{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"BETSY L HAWKINS","gend":1,"currentgend":"","add":"1137 SW Garfield Ave","city":"Topeka","state":"KS","zip":"66604","dob":"1956-06-19","age":"","mstatus":"","insh":"K44012629","cliId":"","pno":"7854809877","cno":"","email":"","ename":"","eno":"","pphy":"JANNA WALPOLE","ppno":"7852325005","pcpadd":"2110 SW BELLE AVE","pcpcity":"TOPEKA","pcpstate":"KS","pcpzip":"66606-1963","pcpcounty":"","pcpid":"","pcpname":"HERITAGE MENTAL HEALTH CLINIC LLC","plan":"BCBSKS","program":"Medicare","lob":"001","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"","madd2":"","madd3":"","mcity":"","mstate":"","mzip":"         ","pcpfaxno":"7852725967","pcpnpi":"1023414570","currentgendcomment":"","pphycomment":"","uniqueid":"M3AK44012629","medicareid":"6P52JT7CK01","medicaidid":"","pcpFlag":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":{"indx":["1",""],"comment":["",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F4312","F4481","M79674","M79675","L988","M79672","M79671","M5450","M47896","R2689","M797","M25561","M25562","Z961","H3561","J0100","E559","R933","K219","M533","D649","K5289","K649","K621","G894","R2242","M7742","I10","F32A","Z9109","Z882","Z880","Z91040","Z885","Z881","Z888"],"date":["2026-05-12","2026-04-21","2026-01-28","2026-01-28","2026-01-28","2026-05-19","2026-01-28","2026-01-26","2026-01-26","2026-01-26","2026-04-20","2026-01-26","2026-01-26","2026-02-20","2026-02-20","2026-03-05","2026-03-05","2026-01-14","2026-03-25","2026-03-04","2026-03-25","2026-03-25","2026-03-25","2026-03-25","2026-04-20","2026-04-20","2026-05-19","2026-03-25","2026-03-25","2026-03-25","2026-03-25","2026-03-25","2026-03-25","2026-03-25","2026-03-25","2026-03-25"],"priorHcc":["","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","","",""]}},{"a":[]}]},{"t":"COVID Screening","q":[{"a":[]},{"a":[]},{"a":[]}]},{"t":"Self-Assessment and Social History (SDOH)","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":[]}]},{"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":[]}]},{"t":"Allergies \/ Medications","q":[{"a":[]},{"a":{"comment":"","sub":[["","","DONEPEZIL HCL","10 MG","","Select","Select",""],["","","GABAPENTIN","100 MG","","Select","Select",""],["","","OMEPRAZOLE","40 MG","","Select","Select",""],["","","ALBUTEROL SULFATE HFA","","","Select","Select",""],["","","OXYCODONE\/ACETAMINOPHEN","325 MG","","Select","Select",""],["","","ATORVASTATIN CALCIUM","20 MG","","Select","Select",""],["","","CLONAZEPAM","0.5 MG","","Select","Select",""],["","","CEFUROXIME AXETIL","500 MG","","Select","Select",""],["","","FLUOXETINE HYDROCHLORIDE","40 MG","","Select","Select",""],["","","CYCLOBENZAPRINE HYDROCHLORIDE","10 MG","","Select","Select",""],["","","TRAZODONE HYDROCHLORIDE","50 MG","","Select","Select",""],["","","ONDANSETRON ODT","4 MG","","Select","Select",""],["","","ZOLPIDEM TARTRATE","10 MG","","Select","Select",""],["","","TROSPIUM CHLORIDE","20 MG","","Select","Select",""],["","","MELOXICAM","15 MG","","Select","Select",""]]}},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Assessment of 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":[]}]},{"t":"Pain","q":[{"a":[]}]},{"t":"Vital Signs","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Exam Review","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Screenings Needed","q":[{"a":{"indx":["",""],"comment":["",""],"sub":[]}},{"a":{"indx":["",""],"comment":["",""],"sub":[]}},{"a":{"indx":["",""],"comment":["",""],"sub":[]}},{"a":{"indx":["",""],"comment":["",""],"sub":[]}},{"a":{"indx":["",""],"comment":["",""],"sub":[]}},{"a":{"indx":["",""],"comment":["",""],"sub":[]}},{"a":{"indx":["",""],"comment":["",""],"sub":[]}},{"a":{"indx":["","1"],"comment":["",""],"sub":[]}},{"a":[]}]},{"t":"Mini-Cog","q":[{"a":[]},{"a":[]},{"a":[]}]},{"t":"Home Safety & Personal Goals","q":[{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"a":[]},{"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":""}]}]}