{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"TERESA   B CLEMENTS","gend":1,"add":"1813 PARK AVE APT A","city":"LYNCHBURG","state":"VA","zip":"24501-9998","dob":"1966-04-13","age":"","mstatus":"","insh":"20025486*01","cliId":"","pno":"434\/376-9823","cno":"434\/376-9823","email":"","ename":"","eno":"","pphy":"RENNINGER, VALERIE MD","ppno":"434\/200-3366","pcpadd":"1900 TATE SPRINGS ROAD SUITE 3","pcpcity":"LYNCHBURG","pcpstate":"VA","pcpzip":24501,"pcpcounty":"","pcpid":190030,"pcpname":"","plan":"OHP","program":"MEDICAID","lob":"OHCC","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"434\/616-0685","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"434\/528-9101","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z20.828","M17.11","Z51.81","G40.109","E55.9","Z11.59","M25.561","D64.9","Z23.","E53.8","H02.60","E78.2","Z78.9","Z68.42","I87.8","E04.2","E66.01","G40.909","Z12.31","Z12.11"],"date":["2020-06-18","2020-06-30","2021-01-07","2020-07-14","2020-07-14","2020-12-28","2021-01-07","2021-03-03","2020-09-03","2021-03-03","2021-03-03","2021-03-03","2021-03-03","2020-09-03","2020-09-03","2020-10-22","2020-01-14","2021-03-03","2021-03-03","2021-03-03"],"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":[["","00078051105","TEGRETOL-XR ","200MG","300","Select","Select",""],["","69452015120","VITAMIN ","50000UNT","4","Select","Select",""],["","00245010801","FERROUS ","325MG EC","60","Select","Select",""],["","43386035701","HYDROCO\/APAP ","7.5-325","21","Select","Select",""],["","29300012510","MELOXICAM ","15MG","30","Select","Select",""],["","45802091987","CETIRIZINE ","10MG","30","Select","Select",""],["","42858011830","LIDOCAINE ","5%","30","Select","Select",""],["","45802000403","HYDROCORT ","2.50%","28","Select","Select",""],["","59779045870","CVS ","10MG","30","Select","Select",""],["","80777027399","MODERNA ","COVID-19","0","Select","Select",""],["","00078051105","TEGRETOL-XR","200MG","300","Select","Select",""],["","69452015120","VITAMIN","50000UNT","4","Select","Select",""],["","00245010801","FERROUS","325MG EC","60","Select","Select",""],["","43386035701","HYDROCO\/APAP","7.5-325","90","Select","Select",""],["","29300012510","MELOXICAM","15MG","30","Select","Select",""],["","42858011830","LIDOCAINE","5%","30","Select","Select",""],["","45802000403","HYDROCORT","2.50%","28","Select","Select",""],["","45802091987","CETIRIZINE","10MG","30","Select","Select",""],["","59779045870","CVS","10MG","30","Select","Select",""],["","80777027399","MODERNA","COVID-19","0","Select","Select",""],["","67877025130","TRIAMCINOLON","0.10%","30","Select","Select",""],["","58765000540","","","90","Select","Select",""],["","67877025130","TRIAMCINOLON ","CRE 0.001","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":""}]}]}