{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"WYATT   L LAFEVERS","gend":0,"add":"PO BOX 142","city":"COURTLAND","state":"VA","zip":"23837-9998","dob":"2003-10-20","age":"","mstatus":"","insh":"8968705*01","cliId":"","pno":"757\/556-5031","cno":"757\/556-5031","email":"","ename":"","eno":"","pphy":"COLEMAN, GEORGE C MD","ppno":"804\/834-8871","pcpadd":"344 WEST MAIN ST","pcpcity":"WAVERLY","pcpstate":"VA","pcpzip":23890,"pcpcounty":"","pcpid":671580,"pcpname":"","plan":"OHP","program":"MEDICAID","lob":"M4","region":"CENTRAL","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"","pcpfaxno":"804\/834-8875","pcpnpi":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["E03.9","F33.2","I10.","E66.9","E11.9","Z79.4","Z68.51","F41.9","E78.2","F32.9","Z68.54","E10.9","H52.7"],"date":["2020-09-11","2020-09-11","2020-09-11","2020-09-11","2020-10-14","2020-10-14","2020-09-11","2020-10-14","2020-10-14","2020-10-14","2020-10-14","2020-09-21","2020-09-21"],"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":[["","51224000760","METFORMIN ","500MG ER","90","Select","Select",""],["","00088221905","LANTUS ","100\/ML","6","Select","Select",""],["","00115165901","PROPRANOLOL ","10MG","90","Select","Select",""],["","69238183107","LEVOTHYROXIN ","50MCG","30","Select","Select",""],["","00378623201","CITALOPRAM ","20MG","45","Select","Select",""],["","57237004705","DIVALPROEX ","250MG DR","60","Select","Select",""],["","68180098103","LISINOPRIL ","20MG","30","Select","Select",""],["","55111032201","GLIMEPIRIDE ","4MG","60","Select","Select",""],["","55111012205","ATORVASTATIN ","20MG","30","Select","Select",""],["","60505014202","GLIPIZIDE ","10MG","30","Select","Select",""],["","16714089803","LORATADINE ","10MG","90","Select","Select",""],["","49035026045","","","90","Select","Select",""],["","59267100001","PFIZER ","COVID-19","0","Select","Select",""],["","00115165901","PROPRANOLOL","10MG","90","Select","Select",""],["","69238183107","LEVOTHYROXIN","50MCG","30","Select","Select",""],["","51224000760","METFORMIN","500MG ER","90","Select","Select",""],["","00378623201","CITALOPRAM","20MG","45","Select","Select",""],["","68180098103","LISINOPRIL","20MG","30","Select","Select",""],["","57237004705","DIVALPROEX","250MG DR","60","Select","Select",""],["","00088221905","LANTUS","100\/ML","6","Select","Select",""],["","55111012205","ATORVASTATIN","20MG","30","Select","Select",""],["","55111032201","GLIMEPIRIDE","4MG","60","Select","Select",""],["","60505014202","GLIPIZIDE","10MG","30","Select","Select",""],["","45802065087","LORATADINE","10MG","90","Select","Select",""],["","59267100001","PFIZER","COVID-19","0","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":""}]}]}