{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"DONNA GAINER","gend":1,"add":"200 RIGGLEMAN DR APT C","city":"TIMBERVILLE","state":"VA","zip":"22853-9998","dob":"1963-12-11","age":"","mstatus":"","insh":"20027629*01","cliId":"","pno":"540\/282-2358","cno":"540\/282-2358","email":"","ename":"","eno":"","pphy":"LOUCKS, AMANDA M MD","ppno":"540\/433-9151","pcpadd":"1831 RESERVOIR STREET","pcpcity":"HARRISONBURG","pcpstate":"VA","pcpzip":22801,"pcpcounty":"","pcpid":113977,"pcpname":"Harrisonburg Family Practice Associates","plan":"OHP","program":"MEDICAID","lob":"OHCC","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"540\/208-8983","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"540\/433-0547","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R25.2","Z96.641","M16.11","Z96.642","M70.62","M70.61","E03.9","G47.33","E78.5","Z86.73","I10.","R41.3","R42.","J43.9","I42.1","N39.490","Z90.710","R39.81","R94.31","M54.5","R79.89","Z91.09","K21.9","E55.9","G47.30","F31.9","Z51.81","J44.1","Z87.891","M87.051","R55.","F01.50","G47.00","F32.9","F41.9","I49.1","F03.90","R52.","S79.912A","S89.92XA","I44.7","I25.10","I25.2","F31.0","Z79.82","Z95.1","Z91.81","F31.32","F51.01","F43.10","F41.0","Z65.9","Z63.9","F39.","R07.9","F51.13","F06.30","Z63.4","M79.604","I67.82","R27.0","I65.23","R41.89","R25.1","Z96.643","W19.XXXD","R29.6","M79.661","H92.09","H61.23","M25.551","M54.2","M79.641","Z79.899","Z09.","N28.9","I15.9","R07.89","I51.7","R06.02","R19.7","R19.00","Z80.0","R09.02","J44.9","F31.89","Z88.6","Z88.1","Z88.0","Z88.8","Z86.79","Z20.822","Z23.","NO DATA","Z71.89","D51.0"],"date":["2021-09-21","2021-01-26","2021-01-26","2021-10-25","2021-10-25","2021-01-26","2021-08-02","2021-10-25","2021-09-21","2021-09-21","2021-09-21","2021-08-27","2021-06-21","2021-06-21","2021-03-08","2021-09-10","2021-09-10","2021-09-10","2021-03-22","2021-07-09","2020-05-18","2020-10-15","2021-08-02","2021-09-21","2021-08-27","2020-10-02","2020-08-25","2020-01-13","2021-03-05","2021-10-25","2021-03-05","2021-03-19","2021-08-17","2021-03-19","2021-03-19","2021-05-10","2021-08-17","2020-04-17","2020-04-17","2020-04-17","2021-07-13","2021-08-19","2020-10-09","2020-10-09","2021-08-02","2020-10-09","2020-10-09","2021-08-27","2021-08-27","2021-08-27","2021-08-27","2021-08-27","2021-08-27","2021-08-27","2021-07-22","2020-09-01","2020-09-01","2021-06-28","2020-10-01","2020-10-01","2020-10-01","2020-10-01","2020-10-08","2020-10-08","2021-07-22","2020-10-02","2020-10-02","2020-10-02","2021-05-13","2021-05-13","2020-04-17","2020-04-17","2020-09-07","2021-08-02","2021-07-22","2021-07-22","2020-04-17","2021-07-13","2020-10-20","2021-07-14","2021-07-20","2021-07-20","2021-07-20","2021-07-13","2021-08-02","2021-08-02","2021-08-02","2021-08-02","2021-08-02","2021-08-02","2021-07-13","2021-07-13","2021-09-21","2021-09-21","2021-09-21","2021-11-16"],"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":[["","67877024210","QUETIAPINE ","25MG","30","Select","Select",""],["","69238183901","LEVOTHYROXIN ","175MCG","28","Select","Select",""],["","00085461001","DULERA ","200-5MCG","39","Select","Select",""],["","64764017530","DEXILANT ","60MG DR","18","Select","Select",""],["","29300011101","LAMOTRIGINE ","25MG","9","Select","Select",""],["","31722088530","ROSUVASTATIN ","40MG","22","Select","Select",""],["","68382080601","TRAZODONE ","100MG","30","Select","Select",""],["","43547027603","DONEPEZIL ","10MG","30","Select","Select",""],["","29300014005","DIVALPROEX ","500MG DR","60","Select","Select",""],["","52817036100","METOPROL ","50MG","60","Select","Select",""],["","00143314250","DOXYCYCL ","100MG","20","Select","Select",""],["","00597007541","SPIRIVA ","HANDIHLR","30","Select","Select",""],["","59310057922","PROAIR ","","8","Select","Select",""],["","16729016801","ESCITALOPRAM ","5MG","4","Select","Select",""],["","64380073706","VITAMIN ","50000UNT","4","Select","Select",""],["","00378875006","DICLOFENAC ","1%","100","Select","Select",""],["","68180032301","ESZOPICLONE ","2MG","30","Select","Select",""],["","69315090505","LORAZEPAM ","1MG","10","Select","Select",""],["","16729004517","ATORVASTATIN ","20MG","30","Select","Select",""],["","16729011917","MONTELUKAST ","10MG","30","Select","Select",""],["","00904671760","CETIRIZINE ","10MG","30","Select","Select",""],["","60432026415","FLUTICASONE ","50MCG","16","Select","Select",""],["","70954006110","PREDNISONE ","50MG","5","Select","Select",""],["","50111078751","AZITHROMYCIN ","250MG","6","Select","Select",""],["","65162044210","MECLIZINE ","25MG","20","Select","Select",""],["","66993001968","ALBUTEROL ","HFA","18","Select","Select",""],["","57896020110","PAIN ","500MG","150","Select","Select",""],["","31722058160","DULOXETINE ","20MG","39","Select","Select",""],["","16729000916","PRAVASTATIN ","20MG","30","Select","Select",""],["","50228018005","GABAPENTIN ","300MG","90","Select","Select",""],["","24208063110","NEO\/POLY\/HC ","1% OTIC","10","Select","Select",""],["","68645051554","AMLODIPINE ","5MG","30","Select","Select",""],["","00173068220","VENTOLIN ","","18","Select","Select",""],["","16729014701","QUETIAPINE","100MG","30","Select","Select",""],["","68382080601","TRAZODONE","100MG","30","Select","Select",""],["","29300011405","LAMOTRIGINE","200MG","30","Select","Select",""],["","43547027603","DONEPEZIL","10MG","30","Select","Select",""],["","64764017530","DEXILANT","60MG DR","30","Select","Select",""],["","29300014005","DIVALPROEX","500MG DR","60","Select","Select",""],["","69238183901","LEVOTHYROXIN","175MCG","30","Select","Select",""],["","31722088530","ROSUVASTATIN","40MG","30","Select","Select",""],["","52817036100","METOPROL","50MG","60","Select","Select",""],["","00085461001","DULERA","200-5MCG","39","Select","Select",""],["","59746017509","PREDNISONE","20MG","12","Select","Select",""],["","59310057922","PROAIR","","8","Select","Select",""],["","00143314250","DOXYCYCL","100MG","20","Select","Select",""],["","00597007541","SPIRIVA","HANDIHLR","30","Select","Select",""],["","69315090505","LORAZEPAM","1MG","10","Select","Select",""],["","68180032301","ESZOPICLONE","2MG","30","Select","Select",""],["","00378875006","DICLOFENAC","1%","100","Select","Select",""],["","64380073706","VITAMIN","50000UNT","4","Select","Select",""],["","00904671760","CETIRIZINE","10MG","13","Select","Select",""],["","60432026415","FLUTICASONE","50MCG","16","Select","Select",""],["","16729016801","ESCITALOPRAM","5MG","4","Select","Select",""],["","66993001968","ALBUTEROL","HFA","18","Select","Select",""],["","29300022010","MONTELUKAST","10MG","30","Select","Select",""],["","16729004517","ATORVASTATIN","20MG","30","Select","Select",""],["","65162044210","MECLIZINE","25MG","20","Select","Select",""],["","57896020110","PAIN","500MG","150","Select","Select",""],["","16729000916","PRAVASTATIN","20MG","30","Select","Select",""],["","31722058160","DULOXETINE","20MG","39","Select","Select",""],["","50111078751","AZITHROMYCIN","250MG","6","Select","Select",""],["","50228018005","GABAPENTIN","300MG","90","Select","Select",""],["","24208063110","NEO\/POLY\/HC","1% OTIC","10","Select","Select",""],["","00173068220","VENTOLIN","","18","Select","Select",""],["","68645051554","AMLODIPINE","5MG","30","Select","Select",""],["","16729043316","EZETIMIBE","10MG","23","Select","Select",""],["","16729043316","EZETIMIBE ","TAB 10MG","23","Select","Select",""],["","65862018730","ONDANSETRON ","TAB 4MG","3","Select","Select",""],["","59267100001","PFIZER ","INJ COVID-19","0","Select","Select",""],["","08290305270","3ML ","MIS 25GX1\"","15","Select","Select",""],["","70069000510","CYANOCOBALAM ","INJ 1000MCG","4","Select","Select",""],["","10572010001","PEG-3350 ","SOL ELECTROL","4000","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":""}]}]}