{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Josefina Gutierrez Licano","gend":1,"add":"418 Anderson Ave","city":"Dalton","state":"GA","zip":30721,"dob":"1951-09-25","age":"","mstatus":"","insh":3975271001,"cliId":"","pno":7066184174,"cno":"","email":"mamichefy51@gmail.com","ename":"","eno":"","pphy":"PABLO PEREZ","ppno":"","pcpadd":"1102 W Waugh St","pcpcity":"Dalton","pcpstate":"GA","pcpzip":"","pcpcounty":"Dalton","pcpid":"","pcpname":"","plan":"ALLIANT","program":"ACA","lob":"","region":"","aligned":"","ano":"","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":["I10","E78.5","F32.9","Z87.891","M54.50","M48.062","M43.17","M54.16","Z23","I20.0","R07.89","E78.49","H40.061","M47.816","M43.16","F32.1","G45.8","H40.10X","H16.223","H25.11","R07.9","R07.2","Z00.00","K21.9","H26.492","E66.9","R07.1","F41.1"],"date":["2021-11-23","2020-09-01","2020-02-11","2020-02-11","2021-12-28","2021-12-28","2021-11-23","2021-11-23","2021-11-23","2020-03-03","2020-03-03","2020-03-03","2020-03-03","2021-11-23","2021-11-23","2021-11-18","2021-11-18","2021-12-07","2021-12-07","2021-12-07","2020-09-01","2020-03-03","2020-02-25","2020-08-04","2021-11-09","2021-12-21","2020-02-18","2020-08-04"],"priorHcc":["","","","","","","","","","","","","","","","","","","","","","","","","","","",""]}}]},{"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":[]},{"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":[]}]},{"t":"Allergies \/ Medications","q":[{"a":[]},{"a":{"comment":"","sub":[["","57664047752","METOPROLOL","TARTRATE50MGTAB","60","Select","Select",""],["","69315013110","HYDROCHLOROTHIAZIDE","25MGTAB","30","Select","Select",""],["","16714087601","ATORVASTATIN","40MGTABLET","30","Select","Select",""],["","62175026137","NIFEDIPINE","ER60MGTABLET","30","Select","Select",""],["","65862056090","PANTOPRAZOLE","SODDR40MGTAB","30","Select","Select",""],["","47335089481","CLOPIDOGREL","75MGTABLET","30","Select","Select",""],["","23916360","RESTASIS","0.0005EYEEMULSION","60","Select","Select",""],["","591354060","BUPROPION","HCLSR100MGTABLET","30","Select","Select",""],["","16714061306","SERTRALINE","HCL100MGTABLET","30","Select","Select",""],["","781601485","BRINZOLAMIDE","0.01EYEDROPS","15","Select","Select",""],["","536114941","ASPIRIN","EC81MGTABLET","30","Select","Select",""],["","781502207","METHYLPREDNISOLONE","4MGDOSEPK","21","Select","Select",""],["","60505025203","TIZANIDINE","HCL4MGTABLET","45","Select","Select",""],["","16729013600","CLONAZEPAM","0.5MGTABLET","30","Select","Select",""],["","16714066201","GABAPENTIN","300MGCAPSULE","60","Select","Select",""],["","143992801","CIPROFLOXACIN","HCL500MGTAB","14","Select","Select",""],["","57237001830","DULOXETINE","HCLDR30MGCAP","60","Select","Select",""],["","50383023310","DORZOLAMIDE-TIMOLOL","EYEDROPS","10","Select","Select",""],["","65862020390","LOSARTAN","POTASSIUM100MGTAB","30","Select","Select",""],["","16714063201","ALENDRONATE","SODIUM35MGTAB","4","Select","Select",""],["","185012201","NITROFURANTOIN","MONO-MCR100MG","10","Select","Select",""]]}},{"a":[]},{"a":[]},{"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":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Pain","q":[{"a":[]}]},{"t":"Vital Signs","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Exam Review","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Screenings Needed","q":[{"a":{"indx":["","1"],"comment":["",""]}},{"a":{"indx":["","1"],"comment":["",""]}},{"a":{"indx":["","1"],"comment":["",""]}},{"a":{"indx":["","1"],"comment":["",""]}},{"a":{"indx":["","1"],"comment":["",""]}},{"a":{"indx":["","1"],"comment":["",""]}},{"a":{"indx":["","1"],"comment":["",""]}},{"a":[]}]},{"t":"Mini-Cog","q":[{"a":[]},{"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":"","a13":""}]}]}