{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"STEPHANIE BARBOUR","gend":1,"add":"37 BAXTER ST LOT 11","city":"HAMPTON","state":"VA","zip":"23669-9998","dob":"1965-03-05","age":"","mstatus":"","insh":"20023573*01","cliId":"","pno":"757\/850-1689","cno":"757\/750-7123","email":"","ename":"","eno":"","pphy":"WALLACE, DAVID M MD","ppno":"757\/726-5000","pcpadd":"200 EATON ST","pcpcity":"HAMPTON","pcpstate":"VA","pcpzip":23669,"pcpcounty":"","pcpid":101284,"pcpname":"SMG - Sentara Family Medicine Physicians - Old Hampton","plan":"OHP","program":"MEDICAID","lob":"OHCC","region":"TIDEWATER","aligned":"","ano":"757\/281-8863","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/726-5001","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R06.02","R07.9","I48.0","Z12.31","I10.","Z71.89","E03.9","F17.200","Z28.21","F41.9","N87.1","J44.1","J44.9","J41.0","Z87.891","Z23.","Z01.30","Z00.00","M35.00","R87.610","R87.810","Z12.11","Z01.818","K04.7","I25.10","Z01.810","R53.1","B37.0","D64.9","N30.00","K92.2","NO DATA","K31.819","K92.0","G62.9","M32.9","M21.371","E53.8","M21.372","K31.811","A41.9","E43.","N17.9","N39.0","D62.","D61.818","Z20.822","M06.9","G35.","F17.210","I08.3","K22.2","K31.89","M79.609","R26.2","R11.2","I48.91","D69.6","E86.0","R82.998","Z09.","Z87.19","D50.9","R06.82","B37.9","G89.4","Z79.51","Z79.899","Z79.890","Z88.0","Z88.2","Z88.5","Z88.6","Z91.018","Z91.09","I25.118","M35.9","R32.","R26.0","R21.","I11.0","I50.9","I73.00"],"date":["2020-03-06","2021-02-15","2021-10-18","2020-12-02","2021-09-16","2020-12-02","2021-10-18","2020-12-02","2020-12-02","2020-12-02","2020-12-02","2020-05-26","2021-10-18","2020-06-02","2020-05-26","2020-06-09","2020-06-09","2020-06-02","2021-08-19","2020-06-02","2020-06-02","2020-06-02","2020-02-28","2020-06-25","2021-10-18","2020-01-15","2021-08-08","2021-08-26","2021-07-23","2021-06-16","2021-08-19","2021-08-11","2021-08-11","2021-08-11","2021-10-18","2021-10-18","2021-08-15","2021-10-18","2021-08-15","2021-08-07","2021-08-07","2021-10-18","2021-08-07","2021-10-18","2021-08-07","2021-08-07","2021-08-07","2021-10-18","2021-10-18","2021-08-07","2021-08-10","2021-10-18","2021-08-10","2021-08-18","2021-07-22","2021-08-07","2021-08-07","2021-10-18","2021-08-05","2021-08-05","2021-08-26","2021-08-26","2021-08-09","2021-08-07","2021-07-22","2021-09-16","2021-09-16","2021-09-16","2021-09-16","2021-09-16","2021-09-16","2021-09-16","2021-09-16","2021-09-16","2021-09-16","2021-08-19","2021-08-19","2021-09-22","2021-10-08","2021-10-18","2021-10-18","2021-10-18","2021-10-18"],"priorHcc":["","",null,"","","",null,"","","","","",null,"","","","","","","","","","","",null,"","","","","","","","","",null,null,"",null,"","","",null,"",null,"","","",null,null,"","",null,"","","","","",null,"","","","","","","","","","","","","","","","","","","","",null,null,null,null,null]}},{"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":[["","59310057922","PROAIR ","","8","Select","Select",""],["","00591544305","PREDNISONE ","20MG","15","Select","Select",""],["","50111078751","AZITHROMYCIN ","250MG","6","Select","Select",""],["","68180072003","AMLODIPINE ","5MG","30","Select","Select",""],["","00378623301","CITALOPRAM ","40MG","30","Select","Select",""],["","43598043611","NITROGLYCERN ","0.4MG","100","Select","Select",""],["","00093354143","ESTRADIOL ","0.01%","42","Select","Select",""],["","13668010601","ISOSORB ","120MG ER","30","Select","Select",""],["","00536110788","NICOTINE ","14MG\/24H","28","Select","Select",""],["","76204020025","ALBUTEROL ","0.08%","150","Select","Select",""],["","00085113204","PROVENTIL ","HFA","7","Select","Select",""],["","16729021816","CLOPIDOGREL ","75MG","30","Select","Select",""],["","69238183407","LEVOTHYROXIN ","100MCG","30","Select","Select",""],["","68180047301","AMLOD\/BENAZP ","10-40MG","30","Select","Select",""],["","65862053650","LEVOFLOXACIN ","250MG","7","Select","Select",""],["","00310008839","DALIRESP ","250MCG","30","Select","Select",""],["","00173087310","INCRUSE ","62.5MCG","30","Select","Select",""],["","76204010025","IPRATROPIUM ","0.02%INH","62","Select","Select",""],["","00116200116","CHLORHEX ","0.12%","946","Select","Select",""],["","00378932132","WIXELA ","250\/50","60","Select","Select",""],["","65862090801","CELECOXIB ","100MG","90","Select","Select",""],["","00143314205","DOXYCYCL ","100MG","14","Select","Select",""],["","00406012505","HYDROCO\/APAP ","10-325MG","21","Select","Select",""],["","27808008201","MORPHINE ","100\/5ML","15","Select","Select",""],["","50228018001","GABAPENTIN ","300MG","180","Select","Select",""],["","68180063709","ATORVASTATIN ","40MG","90","Select","Select",""],["","64380073706","VITAMIN ","50000UNT","12","Select","Select",""],["","68180098003","LISINOPRIL ","10MG","90","Select","Select",""],["","00143962125","CYANOCOBALAM ","1000MCG","10","Select","Select",""],["","31604002717","B-12 ","1000MCG","30","Select","Select",""],["","11534016501","FOLIC ","1MG","30","Select","Select",""],["","51645087510","THERA-M ","","90","Select","Select",""],["","65862039010","ONDANSETRON ","4MG ODT","12","Select","Select",""],["","51824003203","ZINC ","20%","28","Select","Select",""],["","00054414622","CLOTRIMAZOLE ","10MG","50","Select","Select",""],["","55111064501","OMEPRAZOLE ","40MG","30","Select","Select",""],["","11917014484","BP ","AUTO ARM","1","Select","Select",""],["","11822033670","RA ","100MG","90","Select","Select",""],["","60432053716","NYSTATIN ","100000","60","Select","Select",""],["","58657067601","CIPROFLOXACN ","500MG","14","Select","Select",""],["","64380071206","BENZONATATE ","100MG","30","Select","Select",""],["","67877021901","CEPHALEXIN ","500MG","10","Select","Select",""],["","11822046713","PAIN ","325MG","240","Select","Select",""],["","64380071206","BENZONATATE","100MG","30","Select","Select",""],["","76204020025","ALBUTEROL","0.08%","150","Select","Select",""],["","00093354143","ESTRADIOL","0.01%","42","Select","Select",""],["","00591544305","PREDNISONE","20MG","15","Select","Select",""],["","50111078751","AZITHROMYCIN","250MG","6","Select","Select",""],["","00378623301","CITALOPRAM","40MG","30","Select","Select",""],["","13668010601","ISOSORB","120MG ER","30","Select","Select",""],["","59762330403","NITROGLYCERN","0.4MG","100","Select","Select",""],["","68180072003","AMLODIPINE","5MG","30","Select","Select",""],["","16729021816","CLOPIDOGREL","75MG","30","Select","Select",""],["","69238183407","LEVOTHYROXIN","100MCG","30","Select","Select",""],["","59310057922","PROAIR","","8","Select","Select",""],["","76204010025","IPRATROPIUM","0.02%INH","62","Select","Select",""],["","00536589588","NICOTINE","14MG\/24H","28","Select","Select",""],["","00085113204","PROVENTIL","HFA","7","Select","Select",""],["","00378932132","WIXELA","250\/50","60","Select","Select",""],["","00310008839","DALIRESP","250MCG","30","Select","Select",""],["","00173087310","INCRUSE","62.5MCG","30","Select","Select",""],["","68180047301","AMLOD\/BENAZP","10-40MG","30","Select","Select",""],["","00143980305","DOXYCYCL","100MG","14","Select","Select",""],["","65862053650","LEVOFLOXACIN","250MG","7","Select","Select",""],["","00116200116","CHLORHEX","0.12%","946","Select","Select",""],["","00406012505","HYDROCO\/APAP","10-325MG","21","Select","Select",""],["","68180098003","LISINOPRIL","10MG","30","Select","Select",""],["","65862090801","CELECOXIB","100MG","90","Select","Select",""],["","00054414622","CLOTRIMAZOLE","10MG","50","Select","Select",""],["","58657067601","CIPROFLOXACN","500MG","14","Select","Select",""],["","51645087510","THERA-M","","90","Select","Select",""],["","11845009661","VITAMIN","1000MCG","30","Select","Select",""],["","51824003203","ZINC","20%","28","Select","Select",""],["","27808008201","MORPHINE","100\/5ML","15","Select","Select",""],["","50228018001","GABAPENTIN","300MG","180","Select","Select",""],["","68180063709","ATORVASTATIN","40MG","90","Select","Select",""],["","66689000802","NYSTATIN","100000","60","Select","Select",""],["","65862039010","ONDANSETRON","4MG ODT","12","Select","Select",""],["","00143962125","CYANOCOBALAM","1000MCG","10","Select","Select",""],["","55111064501","OMEPRAZOLE","40MG","30","Select","Select",""],["","67877021901","CEPHALEXIN","500MG","10","Select","Select",""],["","11822033670","RA","100MG","90","Select","Select",""],["","11917014484","BP","AUTO ARM","1","Select","Select",""],["","55111018015","TIZANIDINE","4MG","30","Select","Select",""],["","11822046713","PAIN","325MG","240","Select","Select",""],["","11534016501","FOLIC","1MG","30","Select","Select",""],["","31604002717","B-12","1000MCG","30","Select","Select",""],["","55111018015","TIZANIDINE ","TAB 4MG","30","Select","Select",""],["","45802006405","TRIAMCINOLON ","CRE 0.001","454","Select","Select",""],["","00713065631","CLOBETASOL ","OIN 0.0005","60","Select","Select",""],["","00003089421","ELIQUIS ","TAB 5MG","60","Select","Select",""],["","50458057930","XARELTO ","TAB 20MG","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","",""],["Yes","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":""}]}]}