{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"JA'LECE RAINEY","gend":1,"add":"1314 MACDONALD RD APT B","city":"CHESAPEAKE","state":"VA","zip":"23325-9998","dob":"2002-12-07","age":"","mstatus":"","insh":"8437041*01","cliId":"","pno":"757\/971-3006","cno":"757\/971-3006","email":"","ename":"","eno":"","pphy":"BURROWS, ADAYNA MD","ppno":"757\/962-8605","pcpadd":"1682 CHURCH STREET","pcpcity":"NORFOLK","pcpstate":"VA","pcpzip":23504,"pcpcounty":"","pcpid":350008,"pcpname":"","plan":"OHP","program":"MEDICAID","lob":"M4","region":"TIDEWATER","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/962-8915","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F33.1","V58.89","E66.9","Z68.51","K21.9","J30.2","F32.9","T50.902A","V62.84","F33.9","G93.2","G43.019","E66.01","G47.00","J02.9","H47.10","G44.52","R94.02","J06.9","Z91.018","J30.1","R09.82","R09.89","F33.2","J02.0","L20.9","H47.11","H40.013","H40.053","Z74.3","Z11.1"],"date":["2020-08-27","2020-07-24","2020-07-24","2020-07-24","2020-07-24","2020-07-24","2020-07-24","2020-07-24","2020-07-24","2020-07-25","2021-02-02","2021-02-02","2021-02-02","2021-02-02","2020-03-19","2020-09-10","2020-08-26","2020-08-26","2020-01-09","2020-03-08","2020-03-19","2020-03-19","2020-03-19","2020-07-27","2021-09-10","2020-10-26","2021-08-30","2020-05-20","2020-05-20","2020-07-24","2021-08-08"],"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":[["","00168008031","HYDROCORT ","2.50%","30","Select","Select",""],["","57237002801","AMOXICILLIN ","500MG","30","Select","Select",""],["","45802065087","LORATADINE ","10MG","90","Select","Select",""],["","45802010901","TRIAMCINOLON ","55MCG\/AC","17","Select","Select",""],["","23155012001","ACETAZOLAMID ","500MG ER","60","Select","Select",""],["","59267100002","PFIZER ","COVID-19","0","Select","Select",""],["","45802010901","TRIAMCINOLON","55MCG\/AC","17","Select","Select",""],["","45802065087","LORATADINE","10MG","90","Select","Select",""],["","51672300302","HYDROCORT","2.50%","28","Select","Select",""],["","23155012001","ACETAZOLAMID","500MG ER","60","Select","Select",""],["","59267100002","PFIZER","COVID-19","0","Select","Select",""],["","65862001501","AMOXICILLIN","875MG","20","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":""}]}]}