{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"SHENA CARTER","gend":1,"add":"510 PURLIEU DR APT 102","city":"NEWPORT NEWS","state":"VA","zip":"23606-9998","dob":"1973-07-21","age":"","mstatus":"","insh":"1887394*01","cliId":"","pno":"757\/310-3914","cno":"757\/310-3914","email":"","ename":"","eno":"","pphy":"HUSEN, SRIE D MD","ppno":"757\/594-1850","pcpadd":"STE 100 11803 JEFFERSON AVE","pcpcity":"NEWPORT NEWS","pcpstate":"VA","pcpzip":23606,"pcpcounty":"","pcpid":119880,"pcpname":"SMG - Sentara Family Medicine Physicians - Port Warwick","plan":"OHP","program":"MEDICAID","lob":"M4","region":"TIDEWATER","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/594-1841","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["J32.4","R09.81","J34.3","J34.2","I10.","K21.9","E66.01","Z68.39","E11.9","Z79.899","Z79.82","T81.9XXA","R07.9","R07.89","R16.1","F33.41","F31.9","J30.89","R06.09","I50.30","J30.1","J30.81","R09.82","R04.0","J01.90","K80.10","Z20.828","H00.013","S33.5XXA","J06.9","N62.","M54.9","R00.2","R73.03","I51.89","M17.0","M25.569","F41.8","G43.909","L73.9","Z01.810","Z01.812","K59.00","Z20.822","F31.63","F41.1","F51.01","F90.0","N89.8","M17.12","R45.86","F41.9","Z23.","M25.562","Z00.00","Z01.818","R20.0","Z13.220","R19.7","E66.9","S80.02XA","Z68.41","R56.9","B18.2","H60.339","F32.9","Z86.010","J02.9","M54.5","E66.09","Z68.37","Z12.11","E55.9","M54.2"],"date":["2020-06-29","2021-05-07","2020-11-19","2020-11-19","2021-08-30","2021-02-05","2020-07-14","2020-07-14","2020-07-15","2020-07-15","2020-07-15","2020-07-15","2020-09-15","2020-09-15","2020-09-15","2021-04-14","2020-09-24","2021-09-27","2021-02-05","2021-02-05","2021-05-07","2021-05-07","2021-05-07","2021-05-07","2021-11-20","2020-08-28","2021-08-03","2020-11-30","2021-01-29","2021-06-11","2020-03-24","2020-03-24","2020-08-01","2021-08-30","2021-04-14","2020-06-12","2020-06-12","2020-08-28","2020-08-28","2020-11-19","2020-12-02","2021-01-25","2020-12-02","2021-03-29","2021-05-17","2021-05-17","2021-05-17","2021-05-17","2021-05-20","2021-08-27","2020-08-03","2021-01-12","2021-01-12","2021-07-20","2021-08-30","2020-07-13","2020-07-13","2020-07-13","2021-02-05","2021-02-05","2020-07-12","2021-04-14","2021-04-14","2021-04-14","2021-07-02","2020-07-31","2020-07-31","2020-09-28","2020-09-28","2021-08-30","2021-08-30","2021-08-30","2021-08-30","2021-08-30"],"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":[["","00143924920","AMOX\/K","875-125","20","Select","Select",""],["","42195095510","BUT\/APAP\/CAF ","","30","Select","Select",""],["","68462010340","FLUCONAZOLE ","150MG","1","Select","Select",""],["","67877019805","AMLODIPINE ","5MG","30","Select","Select",""],["","50742061701","METOPROL ","100MG ER","30","Select","Select",""],["","53885001110","ONETOUCH ","PLUS 30G","100","Select","Select",""],["","65162037110","OXYBUTYNIN ","5MG ER","30","Select","Select",""],["","68462019001","NAPROXEN ","500MG","40","Select","Select",""],["","99073070822","FREESTYLE    TES LITE","LITE","50","Select","Select",""],["","11822316910","RA ","81MG EC","90","Select","Select",""],["","33342030111","ESZOPICLONE ","3MG","30","Select","Select",""],["","00054429931","FUROSEMIDE ","40MG","30","Select","Select",""],["","60432060416","PROMETHAZINE ","DM","120","Select","Select",""],["","00116200116","CHLORHEX ","0.12%","473","Select","Select",""],["","11822060597","ALLERGY ","10MG","30","Select","Select",""],["","11822511220","VITAMIN ","5000UNIT","30","Select","Select",""],["","69097081803","TOPIRAMATE ","100MG","60","Select","Select",""],["","61874014530","VRAYLAR ","4.5MG","30","Select","Select",""],["","59417010110","VYVANSE ","10MG","30","Select","Select",""],["","16729017101","AMITRIPTYLIN ","10MG","60","Select","Select",""],["","00185067401","HYDROXYZ ","25MG","90","Select","Select",""],["","43072000128","NASAL ","0.05%","30","Select","Select",""],["","31722094101","HYDROCO\/APAP ","5-325MG","20","Select","Select",""],["","60432026415","FLUTICASONE ","50MCG","16","Select","Select",""],["","55111015901","OMEPRAZOLE ","40MG","30","Select","Select",""],["","49035089212","NATURAL ","8.6MG","60","Select","Select",""],["","54092038301","ADDERALL ","10MG","30","Select","Select",""],["","00591024005","LORAZEPAM ","0.5MG","30","Select","Select",""],["","67877014601","TEMAZEPAM ","15MG","30","Select","Select",""],["","59762045001","COLESTIPOL ","1GM","120","Select","Select",""],["","29300014801","QUETIAPINE ","50MG","30","Select","Select",""],["","11523116705","AFRIN ","0.05%","30","Select","Select",""],["","49035029812","NAT ","8.6MG","60","Select","Select",""],["","57237007710","ONDANSETRON ","4MG ODT","20","Select","Select",""],["","00501290218","SUDAFED ","10MG","12","Select","Select",""],["","50383002510","OFLOXACIN ","0.3%OTIC","10","Select","Select",""],["","67877021901","CEPHALEXIN ","500MG","20","Select","Select",""],["","65862049647","SMZ-TMP ","200-40\/5","140","Select","Select",""],["","65162027210","SMZ\/TMP ","800-160","20","Select","Select",""],["","69784018010","POLYETH ","3350 NF","12","Select","Select",""],["","63402030430","LATUDA ","40MG","30","Select","Select",""],["","00378803077","LANSOPRAZOLE ","30MG DR","30","Select","Select",""],["","31722071390","PANTOPRAZOLE ","40MG","90","Select","Select",""],["","65862001330","SERTRALINE ","100MG","30","Select","Select",""],["","59746021106","CYCLOBENZAPR ","5MG","15","Select","Select",""],["","72647033104","METHYLPRED ","4MG","21","Select","Select",""],["","00904645780","DOK ","100MG","20","Select","Select",""],["","49035023814","EQ ","SOFTENER","20","Select","Select",""],["","00228305911","AMPHET\/DEXTR ","10MG ER","30","Select","Select",""],["","00093101042","MUPIROCIN ","2%","22","Select","Select",""],["","17478007035","ERYTHROMYCIN ","5MG\/GM","4","Select","Select",""],["","61314064175","NEO\/POLY\/HC ","OP","8","Select","Select",""],["","00093598627","EPINEPHRINE ","0.3MG","2","Select","Select",""],["","65162046650","IBUPROFEN ","800MG","60","Select","Select",""],["","10702002501","PHENTERMINE ","37.5MG","30","Select","Select",""],["","59310057922","PROAIR ","","8","Select","Select",""],["","68001043696","CETIRIZINE ","10MG","30","Select","Select",""],["","00143924920","AMOX\/K ","875-125","14","Select","Select",""],["","00054001925","PREDNISONE ","50MG","5","Select","Select",""],["","68180096301","ALBUTEROL ","HFA","8","Select","Select",""],["","55111018015","TIZANIDINE ","4MG","60","Select","Select",""],["","00054429931","FUROSEMIDE","40MG","30","Select","Select",""],["","11822316910","RA","81MG EC","30","Select","Select",""],["","65862096901","ESZOPICLONE","3MG","30","Select","Select",""],["","65162037110","OXYBUTYNIN","5MG ER","30","Select","Select",""],["","68462019001","NAPROXEN","500MG","40","Select","Select",""],["","53885099425","ONETOUCH","ULTRA BL","25","Select","Select",""],["","50742061701","METOPROL","100MG ER","30","Select","Select",""],["","99073070822","FREESTYLE