{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Jaime Uribe Carvajal","gend":0,"currentgend":"","add":"8 Dale St","city":"Haverhill","state":"MA","zip":"01832","dob":"1983-07-24","age":"","mstatus":"","insh":"C0026901100","cliId":"","pno":"9788728833","cno":"","email":"","ename":"","eno":"","pphy":"Beverly  Brennan","ppno":"9785213270","pcpadd":"1 Park Way","pcpcity":"Haverhill","pcpstate":"MA","pcpzip":"01830","pcpcounty":"","pcpid":"","pcpname":"Partners Community Physicians Organization Inc.","plan":"Wellsense Health Plan","program":"ACA","lob":"Commercial - MA - Wave 1","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"8 Dale St","madd2":"","madd3":"","mcity":"Haverhill","mstate":"MA","mzip":"01832","pcpfaxno":"","pcpnpi":"1174519730","currentgendcomment":"","pphycomment":"","uniqueid":"112287300","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":["E611","Z800","E119","N529","G2581","K580","R0789","D500","E1169","K635","K648","K269","K2900","R079","D509","Z8719","K922","K2970","B9681","K2090","K2980","K259","F17290","K621","Z7984","Z794","D649","I10","E083293","R072","Z0001","K449","Z8711","K2950","K2080","D128","H524","R99","K2100","E669","Z6831","Z130","H5213","Z0000","Z23","K529"],"date":["2025-07-10","2025-07-17","2025-07-09","2025-07-10","2025-07-10","2025-07-10","2025-04-30","2025-04-30","2025-07-10","2025-04-30","2025-04-30","2025-04-30","2025-04-30","2025-04-29","2025-04-30","2025-04-28","2025-04-29","2025-04-30","2025-04-30","2025-07-17","2025-04-30","2025-07-17","2025-07-17","2025-04-30","2025-04-30","2025-04-30","2025-04-30","2025-04-30","2025-03-08","2025-04-28","2025-07-10","2025-07-17","2025-07-17","2025-07-18","2025-07-18","2025-04-30","2025-09-06","2026-02-27","2025-07-26","2024-07-11","2024-07-11","2025-07-09","2024-04-23","2024-07-11","2024-07-11","2024-07-11"],"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":[["","","MOUNJARO","","","Select","Select",""],["","","VENTOLIN HFA","","","Select","Select",""],["","","GABAPENTIN","","","Select","Select",""],["","","XIFAXAN","","","Select","Select",""],["","","FOLIC ACID","","","Select","Select",""],["","","METRONIDAZOLE","","","Select","Select",""],["","","TETRACYCLINE HCL","","","Select","Select",""],["","","IPOL","","","Select","Select",""],["","","BOOSTRIX TDAP","","","Select","Select",""],["","","TWINRIX","","","Select","Select",""],["","","OMEPRAZOLE","","","Select","Select",""],["","","HEPLISAV-B","","","Select","Select",""],["","","DEXAMETHASONE","","","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":{"indx":[["","","","","",""],[],[""],[""],[""],[""],[""]],"comment":[["","","","","",""],[],[""],[""],[""],[""],[""]],"sub":[]}}},{"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":[]}]},{"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":""}]}]}