{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"MOENESHA   R PAIR","gend":1,"add":"231 S CRATER ROAD PO BOX 1136","city":"PETERSBURG","state":"VA","zip":"23803-9998","dob":"1998-09-30","age":"","mstatus":"","insh":"5265460*01","cliId":"","pno":"434\/368-0307","cno":"434\/368-0307","email":"","ename":"","eno":"","pphy":"MARCELIN, FITZGERALD MD","ppno":"434\/634-7723","pcpadd":"510 NORTH MAIN STREET","pcpcity":"EMPORIA","pcpstate":"VA","pcpzip":23847,"pcpcounty":"","pcpid":163194,"pcpname":"","plan":"OHP","program":"MEDICAID","lob":"M4","region":"CENTRAL","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["K21.9","J30.1","R06.09","R07.0","F41.9","N93.8","L02.415","Z11.3","O69.81X0","D64.9","O99.02","K66.0","Z37.0","Z3A.38","O80.","O36.5910","O34.211","F33.1","R10.84","R11.2","R50.9","R19.7","R52.","R21.","N18.9","Z79.3","F12.90","Z34.93","O82.","Z3A.00"],"date":["2020-03-31","2020-03-31","2020-03-31","2020-02-28","2020-02-28","2020-10-13","2020-10-13","2020-10-13","2020-01-17","2020-01-16","2020-01-16","2020-01-17","2020-01-17","2020-01-17","2020-01-16","2020-01-17","2020-01-17","2021-07-13","2021-05-18","2021-05-18","2021-05-18","2021-05-18","2021-05-18","2021-06-30","2021-06-30","2021-06-30","2021-06-30","2020-01-16","2020-01-17","2020-01-17"],"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":[]},{"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","",""],["N\/A","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":""}]}]}