{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"SHERRY BOMAR","gend":1,"add":"1045 MACDONALD RD","city":"SCOTTSBURG","state":"VA","zip":"24589-9998","dob":"1983-09-14","age":"","mstatus":"","insh":"20048730*01","cliId":"","pno":"434\/446-9439","cno":"434\/446-9439","email":"","ename":"","eno":"","pphy":"PARIKH, NIPUN O MD","ppno":"434\/572-9355","pcpadd":"1627 SEYMOUR DRIVE","pcpcity":"SOUTH BOSTON","pcpstate":"VA","pcpzip":"24592-9998","pcpcounty":"","pcpid":139530,"pcpname":"","plan":"OHP","program":"MEDICAID","lob":"OHCC","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["B18.2","F17.200","F41.1","Z20.828","F22.","R44.3","F31.60","F25.0","F12.10","F14.10","F11.10","F15.10","F13.20","J45.20","F17.210","F11.20","F31.12","F14.920","F41.9","F32.3","J45.909","F31.74","F19.20","F31.9","F14.20","E03.9","F32.0","Z79.899","F31.64","R31.9","R00.0","D72.829","Z91.14","F29.","F11.90","I49.9"],"date":["2020-01-02","2020-08-17","2020-10-29","2020-05-20","2020-08-14","2020-08-14","2020-08-14","2020-08-25","2020-08-25","2020-08-25","2020-08-25","2020-08-25","2020-08-25","2020-08-25","2020-08-25","2021-06-28","2020-02-03","2020-10-13","2021-03-17","2020-08-17","2020-08-17","2020-10-13","2020-10-13","2020-01-03","2020-01-03","2020-09-16","2020-07-24","2020-01-03","2021-11-24","2021-11-15","2021-11-15","2021-11-15","2021-11-15","2021-11-15","2021-11-15","2021-11-16"],"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":[["","33342007007","OLANZAPINE ","10MG","60","Select","Select",""],["","65162075710","DIVALPROEX ","500MG ER","60","Select","Select",""],["","68382011514","RISPERIDONE ","2MG","30","Select","Select",""],["","43547040710","CLONAZEPAM ","1MG","60","Select","Select",""],["","50111043301","TRAZODONE ","50MG","30","Select","Select",""],["","50111064801","FLUOXETINE ","20MG","30","Select","Select",""],["","47781035703","BUPREN\/NALOX ","8-2MG","60","Select","Select",""],["","00536110788","NICOTINE ","14MG\/24H","14","Select","Select",""],["","16729020201","BUSPIRONE ","10MG","60","Select","Select",""],["","12496120803","SUBOXONE ","8-2MG","60","Select","Select",""],["","64125090510","LORAZEPAM ","1MG","60","Select","Select",""],["","51862094205","DIAZEPAM ","5MG","60","Select","Select",""],["","00093738001","VENLAFAXINE ","37.5MG","60","Select","Select",""],["","33342007007","OLANZAPINE","10MG","60","Select","Select",""],["","49884072501","BUSPIRONE","7.5MG","60","Select","Select",""],["","00093738001","VENLAFAXINE","37.5MG","60","Select","Select",""],["","43547040710","CLONAZEPAM","1MG","60","Select","Select",""],["","65162075710","DIVALPROEX","500MG ER","60","Select","Select",""],["","68382011514","RISPERIDONE","2MG","30","Select","Select",""],["","50111043301","TRAZODONE","50MG","30","Select","Select",""],["","12496120803","SUBOXONE","8-2MG","60","Select","Select",""],["","50111064801","FLUOXETINE","20MG","30","Select","Select",""],["","00536110788","NICOTINE","14MG\/24H","14","Select","Select",""],["","64125090510","LORAZEPAM","1MG","60","Select","Select",""],["","51862094205","DIAZEPAM","5MG","60","Select","Select",""],["","00406802003","BUPREN\/NALOX","8-2MG","60","Select","Select",""],["","47335076583","PALIPERIDONE ","TAB ER 3MG","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","",""],["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":""}]}]}