{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"CIDNEY FORNEY","gend":1,"add":"509 SPECTATOR ST","city":"PORTSMOUTH","state":"VA","zip":"23701-9998","dob":"2003-06-27","age":"","mstatus":"","insh":"8831777*01","cliId":"","pno":"757\/535-1589","cno":"757\/535-1589","email":"","ename":"","eno":"","pphy":"RAMOLIA, MANSUKHLAL R MD","ppno":"757\/483-6401","pcpadd":"4035 TAYLOR RD #K","pcpcity":"CHESAPEAKE","pcpstate":"VA","pcpzip":23321,"pcpcounty":"","pcpid":210204,"pcpname":"","plan":"OHP","program":"MEDICAID","lob":"M4","region":"TIDEWATER","aligned":"","ano":"397-4202","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"","pcpnpi":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["U07.1","H21.41","H52.13","H52.223","H90.12"],"date":["2020-12-18","2021-05-10","2021-05-10","2021-05-10","2021-09-14"],"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":[["","66993001968","ALBUTEROL ","HFA","54","Select","Select",""],["","08373982700","OPTICHAMBER ","DIA LG","1","Select","Select",""],["","00173071920","FLOVENT ","110MCG","12","Select","Select",""],["","59310057922","PROAIR ","","26","Select","Select",""],["","66993001968","ALBUTEROL","HFA","54","Select","Select",""],["","59310057922","PROAIR","","26","Select","Select",""],["","00173071920","FLOVENT","110MCG","12","Select","Select",""],["","08373982700","OPTICHAMBER","DIA LG","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":""}]}]}