{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Stephen Facteau","gend":0,"currentgend":"","add":"32 COLLETTES GROVE RD","city":"DERRY","state":"NH","zip":"03038","dob":"1962-10-23","age":"","mstatus":"","insh":61000051200,"cliId":"","pno":"6038051128","cno":"","email":"","ename":"","eno":"","pphy":"Nicole C Poitras","ppno":"6038940063","pcpadd":"5 Industrial Dr, Unit B","pcpcity":"Windham","pcpstate":"NH","pcpzip":"03087","pcpcounty":"","pcpid":"","pcpname":"Elliot Physicians Network","plan":"Wellsense Health Plan","program":"ACA","lob":"Commercial - NH - Wave 1","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"32 COLLETTES GROVE RD","madd2":"","madd3":"","mcity":"DERRY","mstate":"NH","mzip":"03038","pcpfaxno":"","pcpnpi":"1104276757","currentgendcomment":"","pphycomment":"","uniqueid":"147702350","medicareid":"","medicaidid":"","pcpFlag":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["N170","Z992","D689","D509","E8339","N2889","N179","D649","N055","D72829","E039","E8770","E8809","I10","Z7982","Z880","R531","Z720","R7303","N049","Z4901","E038","Z125","Z1211","Z130","Z2821","D72828","R229","Z13220","D492","D225","J40","R079","R0602","R059","I214","R030","R600","N19","K5730","R1900","R7989","R2243","N281","N059","R809","R9431","D801","I440","I498","E7800","E785","Z0000","R000","N178","R002","E782","R99","L738","L818","F17200","Z79890","F17210","N040","I823","E8341","E878","E8351","D638","E063","E669","Z6830","Z87891","Z20822","I2510","E875","Z0184","Z79899"],"date":["2025-05-21","2025-05-21","2025-05-21","2025-06-17","2025-05-21","2025-04-15","2025-10-03","2025-08-21","2025-04-25","2025-05-27","2025-05-27","2025-04-26","2025-04-26","2025-12-24","2025-04-25","2025-04-25","2025-04-25","2025-04-25","2025-08-21","2025-12-24","2025-06-12","2025-03-12","2025-10-03","2025-08-26","2025-03-07","2025-08-26","2025-03-07","2025-02-25","2025-03-07","2025-03-20","2025-03-20","2025-04-13","2025-04-09","2025-04-13","2025-04-13","2025-04-20","2025-05-27","2025-04-20","2025-04-21","2025-04-13","2025-04-13","2025-05-27","2025-04-13","2025-04-26","2025-04-15","2025-04-21","2025-05-05","2025-04-26","2025-04-15","2025-09-03","2025-05-27","2025-10-16","2025-08-26","2025-08-26","2025-08-26","2025-09-03","2025-09-03","2026-02-18","2025-03-20","2025-03-20","2025-04-09","2025-04-13","2025-04-13","2025-04-26","2025-04-26","2025-04-26","2025-04-26","2025-04-26","2025-04-26","2025-04-26","2025-04-26","2025-04-26","2025-04-26","2025-04-26","2025-04-26","2025-04-26","2025-04-26","2025-05-27"],"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":[["","","SEVELAMER CARBONATE","","","Select","Select",""],["","","FAMOTIDINE","","","Select","Select",""],["","","VITAMIN D2","","","Select","Select",""],["","","TORSEMIDE","","","Select","Select",""],["","","PREDNISONE","","","Select","Select",""],["","","ROSUVASTATIN CALCIUM","","","Select","Select",""],["","","ATOVAQUONE","","","Select","Select",""],["","","LEVOTHYROXINE SODIUM","","","Select","Select",""],["","","MYCOPHENOLATE MOFETIL","","","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":["","1"],"comment":["",""],"sub":[]}},{"a":{"indx":["","1"],"comment":["",""],"sub":{"indx":[["","","","","",""],[],[""],[""],[""],[""],[""]],"comment":[["","","","","",""],[],[""],[""],[""],[""],[""]],"sub":[]}}},{"a":{"indx":["","1"],"comment":["",""],"sub":[]}},{"a":{"indx":["","1"],"comment":["",""],"sub":[]}},{"a":{"indx":["","1"],"comment":["",""],"sub":[]}},{"a":{"indx":["","1"],"comment":["",""],"sub":[]}},{"a":{"indx":["","1"],"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":""}]}]}