{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Marie M Antoine","gend":1,"currentgend":"","add":"105 EVANS ST","city":"DORCHESTER","state":"MA","zip":"02124","dob":"1961-12-23","age":"","mstatus":"","insh":"C0019184600","cliId":"","pno":"6179478227","cno":"","email":"","ename":"","eno":"","pphy":"Darryl A Woods","ppno":"6174145951","pcpadd":"801 Massachusetts Ave","pcpcity":"Boston","pcpstate":"MA","pcpzip":"02118","pcpcounty":"","pcpid":"","pcpname":"Evans Medical Foundation, Inc.","plan":"Wellsense Health Plan","program":"ACA","lob":"Commercial - MA - Wave 2","region":"","aligned":"","ano":"","add2":"APT 2","add3":"","madd1":"105 EVANS ST","madd2":"APT 2","madd3":"","mcity":"DORCHESTER","mstate":"MA","mzip":"02124","pcpfaxno":"","pcpnpi":"1508882341","currentgendcomment":"","pphycomment":"","uniqueid":"96638700","medicareid":"","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":["R99","M25561","G8929","M25511","E119","I10","Z1231","Z23","M79604","K219","H401112","H401122","M25551","M7541","H2513","Z0000","Z59811","Z599","Z5941","Z5987","Z741","Z559","Z1211","E663","H0012","Z0001"],"date":["2026-05-20","2026-03-06","2026-03-13","2026-03-13","2026-03-06","2025-10-31","2025-12-04","2025-10-31","2025-10-31","2025-10-31","2026-04-21","2026-02-10","2026-03-06","2026-03-13","2026-04-21","2025-03-21","2025-03-21","2025-03-21","2025-03-21","2025-03-21","2025-03-21","2025-03-21","2025-04-17","2025-05-02","2025-05-27","2025-03-21"],"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":[["","","TRULICITY","","","Select","Select",""],["","","TIZANIDINE HCL","","","Select","Select",""],["","","CELECOXIB","","","Select","Select",""],["","","AMITRIPTYLINE HCL","","","Select","Select",""],["","","DICLOFENAC SODIUM","","","Select","Select",""],["","","LATANOPROST","","","Select","Select",""],["","","METOPROLOL TARTRATE","","","Select","Select",""],["","","OMEPRAZOLE","","","Select","Select",""],["","","DORZOLAMIDE-TIMOLOL","","","Select","Select",""],["","","BRIMONIDINE TARTRATE","","","Select","Select",""],["","","AMLODIPINE BESYLATE","","","Select","Select",""],["","","LOSARTAN POTASSIUM","","","Select","Select",""],["","","HYDROCHLOROTHIAZIDE","","","Select","Select",""],["","","ATORVASTATIN CALCIUM","","","Select","Select",""],["","","METFORMIN HCL","","","Select","Select",""],["","","METHOCARBAMOL","","","Select","Select",""],["","","GLIPIZIDE ER","","","Select","Select",""],["","","FREESTYLE LITE TEST STRIP","","","Select","Select",""],["","","ASPIRIN EC","","","Select","Select",""],["","","CYCLOBENZAPRINE HCL","","","Select","Select",""],["","","ACETAMINOPHEN-CODEINE","","","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":""}]}]}