{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Amanda Jacobs","gend":1,"currentgend":"","add":"16 MAZARIN ST","city":"INDIAN ORCH","state":"MA","zip":"01151","dob":"1989-01-31","age":"","mstatus":"","insh":"C0027703200","cliId":"","pno":"4439681387","cno":"","email":"","ename":"","eno":"","pphy":"Ashley  Rosati","ppno":"4137334101","pcpadd":"305 Bicentennial Hwy","pcpcity":"Springfield","pcpstate":"MA","pcpzip":"01118","pcpcounty":"","pcpid":"","pcpname":"Riverbend Medical Group,Inc","plan":"Wellsense Health Plan","program":"ACA","lob":"Commercial - MA - Wave 2","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"16 MAZARIN ST","madd2":"","madd3":"","mcity":"INDIAN ORCH","mstate":"MA","mzip":"01151","pcpfaxno":"","pcpnpi":"1447611041","currentgendcomment":"","pphycomment":"","uniqueid":"133774250","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":["F4310","F900","R079","R1013","G8929","R5383","R110","K223","E041","E049","D649","R42","R4189","R55","Z113","J189","M797","L4050","R0789","I499","L400","D224","D2261","D2271","Z79899","R000","R112","F10139","F1020","R0602","R1084","R1010","B974","I498","K0889","R002","R99","E079","F17210","F10239","E119","Z9884","Z87891","R945","F1010","Z720","R1310","F988","G43909","R052","Z3009","D2262","Z0000","D2239"],"date":["2026-05-05","2026-05-05","2025-10-30","2026-01-11","2025-07-27","2025-08-17","2026-03-19","2025-07-27","2025-07-27","2025-07-27","2026-03-27","2025-08-17","2025-08-17","2025-10-30","2025-09-10","2025-10-30","2025-10-30","2025-10-30","2026-03-19","2025-10-30","2025-12-19","2025-12-19","2025-12-19","2025-12-19","2026-03-27","2026-01-11","2026-01-11","2026-01-11","2026-05-05","2026-03-19","2026-03-19","2026-03-19","2026-03-19","2026-03-19","2026-04-11","2026-03-27","2026-03-31","2025-07-27","2025-07-27","2026-01-11","2026-01-11","2026-01-11","2026-01-11","2026-03-19","2026-03-27","2026-03-27","2024-08-28","2024-08-01","2024-09-28","2024-09-11","2024-09-11","2024-10-30","2025-04-11","2025-06-20"],"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":[["","","VITAMIN D2","","","Select","Select",""],["","","DEXTROAMPHETAMINE-AMPHETAMINE","","","Select","Select",""],["","","RIZATRIPTAN","","","Select","Select",""],["","","BUDESONIDE-FORMOTEROL FUMARATE","","","Select","Select",""],["","","TALTZ AUTOINJECTOR","","","Select","Select",""],["","","ALCOHOL PREP PADS","","","Select","Select",""],["","","VYVANSE","","","Select","Select",""],["","","BUPROPION XL","","","Select","Select",""],["","","CLONAZEPAM","","","Select","Select",""],["","","ONDANSETRON ODT","","","Select","Select",""],["","","CHLORDIAZEPOXIDE HCL","","","Select","Select",""],["","","NALTREXONE HCL","","","Select","Select",""],["","","LISDEXAMFETAMINE DIMESYLATE","","","Select","Select",""],["","","CLINDAMYCIN 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":""}]}]}