{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Leslie Siraco","gend":1,"currentgend":"","add":"15 LAKESHORE DR","city":"AMESBURY","state":"MA","zip":"01913","dob":"1965-03-03","age":"","mstatus":"","insh":"C0042170301","cliId":"","pno":"6172851208","cno":"","email":"","ename":"","eno":"","pphy":"Mark E Allara","ppno":"9787742555","pcpadd":"147 S Main St","pcpcity":"Middleton","pcpstate":"MA","pcpzip":"01949","pcpcounty":"","pcpid":"","pcpname":"Middleton Family Medicine Urgent Care, LLC","plan":"Wellsense Health Plan","program":"ACA","lob":"Commercial - MA - Wave 2","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"15 LAKESHORE DR","madd2":"","madd3":"","mcity":"AMESBURY","mstate":"MA","mzip":"01913","pcpfaxno":"","pcpnpi":"1659457984","currentgendcomment":"","pphycomment":"","uniqueid":"159287451","medicareid":"","medicaidid":"","pcpFlag":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["E2839","I10","F418","N952","R99","Z79890","N950","R9389","E7800","E039","F419","G4730","G894","G250","Z803","Z7985","Z79899","Z800","N951","Z0000","Z1331","Z124","Z1231","Z1211","N959","Z1283","D179","D251","D250","Z01818","T385X5A"],"date":["2026-03-10","2026-04-24","2026-04-23","2026-03-02","2026-05-27","2026-05-28","2026-04-15","2026-04-15","2026-04-15","2026-04-15","2026-04-15","2026-04-15","2026-04-15","2026-04-15","2026-04-15","2026-04-15","2026-04-15","2026-04-15","2026-01-26","2026-02-02","2026-02-02","2026-02-02","2026-02-02","2026-02-02","2026-02-02","2026-02-02","2026-02-02","2026-04-06","2026-02-11","2026-04-06","2026-04-06"],"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":[["","","PROGESTERONE","","","Select","Select",""],["","","PROPRANOLOL HCL","","","Select","Select",""],["","","VENLAFAXINE HCL ER","","","Select","Select",""],["","","ESTRADIOL","","","Select","Select",""],["","","ESTRADIOL (TWICE WEEKLY)","","","Select","Select",""],["","","TESTOSTERONE","","","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":""}]}]}