{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"JAYLAN   I UNDERWOOD","gend":1,"add":"206 AERO CIR APT 312","city":"HAMPTON","state":"VA","zip":"23666-9998","dob":"2000-12-19","age":"","mstatus":"","insh":"6768148*01","cliId":"","pno":"757\/593-9621","cno":"757\/593-9621","email":"","ename":"","eno":"","pphy":"BROOKS, BONNIE J MD","ppno":"757\/594-1803","pcpadd":"SUITE 140 1183 JEFFERSON AVE","pcpcity":"NEWPORT NEWS","pcpstate":"VA","pcpzip":23606,"pcpcounty":"","pcpid":119865,"pcpname":"SMG - Sentara Internal Medicine Physicians - Port Warwick","plan":"OHP","program":"MEDICAID","lob":"M4","region":"TIDEWATER","aligned":"","ano":"757\/945-8241","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/510-9226","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F33.1","F41.1","Z20.2","E55.9","G43.109","B00.9","F90.0","L50.9","L29.9","J30.89","E66.9","L50.0","J30.5","B34.9"],"date":["2020-12-02","2020-08-19","2021-11-08","2020-11-12","2020-11-12","2020-12-02","2020-12-02","2021-07-21","2021-07-21","2021-07-21","2020-12-15","2021-09-17","2021-09-17","2021-11-08"],"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":[["","63402030230","LATUDA ","20MG","30","Select","Select",""],["","65862066130","ARIPIPRAZOLE ","2MG","30","Select","Select",""],["","68382009810","PAROXETINE ","20MG","30","Select","Select",""],["","00591024205","LORAZEPAM ","2MG","60","Select","Select",""],["","00115180401","HYDROXYZ ","50MG","60","Select","Select",""],["","00054327099","FLUTICASONE ","50MCG","16","Select","Select",""],["","00363011246","WAL-PHED ","30MG","30","Select","Select",""],["","53191036201","VITAMIN ","50000UNT","8","Select","Select",""],["","16729013716","CLONAZEPAM ","1MG","15","Select","Select",""],["","00115166101","PROPRANOLOL ","40MG","60","Select","Select",""],["","00228203150","ALPRAZOLAM ","1MG","7","Select","Select",""],["","59417010310","VYVANSE ","30MG","30","Select","Select",""],["","68382050010","OMEPRAZOLE ","40MG","180","Select","Select",""],["","55111029209","SUMATRIPTAN ","50MG","9","Select","Select",""],["","00378718505","METFORMIN ","500MG","60","Select","Select",""],["","65862064230","AZITHROMYCIN ","500MG","2","Select","Select",""],["","00904671152","FEXOFENADINE ","180MG","60","Select","Select",""],["","68382079101","ACYCLOVIR ","400MG","30","Select","Select",""],["","00378808445","TRETINOIN ","0.10%","45","Select","Select",""],["","41167412202","ALLEGRA ","180MG","60","Select","Select",""],["","00187516445","RETIN-A ","0.10%","45","Select","Select",""],["","45802046564","KETOCONAZOLE ","2%","120","Select","Select",""],["","31604002683","D3 ","1000UNIT","30","Select","Select",""],["","45802006405","TRIAMCINOLON ","0.10%","454","Select","Select",""],["","00245904922","ALTINAC ","0.10%","45","Select","Select",""],["","16571040250","CETIRIZINE ","10MG","30","Select","Select",""],["","31722072690","MONTELUKAST ","10MG","90","Select","Select",""],["","65862066130","ARIPIPRAZOLE","2MG","30","Select","Select",""],["","68382009810","PAROXETINE","20MG","30","Select","Select",""],["","63402030230","LATUDA","20MG","30","Select","Select",""],["","00591024205","LORAZEPAM","2MG","60","Select","Select",""],["","00115180401","HYDROXYZ","50MG","60","Select","Select",""],["","00054327099","FLUTICASONE","50MCG","16","Select","Select",""],["","00363011246","WAL-PHED","30MG","30","Select","Select",""],["","16729013716","CLONAZEPAM","1MG","15","Select","Select",""],["","00228203150","ALPRAZOLAM","1MG","7","Select","Select",""],["","68382050010","OMEPRAZOLE","40MG","180","Select","Select",""],["","00115166101","PROPRANOLOL","40MG","60","Select","Select",""],["","75834002012","VITAMIN","50000UNT","12","Select","Select",""],["","00378718505","METFORMIN","500MG","60","Select","Select",""],["","62756052169","SUMATRIPTAN","50MG","9","Select","Select",""],["","59417010310","VYVANSE","30MG","30","Select","Select",""],["","68382079101","ACYCLOVIR","400MG","30","Select","Select",""],["","00904671152","FEXOFENADINE","180MG","60","Select","Select",""],["","51224012230","AZITHROMYCIN","500MG","2","Select","Select",""],["","41167412202","ALLEGRA","180MG","60","Select","Select",""],["","00378808445","TRETINOIN","0.10%","45","Select","Select",""],["","00187516445","RETIN-A","0.10%","45","Select","Select",""],["","45802006405","TRIAMCINOLON","0.10%","454","Select","Select",""],["","00245904922","ALTINAC","0.10%","45","Select","Select",""],["","45802046564","KETOCONAZOLE","2%","120","Select","Select",""],["","31604002683","D3","1000UNIT","30","Select","Select",""],["","31722072690","MONTELUKAST","10MG","30","Select","Select",""],["","16571040250","CETIRIZINE","10MG","30","Select","Select",""],["","57237000511","FLUCONAZOLE","150MG","1","Select","Select",""],["","65862001501","AMOXICILLIN","875MG","20","Select","Select",""],["","65862001501","AMOXICILLIN ","TAB 875MG","20","Select","Select",""],["","57237000511","FLUCONAZOLE ","TAB 150MG","1","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","",""],["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":""}]}]}