{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"BELINDA   G PERROTT","gend":1,"add":"3540 MISSION HOME LN FAITH MISSION HOME","city":"FREE UNION","state":"VA","zip":"22940-9998","dob":"1982-09-17","age":"","mstatus":"","insh":"20033332*01","cliId":"","pno":4349852294,"cno":4349852294,"email":"","ename":"","eno":"","pphy":"GELBURD, GREGORY S DO","ppno":"434\/817-1818","pcpadd":"STE 9 310 AVON STREET","pcpcity":"CHARLOTTESVILLE","pcpstate":"VA","pcpzip":22902,"pcpcounty":"","pcpid":210490,"pcpname":"Privia - Downtown Family Health Care, Inc","plan":"OHP","program":"MEDICAID","lob":"OHCC","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"434\/817-9606","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["G40.409","G40.909","Z00.00","G81.90","F71.","Z11.1","G40.111","G40.119","G40.219"],"date":["2021-04-16","2021-04-16","2020-10-22","2020-10-22","2020-10-22","2020-10-22","2020-02-21","2020-02-21","2020-02-21"],"priorHcc":[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":[["","00131248035","VIMPAT ","TAB 200MG","90","Select","Select",""],["","42571031501","CLOBAZAM ","TAB 10MG","90","Select","Select",""],["","00093321205","CLONAZEPAM ","TAB 1MG","90","Select","Select",""],["","68382014114","TOPIRAMATE ","TAB 200MG","105","Select","Select",""],["","68382080510","TRAZODONE ","TAB 50MG","30","Select","Select",""],["","68180089313","PIRMELLA ","TAB 12785","28","Select","Select",""],["","00555901058","NORTREL ","TAB 12785","28","Select","Select",""],["","00378034505","DIAZEPAM ","TAB 5MG","20","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","",""],["No","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["N\/A","Select","","","","","Select","",""],["No","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":""}]}]}