{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"ADDIE FAIR","gend":1,"add":"103 BRIDGEPORT COVE DR APT 104","city":"HAMPTON","state":"VA","zip":"23663-9998","dob":"1964-05-08","age":"","mstatus":"","insh":"20027115*01","cliId":"","pno":"757\/224-9621","cno":"757\/224-9621","email":"","ename":"","eno":"","pphy":"JOYNER, AERIAN K NP","ppno":"757\/827-2025","pcpadd":"STE 300 4001 COLISEUM DR","pcpcity":"HAMPTON","pcpstate":"VA","pcpzip":23666,"pcpcounty":"","pcpid":700501,"pcpname":"SMG - Sentara Family & Internal Medicine Physicians - CarePlex West","plan":"OHP","program":"MEDICAID","lob":"OHCC","region":"TIDEWATER","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/275-9802","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["J30.89","E11.42","E11.69","E11.59","E89.0","Z79.4","E78.5","I10.","G40.019","R20.2","E11.9","E11.40","Z46.89","H57.10","M25.552","E66.01","M54.40","Z76.0","R10.2","J30.1","J30.81","M54.17","M54.12","G60.3","H25.12","H25.11","NO DATA","H04.121","H04.122","H43.813","Z96.1","H57.12","H53.9","G50.1","B02.9","L23.89","Z79.899","L30.9","Z12.39","Z72.0","J44.9","J30.9","E11.610","L50.0","J18.9","K76.0","Z78.0","M25.50","L21.8","L73.2","R51.9","L21.9","L81.0","L29.9","F41.9","J45.909","G47.33","H20.013","M54.5","F33.1","I25.118","J43.9","K21.9","G47.00","N89.8","H18.233","H04.123","R30.9","E11.3293","H25.13","H57.11","H11.31","V58.89","I15.2","H59.031","H26.493","F17.210","Z23.","G40.909","L20.89","L70.0"],"date":["2020-03-05","2021-09-01","2021-08-02","2021-08-26","2021-06-30","2021-06-30","2021-06-30","2021-03-30","2021-07-28","2021-07-28","2021-09-01","2021-09-01","2021-03-29","2021-03-29","2021-03-29","2021-08-02","2021-03-29","2021-03-29","2021-05-03","2020-03-05","2020-03-05","2020-03-18","2020-03-18","2020-03-18","2021-01-27","2021-02-17","2021-04-23","2021-04-23","2021-04-23","2021-01-14","2021-04-05","2021-03-23","2021-03-23","2021-03-23","2021-06-02","2021-06-02","2021-08-04","2021-06-02","2020-07-20","2021-08-02","2020-12-30","2020-02-17","2020-08-10","2020-01-03","2020-03-10","2020-07-20","2020-07-20","2021-03-23","2020-10-28","2021-08-04","2021-03-23","2020-02-25","2020-02-25","2020-02-25","2021-08-02","2021-01-27","2021-01-27","2021-04-23","2020-08-25","2021-08-02","2021-08-02","2021-08-02","2020-12-30","2020-12-30","2020-12-30","2021-04-05","2021-04-05","2021-04-16","2020-12-17","2020-12-17","2021-02-19","2021-02-19","2021-02-19","2021-08-26","2021-09-03","2021-09-03","2021-08-02","2021-08-02","2021-08-02","2021-08-04","2021-08-04"],"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":[["","00002751001","HUMALOG ","100\/ML","20","Select","Select",""],["","11917004813","INSULIN ","1ML\/31G","30","Select","Select",""],["","16729021816","CLOPIDOGREL ","75MG","30","Select","Select",""],["","23155010405","METFORMIN ","1000MG","180","Select","Select",""],["","62175011843","OMEPRAZOLE ","20MG","30","Select","Select",""],["","11917011819","D3 ","2000UNIT","30","Select","Select",""],["","00074055402","HUMIRA ","40\/0.4ML","4","Select","Select",""],["","59310057922","PROAIR ","","8","Select","Select",""],["","53885024450","ONETOUCH ","ULTRA BL","100","Select","Select",""],["","68382009810","PAROXETINE ","20MG","30","Select","Select",""],["","23155017801","ISOSORB ","60MG ER","30","Select","Select",""],["","31722072690","MONTELUKAST ","10MG","30","Select","Select",""],["","69238183801","LEVOTHYROXIN ","150MCG","30","Select","Select",""],["","68382014114","TOPIRAMATE ","200MG","90","Select","Select",""],["","65862014205","CARVEDILOL ","3.125MG","120","Select","Select",""],["","00169413212","OZEMPIC ","2\/1.5ML","2","Select","Select",""],["","45802046564","KETOCONAZOLE ","2%","120","Select","Select",""],["","00472040225","CLOBETASOL ","0.05%","50","Select","Select",""],["","00187137316","CERAVE ","","453","Select","Select",""],["","00310737220","BUDES\/FORMOT ","80-4.5","10","Select","Select",""],["","08560940001","V-GO ","","30","Select","Select",""],["","76204020025","ALBUTEROL ","0.08%","75","Select","Select",""],["","16729017317","AMITRIPTYLIN ","50MG","30","Select","Select",""],["","00088222033","LANTUS ","100\/ML","10","Select","Select",""],["","00781569031","EZETIMIBE ","10MG","30","Select","Select",""],["","55111012305","ATORVASTATIN ","40MG","30","Select","Select",""],["","45802091939","CETIRIZINE ","10MG","30","Select","Select",""],["","60505082901","FLUTICASONE ","50MCG","16","Select","Select",""],["","51672135108","CICLOPIROX ","1%","120","Select","Select",""],["","62756020201","GABAPENTIN ","600MG","120","Select","Select",""],["","00904582460","VITAMIN ","1000UNIT","60","Select","Select",""],["","00121077504","GG\/CODEINE ","100-10\/5","118","Select","Select",""],["","51672129003","HC ","0.20%","60","Select","Select",""],["","51672135708","FLUOCIN ","0.01% SC","118","Select","Select",""],["","08290320122","BD  PEN NEEDL","32GX4MM","100","Select","Select",""],["","00234057532","HIBICLENS ","4%","946","Select","Select",""],["","69238110005","DOXYCYCL ","100MG","20","Select","Select",""],["","00169406012","VICTOZA ","18MG\/3ML","12","Select","Select",""],["","65162044210","MECLIZINE ","25MG","90","Select","Select",""],["","08627009111","DEXCOM ","RECEIVER","1","Select","Select",""],["","00310653004","BYDUREON ","2MG","4","Select","Select",""],["","62332025050","DOXYCYC ","100MG","60","Select","Select",""],["","68462022517","MOMETASONE ","0.10%","45","Select","Select",""],["","45802065078","LORATADINE ","10MG","30","Select","Select",""],["","59762374401","CLINDAMYCIN ","10MG\/ML","60","Select","Select",""],["","00054001925","PREDNISONE ","50MG","3","Select","Select",""],["","43598043611","NITROGLYCERN ","0.4MG","25","Select","Select",""],["","59267100001","PFIZER ","COVID-19","0","Select","Select",""],["","23155050105","HYDROXYZ ","25MG","60","Select","Select",""],["","61314063705","PREDNISOLONE ","1% OP","10","Select","Select",""],["","60758077305","KETOROLAC ","0.40%","5","Select","Select",""],["","68462060965","PIMECROLIMUS ","1%","60","Select","Select",""],["","00406051205","OXYCOD\/APAP ","5-325MG","12","Select","Select",""],["","43598044874","NICOTINE ","21MG\/24H","28","Select","Select",""],["","00186037220","SYMBICORT ","80-4.5","10","Select","Select",""],["","70710113908","FLUCONAZOLE ","150MG","1","Select","Select",""],["","00536252525","CAPSAICIN ","0.03%","60","Select","Select",""],["","00378427677","VALACYCLOVIR ","1GM","14","Select","Select",""],["","68180072003","AMLODIPINE ","5MG","30","Select","Select",""],["","00378808245","TRETINOIN ","0.03%","45","Select","Select",""],["","00093101042","MUPIROCIN ","2%","44","Select","Select",""],["","00904530660","BANOPHEN ","25MG","2","Select","Select",""],["","12547017021","BENADRYL ","25MG","2","Select","Select",""],["","68382014114","TOPIRAMATE","200MG","90","Select","Select",""],["","23155010405","METFORMIN","1000MG","60","Select","Select",""],["","16729017317","AMITRIPTYLIN","50MG","30","Select","Select",""],["","69238183801","LEVOTHYROXIN","150MCG","30","Select","Select",""],["","00781569031","EZETIMIBE","10MG","30","Select","Select",""],["","31722072690","MONTELUKAST","10MG","30","Select","Select",""],["","16729021816","CLOPIDOGREL","75MG","30","Select","Select",""],["","23155017801","ISOSORB","60MG