{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Sana Rafiq","gend":1,"currentgend":"","add":"20 CLARENDON AVE","city":"CHICOPEE","state":"MA","zip":"01013","dob":"1991-02-04","age":"","mstatus":"","insh":"C0032066001","cliId":"","pno":"4139492885","cno":"","email":"","ename":"","eno":"","pphy":"Loreiny  Penalo","ppno":"4137391100","pcpadd":"1049 Main St","pcpcity":"Springfield","pcpstate":"MA","pcpzip":"01103","pcpcounty":"","pcpid":"","pcpname":"Caring Health Center, Inc.","plan":"Wellsense Health Plan","program":"ACA","lob":"Commercial - MA - Wave 2","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"20 CLARENDON AVE","madd2":"","madd3":"","mcity":"CHICOPEE","mstate":"MA","mzip":"01013","pcpfaxno":"","pcpnpi":"1982375614","currentgendcomment":"","pphycomment":"","uniqueid":"142552301","medicareid":"","medicaidid":"","pcpFlag":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["E559","R99","J4520","J329","M47816","G2581","M5450","G8929","G5702","G259","M7918","G4719","Z79899","Z7189","D509","H538","N920","Z01419","Z1272","Z1151","Z113","Z3169","H18832","H02402","H527","H04123","H0100A","H0100B","Z0000","Z23","R7309","B353","R051","B9689","R718","B3731","J4530","K0889","J4550","M549","M533","M25559","R29898","M48061","N898","R7303","J029","M25551","M25552","M51369","L659","R200","R202","M5431","M5432"],"date":["2026-04-05","2025-08-14","2026-01-07","2026-02-25","2026-03-09","2026-03-09","2025-07-02","2025-07-02","2026-03-16","2026-03-09","2026-03-16","2026-03-09","2025-12-08","2025-12-08","2026-04-28","2026-04-28","2026-04-28","2025-07-08","2025-07-08","2025-07-08","2025-07-08","2025-07-08","2025-07-29","2025-07-29","2025-07-29","2025-07-29","2025-07-29","2025-07-29","2025-08-26","2025-08-26","2025-08-26","2025-08-26","2026-02-25","2026-02-25","2026-04-28","2024-11-21","2025-05-20","2025-02-22","2025-03-26","2024-09-19","2024-10-22","2024-09-19","2025-06-18","2025-03-10","2024-09-18","2024-08-13","2024-08-28","2024-10-22","2024-10-22","2025-03-10","2025-05-22","2025-06-18","2025-06-18","2025-06-18","2025-06-18"],"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":[["","","AMOXICILLIN-CLAVULANATE POTASS","","","Select","Select",""],["","","VITAMIN D2","","","Select","Select",""],["","","FLUCONAZOLE","","","Select","Select",""],["","","ARNUITY ELLIPTA","","","Select","Select",""],["","","VENTOLIN HFA","","","Select","Select",""],["","","GABAPENTIN","","","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":""}]}]}