{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"John Benford","gend":0,"currentgend":"","add":"30 PINE ST","city":"PORTSMOUTH","state":"NH","zip":"03801","dob":"1970-03-13","age":"","mstatus":"","insh":61000137500,"cliId":"","pno":"6039691333","cno":"","email":"","ename":"","eno":"","pphy":"Kristin A Mallett","ppno":"6036108050","pcpadd":"67 Corporate Dr","pcpcity":"Portsmouth","pcpstate":"NH","pcpzip":"03801","pcpcounty":"","pcpid":"","pcpname":"Wentworth Douglass Physician Corp","plan":"Wellsense Health Plan","program":"ACA","lob":"Commercial - NH - Wave 1","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"30 PINE ST","madd2":"","madd3":"","mcity":"PORTSMOUTH","mstate":"NH","mzip":"03801","pcpfaxno":"","pcpnpi":"1972739761","currentgendcomment":"","pphycomment":"","uniqueid":"148544650","medicareid":"","medicaidid":"","pcpFlag":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["J4520","R99","N200","R161","R1084","M7989","R222","D580","E83119","S83521A","S83411A","S8991XA","M25561","S8001XA","S83521D","S83411D","D3610","D492","M25562","Z23","Z1211","D124","Z860101","M1A40X0","Z79899","R945","S86819A","J301","M71572","M79672","K760","Z860100","M25761","J3081","L503","L723","K580","L720","R079","S86111A","Z0001","L570","L817","L728","L821","D1801","L814","Z7189","Z8679"],"date":["2025-12-29","2026-01-30","2025-01-07","2025-01-07","2025-12-02","2025-02-13","2025-02-13","2026-01-09","2026-01-09","2025-04-07","2025-04-07","2025-12-18","2025-12-11","2025-04-10","2025-12-09","2025-08-25","2025-08-08","2025-12-03","2025-07-15","2025-11-13","2025-11-17","2025-11-17","2025-11-17","2025-12-11","2025-12-11","2025-12-22","2025-12-22","2025-06-17","2025-11-06","2025-11-06","2025-03-25","2025-03-25","2025-04-03","2025-06-17","2025-06-17","2025-11-25","2025-12-02","2025-12-15","2026-01-26","2025-12-09","2025-12-03","2025-12-03","2025-12-03","2025-12-03","2025-12-03","2025-12-03","2025-12-03","2025-12-03","2026-01-26"],"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":[["","","MONTELUKAST SODIUM","","","Select","Select",""],["","","ALLOPURINOL","","","Select","Select",""],["","","FOLIC ACID","","","Select","Select",""],["","","DULERA","","","Select","Select",""],["","","SULFAMETHOXAZOLE-TRIMETHOPRIM","","","Select","Select",""],["","","TAMSULOSIN HCL","","","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":[]}},{"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":""}]}]}