M4","region":"TIDEWATER","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/827-9978","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["M54.5","S63.601A","S39.012A","M51.36","R59.9","J40.","R05.","R06.2","Z11.59","I25.10","R06.00","Z12.11","M79.641","S46.912A","S46.812A","G89.29","J98.4","N32.9","Z20.828","Z23.","S63.641A","Z01.818","D12.5","M79.644","Z82.49","Z83.3","Z82.61","Z80.42","Z80.1","Z83.42","V89.2XXD","Z00.00","L73.9","Z71.1","I51.7","I70.90"],"date":["2020-12-23","2020-12-09","2020-12-09","2021-02-22","2021-09-10","2020-10-20","2020-10-22","2020-10-15","2020-10-15","2021-09-02","2020-11-13","2021-01-20","2021-01-06","2021-03-05","2021-03-05","2020-10-13","2020-05-21","2020-05-21","2021-08-08","2020-10-22","2021-02-25","2020-11-14","2021-01-20","2021-07-28","2020-03-06","2020-03-06","2020-03-06","2020-03-06","2020-03-06","2020-03-06","2020-12-23","2021-07-28","2021-07-28","2021-07-28","2021-09-02","2021-09-02"],"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":[["","00591352530","LIDOCAINE ","5%","30","Select","Select",""],["","60505004101","ETODOLAC ","400MG","12","Select","Select",""],["","65162083366","DICLOFENAC ","1%","100","Select","Select",""],["","00487020103","IPRATROPIUM\/ ","ALBUTER","360","Select","Select",""],["","64380071206","BENZONATATE ","100MG","45","Select","Select",""],["","72647033104","METHYLPRED ","4MG","21","Select","Select",""],["","60505257909","ATORVASTATIN ","20MG","90","Select","Select",""],["","51672408103","CLINDAMYCIN ","1%","60","Select","Select",""],["","66993001968","ALBUTEROL ","HFA","18","Select","Select",""],["","00603533932","PREDNISONE ","20MG","21","Select","Select",""],["","00115174501","METAXALONE ","400MG","60","Select","Select",""],["","00143980305","DOXYCYCL ","100MG","20","Select","Select",""],["","00781808926","AZITHROMYCIN ","250MG","6","Select","Select",""],["","55111018015","TIZANIDINE ","4MG","60","Select","Select",""],["","65162019010","NAPROXEN ","500MG","60","Select","Select",""],["","59746021106","CYCLOBENZAPR ","5MG","30","Select","Select",""],["","59267100002","PFIZER ","COVID-19","0","Select","Select",""],["","60505004101","ETODOLAC","400MG","12","Select","Select",""],["","00591352530","LIDOCAINE","5%","30","Select","Select",""],["","65162083366","DICLOFENAC","1%","100","Select","Select",""],["","00487020103","IPRATROPIUM\/","ALBUTER","360","Select","Select",""],["","00115174501","METAXALONE","400MG","60","Select","Select",""],["","00143980305","DOXYCYCL","100MG","20","Select","Select",""],["","00781808926","AZITHROMYCIN","250MG","6","Select","Select",""],["","64380071206","BENZONATATE","100MG","45","Select","Select",""],["","72647033104","METHYLPRED","4MG","21","Select","Select",""],["","00603533932","PREDNISONE","20MG","21","Select","Select",""],["","00093317431","ALBUTEROL","HFA","8","Select","Select",""],["","60505257909","ATORVASTATIN","20MG","90","Select","Select",""],["","55111018015","TIZANIDINE","4MG","60","Select","Select",""],["","65162019010","NAPROXEN","500MG","20","Select","Select",""],["","59746021106","CYCLOBENZAPR","5MG","30","Select","Select",""],["","59267100002","PFIZER","COVID-19","0","Select","Select",""],["","51672408103","CLINDAMYCIN","1%","60","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":""}]}]}