{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"ELBA   I PAGAN","gend":1,"add":"153 ALAN DR APT 5","city":"NEWPORT NEWS","state":"VA","zip":23606,"dob":"1950-08-04","age":"","mstatus":"","insh":"20033021*01","cliId":"","pno":"757\/592-9477","cno":"757\/592-9477","email":"","ename":"","eno":"","pphy":"HUSEN, SRIE D MD","ppno":"757\/594-1850","pcpadd":"STE 100 11803 JEFFERSON AVE","pcpcity":"NEWPORT NEWS","pcpstate":"VA","pcpzip":23606,"pcpcounty":"","pcpid":119880,"pcpname":"SMG - Sentara Family Medicine Physicians - Port Warwick","plan":"OHP","program":"MEDICAID","lob":"OHCC","region":"TIDEWATER","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/594-1841","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z00.00","E11.9","Z23.","E78.2","I10.","M25.551","M54.31","Z12.39","Z13.220","Z12.12","M25.511","G89.29","M25.561","R42.","Z86.69","W19.XXXA","R26.81","N39.0","B96.89","E11.22","NO DATA"],"date":["2020-10-27","2021-08-25","2020-10-27","2021-08-25","2021-08-25","2020-10-27","2021-08-25","2020-10-27","2020-10-27","2020-10-27","2021-08-25","2021-08-25","2021-08-25","2020-01-29","2020-01-29","2020-01-29","2020-01-29","2020-01-29","2020-01-29","2021-08-25","2021-08-25"],"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":[["","67877021901","CEPHALEXIN ","500MG","10","Select","Select",""],["","65162044110","MECLIZINE ","12.5MG","20","Select","Select",""],["","00904688365","ACETAMINOPHE ","650MG ER","90","Select","Select",""],["","00093720198","PRAVASTATIN ","20MG","30","Select","Select",""],["","67877056105","METFORMIN ","500MG","60","Select","Select",""],["","45802008801","ALBUTEROL ","HFA","8","Select","Select",""],["","43547035310","LISINOPRIL ","10MG","90","Select","Select",""],["","65162083366","DICLOFENAC ","1%","100","Select","Select",""],["","00173068220","VENTOLIN ","","18","Select","Select",""],["","59310057922","PROAIR ","","8","Select","Select",""],["","67877021901","CEPHALEXIN","500MG","10","Select","Select",""],["","65162044110","MECLIZINE","12.5MG","20","Select","Select",""],["","67877056105","METFORMIN","500MG","60","Select","Select",""],["","45802008801","ALBUTEROL","HFA","8","Select","Select",""],["","00093720198","PRAVASTATIN","20MG","30","Select","Select",""],["","00904688365","ACETAMINOPHE","650MG ER","90","Select","Select",""],["","65162083366","DICLOFENAC","1%","100","Select","Select",""],["","59310057922","PROAIR","","8","Select","Select",""],["","00173068220","VENTOLIN","","18","Select","Select",""],["","43547035310","LISINOPRIL","10MG","90","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":""}]}]}