{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"DEITRA   M FORD","gend":1,"add":"1010 CLAY ST APT 10A","city":"LYNCHBURG","state":"VA","zip":"24504-9998","dob":"1992-01-14","age":"","mstatus":"","insh":"6460380*01","cliId":"","pno":"434\/294-2816","cno":"434\/294-2816","email":"","ename":"","eno":"","pphy":"DIONISIO, TERESITA C MD","ppno":"434\/392-9438","pcpadd":"502 BEECH ST","pcpcity":"FARMVILLE","pcpstate":"VA","pcpzip":23901,"pcpcounty":"","pcpid":973160,"pcpname":"","plan":"OHP","program":"MEDICAID","lob":"M4","region":"CHARLOTTESVILLE WESTERN","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":["F41.9","F39.","F43.29","F33.41","M25.512","R55.","Z87.891","R10.2","F17.210","Z11.3","K80.20","Z72.0","R10.11","R10.13","G47.01","R11.2","R63.4","NO DATA","R91.8","L02.818","R52.","M25.519","R53.81","K21.9","F43.10","Z91.89","D64.9","Z11.59","Z11.4","R87.612","Z32.02","F32.9","Z76.89","Z13.220","Z13.228","Z13.0","Z13.29","K58.2","M79.645","N89.8","R10.84","K22.9","M79.605"],"date":["2021-04-01","2020-07-24","2020-07-08","2020-07-08","2021-02-27","2021-02-27","2021-02-27","2020-10-17","2020-10-17","2020-10-17","2021-05-18","2021-05-05","2021-04-29","2021-04-29","2020-06-22","2020-06-22","2020-08-08","2020-08-08","2020-08-08","2020-10-17","2021-02-27","2021-02-27","2021-02-27","2021-04-01","2020-09-17","2020-06-19","2020-06-19","2020-09-02","2020-09-02","2021-01-26","2021-01-26","2020-09-17","2020-09-02","2020-09-02","2020-09-02","2020-09-02","2020-09-02","2021-04-29","2021-02-01","2021-03-23","2021-04-01","2021-04-01","2021-07-28"],"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":[["","65862019401","FLUOXETINE ","40MG","30","Select","Select",""],["","13668001005","CITALOPRAM ","20MG","30","Select","Select",""],["","00093506101","HYDROXYZ ","25MG","28","Select","Select",""],["","00378668910","PANTOPRAZOLE ","40MG","30","Select","Select",""],["","65862018730","ONDANSETRON ","4MG","30","Select","Select",""],["","00591079510","DICYCLOMINE ","20MG","120","Select","Select",""],["","68382080510","TRAZODONE ","50MG","30","Select","Select",""],["","43547028111","ESCITALOPRAM ","10MG","30","Select","Select",""],["","67877032105","IBUPROFEN ","800MG","30","Select","Select",""],["","57237023305","SMZ-TMP ","800-160","20","Select","Select",""],["","55111015810","OMEPRAZOLE ","20MG","90","Select","Select",""],["","27241009990","DULOXETINE ","60MG","30","Select","Select",""],["","00093005805","TRAMADOL ","50MG","20","Select","Select",""],["","31722099601","HYDROCO\/APAP ","5-325MG","10","Select","Select",""],["","65862019399","FLUOXETINE","20MG","30","Select","Select",""],["","68382080510","TRAZODONE","50MG","30","Select","Select",""],["","00378668910","PANTOPRAZOLE","40MG","30","Select","Select",""],["","65862018730","ONDANSETRON","4MG","30","Select","Select",""],["","43547028111","ESCITALOPRAM","10MG","30","Select","Select",""],["","67877032105","IBUPROFEN","800MG","30","Select","Select",""],["","57237023305","SMZ-TMP","800-160","20","Select","Select",""],["","55111015810","OMEPRAZOLE","20MG","90","Select","Select",""],["","00591079510","DICYCLOMINE","20MG","120","Select","Select",""],["","00093005805","TRAMADOL","50MG","20","Select","Select",""],["","27241009990","DULOXETINE","60MG","30","Select","Select",""],["","31722099601","HYDROCO\/APAP","5-325MG","10","Select","Select",""],["","13668001005","CITALOPRAM","20MG","30","Select","Select",""],["","00093506101","HYDROXYZ","25MG","28","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","",""],["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":""}]}]}