{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"HALEY LITTON","gend":1,"add":"5808 N OTTAWA RD APT 207","city":"VIRGINIA BEACH","state":"VA","zip":23454,"dob":"2002-09-09","age":"","mstatus":"","insh":"8503001*01","cliId":"","pno":"757\/406-2687","cno":"757\/406-2687","email":"","ename":"","eno":"","pphy":"LY, KRISTEN L MD","ppno":"757\/252-9600","pcpadd":"1800 CAMELOT DR STE 200","pcpcity":"VIRGINIA BEACH","pcpstate":"VA","pcpzip":23454,"pcpcounty":"","pcpid":117350,"pcpname":"SMG - Sentara Pediatric Physicians - Camelot","plan":"OHP","program":"MEDICAID","lob":"M4","region":"TIDEWATER","aligned":"","ano":"757\/463-9822","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"757\/351-2905","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F43.23","J03.90","F33.2","R63.4","F32.9","Z68.51","K11.20","K59.00","G47.9","R10.32","Z00.00","Z71.3","Z71.82","R63.0","R10.2","Z30.9","K59.09","Z20.828","R68.81","F33.1","F41.1"],"date":["2020-10-05","2020-07-01","2020-08-31","2021-07-14","2021-02-17","2021-02-17","2020-12-14","2021-02-17","2021-02-17","2020-09-07","2020-09-09","2020-09-09","2020-09-09","2021-02-23","2020-10-12","2020-10-12","2021-02-23","2021-08-04","2021-07-14","2021-09-20","2021-09-20"],"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":[["","16714040604","LARIN ","Jan-20","28","Select","Select",""],["","16729017001","ESCITALOPRAM ","20MG","30","Select","Select",""],["","00143993905","AMOXICILLIN ","500MG","30","Select","Select",""],["","65862001230","SERTRALINE ","50MG","30","Select","Select",""],["","23155050101","HYDROXYZ ","25MG","30","Select","Select",""],["","68462072029","DROSPIRENONE ","ETHY EST","84","Select","Select",""],["","45802086803","POLYETH ","3350 NF","510","Select","Select",""],["","65862039010","ONDANSETRON ","4MG ODT","10","Select","Select",""],["","65862037401","ESCITALOPRAM","10MG","30","Select","Select",""],["","16714040604","LARIN","Jan-20","28","Select","Select",""],["","00143993905","AMOXICILLIN","500MG","30","Select","Select",""],["","65862001230","SERTRALINE","50MG","30","Select","Select",""],["","68462072029","DROSPIRENONE","ETHY EST","84","Select","Select",""],["","45802086803","POLYETH","3350 NF","510","Select","Select",""],["","65862039010","ONDANSETRON","4MG ODT","10","Select","Select",""],["","00093005301","BUSPIRONE","5MG","60","Select","Select",""],["","23155050101","HYDROXYZ","25MG","30","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":""}]}]}