{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MICHELE  H LONE","gend":1,"add":"836 ROUND BAY ROAD","city":"NORFOLK","state":"VA","zip":"23502-9998","dob":"1973-10-28","age":"","mstatus":"","insh":"1972199*01","cliId":"","pno":"716\/602-8911","cno":"716\/602-8911","email":"","ename":"","eno":"","pphy":"GUZMAN-LEE, JOJO-ANNE A MD","ppno":"757\/955-2828","pcpadd":"STE 320 885 KEMPSVILLE ROAD","pcpcity":"NORFOLK","pcpstate":"VA","pcpzip":23502,"pcpcounty":"","pcpid":161929,"pcpname":"AMELIA MEDICAL ASSOCIATES","plan":"OHP","program":"MEDICAID","lob":"M4","region":"TIDEWATER","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z00.00","E11.9","Z13.1","R11.2","Z12.31","Z12.4","Z12.11","Z13.6","Z11.59","F17.210","Z12.12","J20.9","M25.552","M25.559","M70.62","E78.2","F32.9","I10.","I25.10","K21.9","R05.","R51.9","R09.81","Z20.828","I25.2","Z95.1","Z95.5","Z91.040","R53.83","I25.810"],"date":["2021-07-20","2021-08-24","2021-07-20","2021-07-20","2021-07-20","2021-07-20","2021-07-20","2021-07-20","2021-07-20","2021-07-20","2021-07-20","2020-03-16","2020-07-09","2020-07-16","2020-07-16","2020-07-16","2020-07-16","2020-07-16","2020-11-09","2020-07-16","2020-11-09","2020-11-09","2020-11-09","2020-11-09","2020-11-09","2021-08-24","2020-11-09","2020-11-09","2020-11-09","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":[["","55111015810","OMEPRAZOLE ","20MG","30","Select","Select",""],["","57664047758","METOPROL ","50MG","60","Select","Select",""],["","43598075201","BUPROPION ","150MG SR","60","Select","Select",""],["","00006057761","JANUMET ","50-1000","60","Select","Select",""],["","68180051201","LISINOPRIL ","2.5MG","30","Select","Select",""],["","70377002911","ATORVASTATIN ","40MG","30","Select","Select",""],["","59779046708","ASPIRIN ","81MG","30","Select","Select",""],["","68382076010","METFORMIN ","1000MG","60","Select","Select",""],["","00054327099","FLUTICASONE ","50MCG","16","Select","Select",""],["","68180016013","AZITHROMYCIN ","250MG","6","Select","Select",""],["","12843013105","BAYER ","81MG","30","Select","Select",""],["","67877057305","BENZONATATE ","100MG","30","Select","Select",""],["","42806016005","HYDROXYZ ","25MG","30","Select","Select",""],["","59267100003","PFIZER ","COVID-19","0","Select","Select",""],["","00069047103","CHANTIX ","0.5& 1MG","53","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":""}]}]}