{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Samir Guirguis","gend":0,"currentgend":"","add":"7 HIGH ST","city":"SOUTH EASTON","state":"MA","zip":"02375","dob":"1976-09-05","age":"","mstatus":"","insh":"C0034153700","cliId":"","pno":"6179521092","cno":"","email":"","ename":"","eno":"","pphy":"Nuvair A Imam","ppno":"5088940400","pcpadd":"110 Liberty St","pcpcity":"Brockton","pcpstate":"MA","pcpzip":"02301","pcpcounty":"","pcpid":"","pcpname":"Signature Healthcare Medical Group, Inc.","plan":"Wellsense Health Plan","program":"ACA","lob":"Commercial - MA - Wave 2","region":"","aligned":"","ano":"","add2":"APT 2","add3":"","madd1":"7 HIGH ST","madd2":"APT 2","madd3":"","mcity":"SOUTH EASTON","mstate":"MA","mzip":"02375","pcpfaxno":"","pcpnpi":"1558989491","currentgendcomment":"","pphycomment":"","uniqueid":"146571500","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":["M542","M25512","Z0100","H04123","H5203","H52223","H524","Z973","Z7982","Z0000","Z125","R5383","R99","F524","K5900","N529","F419","F32A","E785","G4700","R7303","F17210","Z79899","K0889","Z7984","Z87891","N5201","R300","F17200","L659","Z559","R059","Z760","E119","B86","L02412","R222","G8929","Z114","Z7689","Z1159","M5001","M47812","M40202"],"date":["2025-12-24","2025-12-24","2025-12-09","2025-12-09","2025-12-09","2025-12-09","2025-12-09","2025-12-09","2025-12-09","2026-04-01","2026-04-01","2026-04-20","2026-05-04","2025-11-11","2025-07-09","2025-11-11","2025-11-11","2025-11-11","2025-11-11","2025-07-09","2025-11-11","2025-07-09","2025-07-09","2025-11-11","2025-11-11","2025-11-11","2025-11-25","2025-11-25","2025-11-11","2025-04-17","2025-04-17","2024-12-14","2024-11-25","2024-11-25","2024-11-25","2025-01-22","2025-01-22","2025-04-17","2024-12-10","2024-12-10","2024-12-10","2024-12-10","2024-12-10","2024-12-10"],"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":[["","","CYCLOBENZAPRINE HCL","","","Select","Select",""],["","","CLINDAMYCIN PHOSPHATE","","","Select","Select",""],["","","METFORMIN HCL","","","Select","Select",""],["","","CITALOPRAM HBR","","","Select","Select",""],["","","EZETIMIBE-SIMVASTATIN","","","Select","Select",""],["","","TRAZODONE HCL","","","Select","Select",""],["","","GAVILAX","","","Select","Select",""],["","","BENZONATATE","","","Select","Select",""],["","","VENTOLIN HFA","","","Select","Select",""],["","","MELOXICAM","","","Select","Select",""],["","","NICOTINE PATCH","","","Select","Select",""],["","","NICOTINE GUM","","","Select","Select",""],["","","AMOXICILLIN-CLAVULANATE POTASS","","","Select","Select",""],["","","LIDOCAINE HCL","","","Select","Select",""],["","","CEFDINIR","","","Select","Select",""],["","","DOXYCYCLINE HYCLATE","","","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":""}]}]}