{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"TOMMY   W WILBORN","gend":0,"add":"1301 CLAIRBORNE ST","city":"DANVILLE","state":"VA","zip":"24540-9998","dob":"1948-12-29","age":"","mstatus":"","insh":"20037354*01","cliId":"","pno":"434\/489-6611","cno":"434\/489-6611","email":"","ename":"","eno":"","pphy":"WATERS, MICHAEL MD","ppno":"434\/797-2828","pcpadd":"125 EXECUTIVE DRIVE","pcpcity":"DANVILLE","pcpstate":"VA","pcpzip":24541,"pcpcounty":"","pcpid":133812,"pcpname":"","plan":"OHP","program":"MEDICAID","lob":"OHCC","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"434\/773-6833","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z51.11","C22.0","C79.9","Z86.718","D69.6","R79.89","Z51.81","Z79.01","I10.","I82.4Y9","T15.92XA","E50.7","T15.91XA","R94.5","C78.7","L03.115","M19.071","Z85.9","M79.671","H25.813"],"date":["2021-09-09","2021-09-09","2020-09-10","2021-09-09","2021-03-11","2020-09-10","2021-09-09","2021-09-09","2021-09-24","2021-03-11","2021-06-03","2021-06-03","2021-06-03","2020-01-30","2021-09-09","2021-09-24","2021-09-24","2021-09-24","2021-09-24","2021-10-25"],"priorHcc":["","","","","","","","","","","","","","","","","","","",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":[["","29300012810","HYDROCHLOROT ","25MG","30","Select","Select",""],["","27241009803","DULOXETINE ","30MG","30","Select","Select",""],["","50419048858","NEXAVAR ","200MG","60","Select","Select",""],["","68180051703","LISINOPRIL ","40MG","30","Select","Select",""],["","50458057930","XARELTO ","20MG","90","Select","Select",""],["","68462016405","CARVEDILOL ","12.5MG","180","Select","Select",""],["","55111015430","ONDANSETRON ","8MG","30","Select","Select",""],["","27241009803","DULOXETINE","30MG","30","Select","Select",""],["","68180051703","LISINOPRIL","40MG","30","Select","Select",""],["","29300012810","HYDROCHLOROT","25MG","30","Select","Select",""],["","55111015430","ONDANSETRON","8MG","30","Select","Select",""],["","50419048858","NEXAVAR","200MG","60","Select","Select",""],["","68462016405","CARVEDILOL","12.5MG","180","Select","Select",""],["","50458057930","XARELTO","20MG","90","Select","Select",""],["","53489012002","DOXYCYCL","100MG","20","Select","Select",""],["","64380080807","IBUPROFEN","600MG","30","Select","Select",""],["","53489012002","DOXYCYCL ","TAB 100MG","20","Select","Select",""],["","64380080807","IBUPROFEN ","TAB 600MG","30","Select","Select",""],["","61314063705","PREDNISOLONE ","SUS 1% OP","5","Select","Select",""],["","61314012605","KETOROLAC ","SOL 0.005","5","Select","Select",""],["","00781713593","MOXIFLOXACIN ","SOL HCL 0.5%","3","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":""}]}]}