{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MARIA   F SHELTON","gend":1,"add":"1050 SPORTSMAN DR LOT 15","city":"DRY FORK","state":"VA","zip":"24549-9998","dob":"1972-03-23","age":"","mstatus":"","insh":"20034832*01","cliId":"","pno":"434\/489-4454","cno":"434\/489-4454","email":"","ename":"","eno":"","pphy":"STEPHENS, AMBER L DO","ppno":"434\/799-4488","pcpadd":"SUITE 201 109 BRIDGE STREET","pcpcity":"DANVILLE","pcpstate":"VA","pcpzip":24541,"pcpcounty":"","pcpid":174776,"pcpname":"","plan":"OHP","program":"MEDICAID","lob":"OHCC","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"434\/773-6977","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R05.","J44.9","R10.84","F41.9","Z85.118","M19.90","E78.5","G25.81","T78.40XA","I10.","K21.9","G47.8","R06.89","J44.1","Z72.0","M54.2","V58.69","F17.210","M54.12","R07.89","Z88.0","E11.65","R00.0","R10.11","D72.829","Z79.1","K76.0","K92.0","K29.50","K31.9","K25.9","G47.30","R53.1","R53.83","G62.9","E66.9","R06.09","R07.9","R10.9","R11.0","E11.9","R10.30","K46.9","J06.9"],"date":["2020-10-09","2021-09-24","2020-10-12","2020-10-09","2020-12-28","2021-09-22","2021-07-06","2021-09-22","2021-09-22","2021-06-23","2021-06-03","2021-07-19","2021-07-19","2021-07-19","2021-08-24","2021-08-24","2020-02-09","2020-09-03","2020-02-25","2020-09-03","2020-09-03","2020-10-21","2020-10-12","2021-06-03","2021-02-09","2021-06-03","2021-02-09","2021-06-23","2021-06-23","2021-06-23","2021-06-23","2021-06-30","2020-12-28","2020-12-28","2021-01-25","2021-06-01","2021-05-13","2021-05-13","2021-06-23","2021-06-23","2021-09-22","2021-06-03","2021-08-24","2021-09-22"],"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":[["","16729004617","ATORVASTATIN ","40MG","30","Select","Select",""],["","53746019005","NAPROXEN ","500MG","60","Select","Select",""],["","68180035103","SERTRALINE ","25MG","30","Select","Select",""],["","23155010410","METFORMIN ","1000MG","60","Select","Select",""],["","00186037020","SYMBICORT ","160-4.5","10","Select","Select",""],["","16729016917","ESCITALOPRAM ","10MG","30","Select","Select",""],["","00093506101","HYDROXYZ ","25MG","90","Select","Select",""],["","43547040011","CYCLOBENZAPR ","10MG","90","Select","Select",""],["","59310057922","PROAIR ","","8","Select","Select",""],["","65162062711","TRAMADOL ","50MG","14","Select","Select",""],["","53746010205","GABAPENTIN ","300MG","30","Select","Select",""],["","55111068405","IBU ","800MG","30","Select","Select",""],["","55111015810","OMEPRAZOLE ","20MG","30","Select","Select",""],["","53885027150","ONETOUCH ","VERIO","50","Select","Select",""],["","00093317431","ALBUTEROL ","HFA","8","Select","Select",""],["","00069047103","CHANTIX ","0.5& 1MG","53","Select","Select",""],["","76204060060","IPRATROPIUM\/ ","ALBUTER","180","Select","Select",""],["","69315011610","FUROSEMIDE ","20MG","30","Select","Select",""],["","11917019262","MUCUS ","600MG ER","60","Select","Select",""],["","66993041230","OMEPRA\/BICAR ","20-1100","30","Select","Select",""],["","45802091987","CETIRIZINE ","10MG","30","Select","Select",""],["","00173068220","VENTOLIN ","","18","Select","Select",""],["","00193731150","CONTOUR ","NEXT","100","Select","Select",""],["","00135051101","NICORETTE ","4MG MINT","72","Select","Select",""],["","68180098003","LISINOPRIL ","10MG","30","Select","Select",""],["","61442010201","DICLOFENAC ","50MG DR","14","Select","Select",""],["","00597007541","SPIRIVA ","HANDIHLR","30","Select","Select",""],["","00310737020","BUDES\/FORMOT ","160-4.5","10","Select","Select",""],["","70010075405","METHOCARBAM ","500MG","56","Select","Select",""],["","63824000815","MUCINEX ","600MG ER","20","Select","Select",""],["","00378064210","PREDNISONE ","20MG","15","Select","Select",""],["","00143211205","DOXYCYCL ","100MG","10","Select","Select",""],["","65162006205","SUCRALFATE ","1GM\/10ML","600","Select","Select",""],["","60505082901","FLUTICASONE ","50MCG","16","Select","Select",""],["","55111028130","LEVOFLOXACIN ","750MG","5","Select","Select",""],["","43547026810","ROPINIROLE ","0.25MG","30","Select","Select",""],["","69452017104","AZITHROMYCIN ","250MG","6","Select","Select",""],["","00536589688","NICOTINE ","21MG\/24H","28","Select","Select",""],["","00591079510","DICYCLOMINE ","20MG","90","Select","Select",""],["","59310057922","PROAIR","","8","Select","Select",""],["","43547040011","CYCLOBENZAPR","10MG","90","Select","Select",""],["","16729004617","ATORVASTATIN","40MG","30","Select","Select",""],["","53746019005","NAPROXEN","500MG","60","Select","Select",""],["","68180035103","SERTRALINE","25MG","30","Select","Select",""],["","23155010410","METFORMIN","1000MG","60","Select","Select",""],["","00186037020","SYMBICORT","160-4.5","10","Select","Select",""],["","16729016917","ESCITALOPRAM","10MG","30","Select","Select",""],["","00093506101","HYDROXYZ","25MG","90","Select","Select",""],["","00597007541","SPIRIVA","HANDIHLR","30","Select","Select",""],["","55111015810","OMEPRAZOLE","20MG","30","Select","Select",""],["","55111068405","IBU","800MG","30","Select","Select",""],["","67877022305","GABAPENTIN","300MG","90","Select","Select",""],["","68180098003","LISINOPRIL","10MG","30","Select","Select",""],["","69315011610","FUROSEMIDE","20MG","30","Select","Select",""],["","66993041230","OMEPRA\/BICAR","20-1100","30","Select","Select",""],["","53885065701","ONETOUCH","VERIO","1","Select","Select",""],["","00193731150","CONTOUR","NEXT","100","Select","Select",""],["","70010075405","METHOCARBAM","500MG","56","Select","Select",""],["","00093317431","ALBUTEROL","HFA","8","Select","Select",""],["","11917019262","MUCUS","600MG ER","20","Select","Select",""],["","00069047103","CHANTIX","0.5& 1MG","53","Select","Select",""],["","63824000815","MUCINEX","600MG ER","20","Select","Select",""],["","00310737020","BUDES\/FORMOT","160-4.5","10","Select","Select",""],["","65162006205","SUCRALFATE","1GM\/10ML","600","Select","Select",""],["","76204060060","IPRATROPIUM\/","ALBUTER","180","Select","Select",""],["","55111028130","LEVOFLOXACIN","750MG","5","Select","Select",""],["","00173068220","VENTOLIN","","18","Select","Select",""],["","60505082901","FLUTICASONE","50MCG","16","Select","Select",""],["","45802091987","CETIRIZINE","10MG","30","Select","Select",""],["","00378064110","PREDNISONE","10MG","16","Select","Select",""],["","00135051101","NICORETTE","4MG MINT","72","Select","Select",""],["","69097052444","DICLOFENAC","1%","100","Select","Select",""],["","69452017104","AZITHROMYCIN","250MG","6","Select","Select",""],["","00536589688","NICOTINE","21MG\/24H","28","Select","Select",""],["","00591079510","DICYCLOMINE","20MG","90","Select","Select",""],["","69452014330","BENZONATATE","100MG","90","Select","Select",""],["","43547026850","ROPINIROLE","0.25MG","30","Select","Select",""],["","65162062711","TRAMADOL","50MG","14","Select","Select",""],["","00143211205","DOXYCYCL","100MG","10","Select","Select",""],["","69452014330","BENZONATATE ","CAP 100MG","90","Select","Select",""],["","70436015542","PROMETHAZINE ","SOL DM","120","Select","Select",""],["","63304069205","CLINDAMYCIN ","CAP 150MG","60","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","",""],["No","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":""}]}]}