{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"JACQUELINE ABUNDIO-GOMEZ","gend":1,"add":"763 JOY CT","city":"CHARLOTTESVILLE","state":"VA","zip":"22902-9998","dob":"2002-10-02","age":"","mstatus":"","insh":"8574340*01","cliId":"","pno":"434\/972-4011","cno":"434\/972-4011","email":"","ename":"","eno":"","pphy":"ARMENGOL, CARLOS MD","ppno":"434\/296-9161","pcpadd":"1011 E JEFFERSON ST","pcpcity":"CHARLOTTESVILLE","pcpstate":"VA","pcpzip":22902,"pcpcounty":"","pcpid":102092,"pcpname":"Pediatric Associates of Charlottesville Downtown","plan":"OHP","program":"MEDICAID","lob":"M4","region":"CHARLOTTESVILLE WESTERN","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"434\/977-6068","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F33.0","F33.1","J30.81","J30.1","J30.89","F33.42","G47.00","Z11.59","J45.20","H10.45","J45.30","Z23.","J45.21"],"date":["2020-03-12","2020-12-14","2021-09-15","2021-09-15","2021-09-15","2020-09-23","2020-09-23","2021-07-20","2020-09-30","2020-09-30","2020-09-30","2021-05-05","2021-08-16"],"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":[["","10370010150","BUPROPN ","150MG XL","30","Select","Select",""],["","51991074690","DULOXETINE ","20MG","60","Select","Select",""],["","45802091987","CETIRIZINE ","10MG","30","Select","Select",""],["","69097014260","ALBUTEROL ","HFA","13","Select","Select",""],["","00093598627","EPINEPHRINE ","0.3MG","2","Select","Select",""],["","00173068220","VENTOLIN ","","18","Select","Select",""],["","00054327099","FLUTICASONE ","50MCG","16","Select","Select",""],["","59779045839","CVS ","10MG","60","Select","Select",""],["","53191022701","MELATONIN ","3MG","30","Select","Select",""],["","59310057922","PROAIR ","","8","Select","Select",""],["","45802091987","CETIRIZINE","10MG","30","Select","Select",""],["","51991074690","DULOXETINE","20MG","60","Select","Select",""],["","10370010150","BUPROPN","150MG XL","30","Select","Select",""],["","69097014260","ALBUTEROL","HFA","13","Select","Select",""],["","53191022701","MELATONIN","3MG","30","Select","Select",""],["","00054327099","FLUTICASONE","50MCG","16","Select","Select",""],["","00115169449","EPINEPHRINE","0.3MG","2","Select","Select",""],["","00173068220","VENTOLIN","","18","Select","Select",""],["","59310057922","PROAIR","","8","Select","Select",""],["","59779045839","CVS","10MG","60","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":""}]}]}