TES LITE","LITE","50","Select","Select",""],["","67877019805","AMLODIPINE","5MG","30","Select","Select",""],["","60432060416","PROMETHAZINE","DM","120","Select","Select",""],["","68462010340","FLUCONAZOLE","150MG","1","Select","Select",""],["","42195095510","BUT\/APAP\/CAF","","30","Select","Select",""],["","60432026415","FLUTICASONE","50MCG","16","Select","Select",""],["","11822060597","ALLERGY","10MG","30","Select","Select",""],["","16729017101","AMITRIPTYLIN","10MG","60","Select","Select",""],["","69097012403","TOPIRAMATE","100MG","60","Select","Select",""],["","67877014601","TEMAZEPAM","15MG","30","Select","Select",""],["","61874014530","VRAYLAR","4.5MG","30","Select","Select",""],["","11822511220","VITAMIN","5000UNIT","30","Select","Select",""],["","00904571135","NASAL","0.05%","30","Select","Select",""],["","67877021901","CEPHALEXIN","500MG","20","Select","Select",""],["","31722094101","HYDROCO\/APAP","5-325MG","20","Select","Select",""],["","59417010110","VYVANSE","10MG","30","Select","Select",""],["","11523116705","AFRIN","0.05%","30","Select","Select",""],["","65162027210","SMZ\/TMP","800-160","20","Select","Select",""],["","00378803077","LANSOPRAZOLE","30MG DR","30","Select","Select",""],["","65862049647","SMZ-TMP","200-40\/5","140","Select","Select",""],["","57237007710","ONDANSETRON","4MG ODT","20","Select","Select",""],["","00501290218","SUDAFED","10MG","12","Select","Select",""],["","00185067401","HYDROXYZ","25MG","90","Select","Select",""],["","63402030430","LATUDA","40MG","30","Select","Select",""],["","00591024005","LORAZEPAM","0.5MG","30","Select","Select",""],["","49035089212","NATURAL","8.6MG","60","Select","Select",""],["","55111015901","OMEPRAZOLE","40MG","30","Select","Select",""],["","65862001330","SERTRALINE","100MG","30","Select","Select",""],["","49035029812","NAT","8.6MG","60","Select","Select",""],["","49035023814","EQ","SOFTENER","20","Select","Select",""],["","69784018010","POLYETH","3350 NF","12","Select","Select",""],["","31722071390","PANTOPRAZOLE","40MG","90","Select","Select",""],["","59746021106","CYCLOBENZAPR","5MG","15","Select","Select",""],["","72647033104","METHYLPRED","4MG","21","Select","Select",""],["","54092038301","ADDERALL","10MG","30","Select","Select",""],["","00228305911","AMPHET\/DEXTR","10MG ER","30","Select","Select",""],["","29300014801","QUETIAPINE","50MG","30","Select","Select",""],["","00904645780","DOK","100MG","20","Select","Select",""],["","17478007035","ERYTHROMYCIN","5MG\/GM","4","Select","Select",""],["","00093101042","MUPIROCIN","2%","22","Select","Select",""],["","61314064175","NEO\/POLY\/HC","OP","8","Select","Select",""],["","59762045001","COLESTIPOL","1GM","120","Select","Select",""],["","00093598627","EPINEPHRINE","0.3MG","2","Select","Select",""],["","10702002501","PHENTERMINE","37.5MG","30","Select","Select",""],["","68001043696","CETIRIZINE","10MG","30","Select","Select",""],["","59310057922","PROAIR","","8","Select","Select",""],["","50383002510","OFLOXACIN","0.3%OTIC","10","Select","Select",""],["","68180096301","ALBUTEROL","HFA","8","Select","Select",""],["","00054001925","PREDNISONE","50MG","5","Select","Select",""],["","55111018015","TIZANIDINE","4MG","60","Select","Select",""],["","00116200116","CHLORHEX","0.12%","473","Select","Select",""],["","65162046650","IBUPROFEN","800MG","60","Select","Select",""],["","43598032675","CIPRO\/DEXA ","SUS 0.3-0.1%","8","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":""}]}]}