{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Luisa Y Diaz Polanco","gend":1,"currentgend":"","add":"83 MAPLE ST","city":"DORCHESTER","state":"MA","zip":"02121","dob":"1982-05-05","age":"","mstatus":"","insh":"C0020832700","cliId":"","pno":"8574882659","cno":"","email":"","ename":"","eno":"","pphy":"Elise M Henricks","ppno":"6172878000","pcpadd":"500 Columbia Rd","pcpcity":"Dorchester","pcpstate":"MA","pcpzip":"02125","pcpcounty":"","pcpid":"","pcpname":"Upham's Corner Health Committee, Inc.","plan":"Wellsense Health Plan","program":"ACA","lob":"Commercial - MA - Wave 2","region":"","aligned":"","ano":"","add2":"APT 5","add3":"","madd1":"83 MAPLE ST","madd2":"APT 5","madd3":"","mcity":"DORCHESTER","mstate":"MA","mzip":"02121","pcpfaxno":"","pcpnpi":"1154392850","currentgendcomment":"","pphycomment":"","uniqueid":"99963700","medicareid":"","medicaidid":"","pcpFlag":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":{"indx":["","1"],"comment":["",""],"sub":{"indx":[["Spanish"]],"comment":[[]],"sub":[]}}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R99","S0231XA","S0231XD","H04123","H029","Z09","N761","Z113","Z124","H25813","H05401","H5340","H04201","Z9079","Z1231","Z0001","Z23","R87810","K219","L293","N920","S0083XA","R079","Z131","T8543XD","N72","B351","L301","T799XXA","R918","V470XXA","Z0189","V892XXA","V4940XA"],"date":["2026-01-07","2025-11-10","2025-11-06","2025-11-06","2025-11-06","2025-11-10","2025-09-23","2025-09-23","2025-09-23","2025-11-06","2025-09-11","2025-09-11","2025-09-11","2025-09-11","2026-01-18","2025-09-23","2025-09-23","2025-09-23","2025-09-23","2026-01-07","2026-01-07","2025-03-01","2025-03-01","2024-09-09","2024-09-09","2024-09-19","2024-12-04","2024-12-04","2025-03-01","2025-03-01","2025-03-01","2025-03-03","2025-03-03","2025-03-01"],"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":[["","","TRANEXAMIC ACID","","","Select","Select",""],["","","MOMETASONE FUROATE","","","Select","Select",""],["","","TERBINAFINE HCL","","","Select","Select",""],["","","KETOCONAZOLE","","","Select","Select",""],["","","AMOXICILLIN-CLAVULANATE POTASS","","","Select","Select",""],["","","TERCONAZOLE","","","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":""}]}]}