{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"ELICK SCRUGGS","gend":0,"add":"345 MOONLIGHT ROAD","city":"APPOMATTOX","state":"VA","zip":"24522-9998","dob":"1951-04-03","age":"","mstatus":"","insh":"20034684*01","cliId":"","pno":"434\/352-7202","cno":"434\/352-7202","email":"","ename":"","eno":"","pphy":"MANNEPALLI, SUPRIYA MD","ppno":"434\/315-5340","pcpadd":"935 S MAIN STREET","pcpcity":"FARMVILLE","pcpstate":"VA","pcpzip":23901,"pcpcounty":"","pcpid":182209,"pcpname":"","plan":"OHP","program":"MEDICAID","lob":"OHCC","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"434\/315-2859","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["N18.3","K59.00","R97.20","N40.0","H25.12","H25.89","Z00.00","Z71.3","Z71.82","Z78.9","I67.89","H47.293","I69.351","I12.9","I69.392","I69.328","E78.5","I10.","Z68.24","H25.11","Z96.1","Z86.73","E53.8","E55.9","H25.012","H25.011","L02.212","R50.9","R00.0"],"date":["2020-03-04","2020-02-21","2020-02-21","2020-02-21","2020-12-18","2021-04-16","2020-01-04","2020-01-04","2020-01-04","2020-01-04","2021-03-25","2021-03-25","2020-03-04","2020-03-04","2020-03-04","2020-03-04","2021-04-28","2021-04-28","2020-03-13","2021-03-25","2021-03-25","2021-04-28","2021-04-28","2021-04-28","2020-12-18","2021-04-16","2021-08-31","2021-08-31","2021-08-31"],"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":[["","50428015144","CVS ","1000UNIT","30","Select","Select",""],["","50428005345","B-12 ","500MCG","30","Select","Select",""],["","57664050658","METOPROL ","25MG","90","Select","Select",""],["","68180051303","LISINOPRIL ","5MG","30","Select","Select",""],["","70377002911","ATORVASTATIN ","40MG","30","Select","Select",""],["","59779027408","ASPIRIN ","81MG","30","Select","Select",""],["","50428015144","VITAMIN ","1000UNIT","30","Select","Select",""],["","68180072103","AMLODIPINE ","10MG","30","Select","Select",""],["","24208060203","PROLENSA ","0.07%","3","Select","Select",""],["","24208050707","LOTEMAX ","0.38%","5","Select","Select",""],["","68180012202","CEPHALEXIN ","500MG","28","Select","Select",""],["","54569556100","VIGAMOX ","0.50%","3","Select","Select",""],["","65862084003","MOXIFLOXACIN ","HCL 0.5%","3","Select","Select",""],["","65862042005","SMZ\/TMP ","800-160","14","Select","Select",""],["","59676058015","JANSSEN ","COVID-19","0","Select","Select",""],["","50428015144","CVS","1000UNIT","30","Select","Select",""],["","50428005345","B-12","500MCG","30","Select","Select",""],["","57664050658","METOPROL","25MG","90","Select","Select",""],["","68180051303","LISINOPRIL","5MG","30","Select","Select",""],["","70377002911","ATORVASTATIN","40MG","30","Select","Select",""],["","59779027408","ASPIRIN","81MG","30","Select","Select",""],["","68180072103","AMLODIPINE","10MG","30","Select","Select",""],["","50428015144","VITAMIN","1000UNIT","30","Select","Select",""],["","24208060203","PROLENSA","0.07%","3","Select","Select",""],["","54569556100","VIGAMOX","0.50%","3","Select","Select",""],["","65862084003","MOXIFLOXACIN","HCL 0.5%","3","Select","Select",""],["","24208050707","LOTEMAX","0.38%","5","Select","Select",""],["","65862042005","SMZ\/TMP","800-160","14","Select","Select",""],["","68180012202","CEPHALEXIN","500MG","28","Select","Select",""],["","59676058015","JANSSEN","COVID-19","0","Select","Select",""],["","87701040731","GNP ","TAB 500MCG","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":""}]}]}