{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Anny Recio","gend":1,"currentgend":"","add":"93 PHILLIPS ST","city":"METHUEN","state":"MA","zip":"01844","dob":"1988-04-20","age":"","mstatus":"","insh":"C0027251600","cliId":"","pno":"2019120576","cno":"","email":"","ename":"","eno":"","pphy":"Ashley S Ko","ppno":"9782061860","pcpadd":"288 Groveland St, Ste C3","pcpcity":"Haverhill","pcpstate":"MA","pcpzip":"01830","pcpcounty":"","pcpid":"","pcpname":"Smithers & Ko Health Services, LLC","plan":"Wellsense Health Plan","program":"ACA","lob":"Commercial - MA - Wave 2","region":"","aligned":"","ano":"","add2":"# 3","add3":"","madd1":"93 PHILLIPS ST","madd2":"# 3","madd3":"","mcity":"METHUEN","mstate":"MA","mzip":"01844","pcpfaxno":"","pcpnpi":"1821462045","currentgendcomment":"","pphycomment":"","uniqueid":"132021400","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":["Z30011","R99","E282","H1132","Z6830","N3281","M25562","E039","G4700","E66811","Z0000","Z131","R350","Z0100","K7581","N920","G9332","K5900","E6609","R232","Z01419","M5450","M542","M9902","M9904","M7910","M62830"],"date":["2026-05-01","2026-02-09","2025-11-10","2025-07-18","2025-07-18","2025-10-27","2025-11-10","2025-11-10","2025-10-27","2025-10-27","2025-10-27","2025-10-27","2025-10-27","2025-10-25","2025-10-27","2025-10-27","2025-10-27","2025-10-27","2025-10-27","2025-10-27","2025-02-14","2025-01-21","2025-01-21","2025-04-18","2025-04-18","2025-04-18","2025-01-21"],"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":[["","","NORETHINDRONE","","","Select","Select",""],["","","PREDNISONE","","","Select","Select",""],["","","AMOXICILLIN-CLAVULANATE POTASS","","","Select","Select",""],["","","FLUCONAZOLE","","","Select","Select",""],["","","MONTELUKAST SODIUM","","","Select","Select",""],["","","CLINDAMYCIN PHOSPHATE","","","Select","Select",""],["","","NAPROXEN","","","Select","Select",""],["","","BUDESONIDE-FORMOTEROL FUMARATE","","","Select","Select",""],["","","VALACYCLOVIR","","","Select","Select",""],["","","IBUPROFEN","","","Select","Select",""],["","","CYCLOBENZAPRINE HCL","","","Select","Select",""],["","","TOBRAMYCIN-DEXAMETHASONE","","","Select","Select",""],["","","PROGESTERONE","","","Select","Select",""],["","","METFORMIN HCL","","","Select","Select",""],["","","FLUCELVAX 2025-2026","","","Select","Select",""],["","","SPIKEVAX 2025-2026 (12Y UP)","","","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":""}]}]}