ER","30","Select","Select",""],["","00074055402","HUMIRA","40\/0.4ML","4","Select","Select",""],["","68382009810","PAROXETINE","20MG","30","Select","Select",""],["","55111012390","ATORVASTATIN","40MG","30","Select","Select",""],["","08560940002","V-GO","","30","Select","Select",""],["","65862014205","CARVEDILOL","3.125MG","120","Select","Select",""],["","53885000810","ONETOUCH","PLUS 33G","100","Select","Select",""],["","00088222033","LANTUS","100\/ML","10","Select","Select",""],["","62175011843","OMEPRAZOLE","20MG","90","Select","Select",""],["","00002751001","HUMALOG","100\/ML","10","Select","Select",""],["","11917004813","INSULIN","1ML\/31G","30","Select","Select",""],["","00054327099","FLUTICASONE","50MCG","16","Select","Select",""],["","00310737220","BUDES\/FORMOT","80-4.5","10","Select","Select",""],["","51672129303","CLOBETASOL","0.05%","50","Select","Select",""],["","00187137316","CERAVE","","453","Select","Select",""],["","59310057922","PROAIR","","8","Select","Select",""],["","76204020025","ALBUTEROL","0.08%","75","Select","Select",""],["","45802046564","KETOCONAZOLE","2%","120","Select","Select",""],["","00169413212","OZEMPIC","2\/1.5ML","2","Select","Select",""],["","00121077504","GG\/CODEINE","100-10\/5","118","Select","Select",""],["","69238110005","DOXYCYCL","100MG","20","Select","Select",""],["","00169406012","VICTOZA","18MG\/3ML","12","Select","Select",""],["","45802065078","LORATADINE","10MG","30","Select","Select",""],["","51672135708","FLUOCIN","0.01% SC","118","Select","Select",""],["","00168027146","MOMETASONE","0.10%","45","Select","Select",""],["","59762374401","CLINDAMYCIN","10MG\/ML","60","Select","Select",""],["","45802045537","HC","0.20%","60","Select","Select",""],["","45802091939","CETIRIZINE","10MG","30","Select","Select",""],["","08290320122","BD PEN NEEDL","32GX4MM","100","Select","Select",""],["","00234057532","HIBICLENS","4%","946","Select","Select",""],["","51672135108","CICLOPIROX","1%","120","Select","Select",""],["","00904582460","VITAMIN","1000UNIT","60","Select","Select",""],["","62756020201","GABAPENTIN","600MG","120","Select","Select",""],["","65162044210","MECLIZINE","25MG","90","Select","Select",""],["","00310653004","BYDUREON","2MG","4","Select","Select",""],["","43598043611","NITROGLYCERN","0.4MG","25","Select","Select",""],["","00406051205","OXYCOD\/APAP","5-325MG","12","Select","Select",""],["","43598044874","NICOTINE","21MG\/24H","28","Select","Select",""],["","08627009111","DEXCOM","RECEIVER","1","Select","Select",""],["","00186037220","SYMBICORT","80-4.5","10","Select","Select",""],["","62332025050","DOXYCYC","100MG","60","Select","Select",""],["","00054001925","PREDNISONE","50MG","3","Select","Select",""],["","00536252525","CAPSAICIN","0.03%","60","Select","Select",""],["","59267100001","PFIZER","COVID-19","0","Select","Select",""],["","00378427677","VALACYCLOVIR","1GM","14","Select","Select",""],["","00904530660","BANOPHEN","25MG","2","Select","Select",""],["","12547017021","BENADRYL","25MG","2","Select","Select",""],["","60758077305","KETOROLAC","0.40%","5","Select","Select",""],["","61314063705","PREDNISOLONE","1% OP","10","Select","Select",""],["","23155050105","HYDROXYZ","25MG","60","Select","Select",""],["","68462060965","PIMECROLIMUS","1%","60","Select","Select",""],["","68382012216","AMLODIPINE","5MG","30","Select","Select",""],["","00378808245","TRETINOIN","0.03%","45","Select","Select",""],["","11917011819","D3","2000UNIT","30","Select","Select",""],["","70710113908","FLUCONAZOLE","150MG","1","Select","Select",""],["","00093101042","MUPIROCIN","2%","44","Select","Select",""],["","65862039010","ONDANSETRON ","TAB 4MG ODT","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":[[["Yes","Select","","","","","Select","",""],["Yes","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":""}]}]}