{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"ANIBAL PACHECO MATIAS","gend":0,"add":"592 HAWKINS ST APT I","city":"HARRISONBURG","state":"VA","zip":"22801-9998","dob":"2001-11-29","age":"","mstatus":"","insh":"8002312*01","cliId":"","pno":"540\/432-7942","cno":"540\/432-7942","email":"","ename":"","eno":"","pphy":"BROOKS, MICHELLE A MD","ppno":"540\/932-0980","pcpadd":"57 BEAM LANE SUITE 202","pcpcity":"FISHERSVILLE","pcpstate":"VA","pcpzip":22939,"pcpcounty":"","pcpid":100698,"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":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["E11.9","I10."],"date":["2020-09-08","2020-09-08"],"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":[["","00088221905","LANTUS ","100\/ML","15","Select","Select",""],["","53885065701","ONETOUCH ","VERIO","1","Select","Select",""],["","00193737701","CONTOUR ","NEXT","1","Select","Select",""],["","00002879959","HUMALOG ","100\/ML","15","Select","Select",""],["","08290320122","BD  PEN NEEDL","32GX4MM","100","Select","Select",""],["","68382075810","METFORMIN ","500MG","120","Select","Select",""],["","56151060101","KETONE ","","100","Select","Select",""],["","63323058282","GLUCAGON ","1MG","1","Select","Select",""],["","00193288021","KETOSTIX ","STRIP","100","Select","Select",""],["","65702072910","ACCU-CHEK ","GUIDE","1","Select","Select",""],["","57599517501","PREC ","FREESTYL","1","Select","Select",""],["","08627001601","DEXCOM ","TRANSMIT","1","Select","Select",""],["","00088221905","LANTUS","100\/ML","15","Select","Select",""],["","53885059501","ONETOUCH","30G","100","Select","Select",""],["","08290320109","BD PEN NEEDL","31GX8MM","100","Select","Select",""],["","00193737701","CONTOUR","NEXT","1","Select","Select",""],["","63323058282","GLUCAGON","1MG","1","Select","Select",""],["","00002879959","HUMALOG","100\/ML","15","Select","Select",""],["","00193288021","KETOSTIX","STRIP","100","Select","Select",""],["","65702072910","ACCU-CHEK","GUIDE","1","Select","Select",""],["","68382075810","METFORMIN","500MG","120","Select","Select",""],["","56151060101","KETONE","","100","Select","Select",""],["","57599517501","PREC","FREESTYL","1","Select","Select",""],["","08627005303","DEXCOM","SENSOR","6","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":[[["Yes","Select","","","","","Select","",""],["Yes","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":""}]}]}