{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"TAMMY BURNO","gend":1,"add":"3423 CLOVER MEADOWS DR RM 125","city":"CHESAPEAKE","state":"VA","zip":"23321-9998","dob":"1967-06-25","age":"","mstatus":"","insh":"1715741*01","cliId":"","pno":"757\/207-8239","cno":"757\/207-8239","email":"","ename":"","eno":"","pphy":"BRADSHAW, ROBERT D MD","ppno":"757\/446-5955","pcpadd":"SUITE 118 825 FAIRFAX AVE","pcpcity":"NORFOLK","pcpstate":"VA","pcpzip":23507,"pcpcounty":"","pcpid":100070,"pcpname":"EVMS Portsmouth Family Medicine","plan":"OHP","program":"MEDICAID","lob":"M4","region":"TIDEWATER","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/397-6344","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["E11.65","E78.2","I83.811","M65.312","R10.13","R68.81","Z87.11","A04.8","K44.9","K29.70","K31.89","R91.1","F17.200","E11.9","Z79.4","Z79.84","M54.2","K04.7","M47.812","M50.30","M62.838","Z72.0","R94.31","K30.","K21.9","E66.3","Z86.010","I10.","R20.2","Z68.31","R20.0","Z68.32"],"date":["2020-11-11","2020-10-14","2020-10-14","2020-11-12","2020-04-27","2020-04-27","2020-01-03","2020-01-03","2020-01-03","2020-01-03","2020-01-03","2020-11-11","2020-11-11","2020-09-29","2020-09-29","2020-09-29","2020-11-06","2020-11-30","2020-11-30","2020-11-30","2020-11-30","2020-11-30","2021-06-23","2020-04-27","2020-04-27","2020-04-27","2020-04-27","2021-09-27","2021-10-15","2021-09-27","2021-10-15","2021-10-15"],"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":[["","00088221905","LANTUS ","100\/ML","15","Select","Select",""],["","68645056854","ATORVASTATIN ","40MG","30","Select","Select",""],["","62175013643","OMEPRAZOLE ","40MG","30","Select","Select",""],["","16729017317","AMITRIPTYLIN ","50MG","30","Select","Select",""],["","00603002436","ASPIRIN ","81MG","30","Select","Select",""],["","00006011231","JANUVIA ","50MG","60","Select","Select",""],["","00006057761","JANUMET ","50-1000","60","Select","Select",""],["","08396903500","RELION ","32GX5\/32","50","Select","Select",""],["","91237000116","EASY ","30G","100","Select","Select",""],["","08463510301","INFINITY ","SYSTEM","1","Select","Select",""],["","51672415403","CALCIPOTRIEN ","0.01%","240","Select","Select",""],["","98302014059","COMFORT ","32GX4MM","100","Select","Select",""],["","65702040710","ACCU-CHEK ","AVIVA PL","100","Select","Select",""],["","00168084401","DICLOFENAC ","3%","100","Select","Select",""],["","52565000814","LIDOCAINE ","5%","35","Select","Select",""],["","60505317007","OMEGA-3-ACID ","1GM","120","Select","Select",""],["","68645055054","LISINOPRIL ","2.5MG","30","Select","Select",""],["","53885024450","ONETOUCH ","ULTRA","100","Select","Select",""],["","91237000128","ALCOHOL ","","100","Select","Select",""],["","65162019011","NAPROXEN ","500MG","20","Select","Select",""],["","49035019502","EQ ","14MG\/24H","28","Select","Select",""],["","00536589571","NICOTINE ","14MG\/24H","28","Select","Select",""],["","57237004101","PENICILLN ","500MG","40","Select","Select",""],["","08396900934","PEN  NEEDLES  ","32GX4MM","50","Select","Select",""],["","10702000709","CYCLOBENZAPR ","10MG","10","Select","Select",""],["","55111015330","ONDANSETRON ","4MG","12","Select","Select",""],["","00781261305","AMOXICILLIN ","500MG","28","Select","Select",""],["","00116200116","CHLORHEX ","0.12%","473","Select","Select",""],["","68645014059","FAMOTIDINE ","20MG","10","Select","Select",""],["","00603002436","ASPIRIN","81MG","30","Select","Select",""],["","00006011231","JANUVIA","50MG","60","Select","Select",""],["","00088221905","LANTUS","100\/ML","15","Select","Select",""],["","68645056854","ATORVASTATIN","40MG","30","Select","Select",""],["","16729017317","AMITRIPTYLIN","50MG","30","Select","Select",""],["","00006057761","JANUMET","50-1000","60","Select","Select",""],["","62175013643","OMEPRAZOLE","40MG","30","Select","Select",""],["","08396901434","RELION","32GX4MM","50","Select","Select",""],["","53885024450","ONETOUCH","ULTRA","100","Select","Select",""],["","91237000117","EASY","EJECT","1","Select","Select",""],["","98302014059","COMFORT","32GX4MM","100","Select","Select",""],["","51672415403","CALCIPOTRIEN","0.01%","240","Select","Select",""],["","52565000814","LIDOCAINE","5%","35","Select","Select",""],["","60505317007","OMEGA-3-ACID","1GM","120","Select","Select",""],["","00168084401","DICLOFENAC","3%","100","Select","Select",""],["","91237000128","ALCOHOL","","100","Select","Select",""],["","65702040710","ACCU-CHEK","AVIVA PL","100","Select","Select",""],["","08463520350","INFINITY","BLD GLUC","100","Select","Select",""],["","68645055054","LISINOPRIL","2.5MG","30","Select","Select",""],["","00536589571","NICOTINE","14MG\/24H","28","Select","Select",""],["","65162019011","NAPROXEN","500MG","20","Select","Select",""],["","49035019502","EQ","14MG\/24H","28","Select","Select",""],["","57237004101","PENICILLN","500MG","40","Select","Select",""],["","10702000709","CYCLOBENZAPR","10MG","10","Select","Select",""],["","68645014059","FAMOTIDINE","20MG","10","Select","Select",""],["","00781261305","AMOXICILLIN","500MG","28","Select","Select",""],["","67877022310","GABAPENTIN","300MG","111","Select","Select",""],["","08396900934","PEN NEEDLES","32GX4MM","50","Select","Select",""],["","55111015330","ONDANSETRON","4MG","12","Select","Select",""],["","00116200116","CHLORHEX","0.12%","473","Select","Select",""],["","00574200802","NYSTOP","100000","60","Select","Select",""],["","67877022310","GABAPENTIN ","CAP 300MG","111","Select","Select",""],["","00574200802","NYSTOP ","POW 100000","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":[[["Yes","Select","","","","","Select","",""],["Yes","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":""}]}]}