{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Irma Gutosic","gend":1,"currentgend":"","add":"293 Common Street","city":"Quincy","state":"MA","zip":"02169","dob":"1975-02-06","age":"","mstatus":"","insh":"C0005044000","cliId":"","pno":6179472071,"cno":"","email":"","ename":"","eno":"","pphy":"Eunice MacAllister","ppno":6176387428,"pcpadd":"720 Harrison Ave,Ste 407","pcpcity":"Boston","pcpstate":"MA","pcpzip":"02118","pcpcounty":"","pcpid":"","pcpname":"Evans Medical Foundation, Inc.","plan":"Wellsense Health Plan","program":"ACA","lob":"ACA - Rollover - Wave 1","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"293 Common Street","madd2":"","madd3":"","mcity":"Quincy","mstate":"MA","mzip":"02169","pcpfaxno":"","pcpnpi":1104932862,"currentgendcomment":"","pphycomment":"","uniqueid":64539800,"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":["R99","S0083XA","S0590XA","L0201","H05012","L03213","E1065","E10319","F419","Z794","D849","T7411XA","E871","Z23","E785","H00035","E109","G5602","E10618","M7500","S199XXA","M47812","M4312","X58XXXA","S0990XA","L03211","H109","T7491XA","L03811","R5381","R5383","R519","T148XXA","S0993XA","Z743","U071","R509","H00039","R609"],"date":["2025-12-05","2024-03-02","2024-10-02","2024-06-06","2024-09-02","2024-12-02","2025-03-03","2024-09-02","2024-09-02","2024-11-02","2024-09-02","2024-09-02","2024-09-02","2025-01-19","2025-01-21","2024-11-02","2024-11-02","2025-01-21","2025-01-21","2025-01-21","2024-03-02","2024-03-02","2024-03-02","2024-03-02","2024-03-02","2024-06-02","2024-06-02","2024-09-02","2024-09-02","2024-09-02","2024-09-02","2024-09-02","2024-03-02","2024-03-02","2024-11-02","2024-04-24","2024-04-24","2024-11-02","2024-11-02"],"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":[["","","DOXYCYCLINE HYCLATE","","","Select","Select",""],["","","POLYMYXIN B SUL-TRIMETHOPRIM","","","Select","Select",""],["","","AMOXICILLIN-CLAVULANATE POTASS","","","Select","Select",""],["","","ERYTHROMYCIN","","","Select","Select",""],["","","FREESTYLE LIBRE 2 SENSOR","","","Select","Select",""],["","","NOVOLOG FLEXPEN","","","Select","Select",""],["","","VENLAFAXINE HCL ER","","","Select","Select",""],["","","TRESIBA FLEXTOUCH U-100","","","Select","Select",""],["","","ATORVASTATIN CALCIUM","","","Select","Select",""],["","","PAXLOVID","","","Select","Select",""],["","","DEXCOM G7 SENSOR","","","Select","Select",""],["","","DEXCOM G6 SENSOR","","","Select","Select",""],["","","OMNIPOD 5 DEXG7G6 INTRO(GEN 5)","","","Select","Select",""],["","","OMNIPOD 5 DEXG7G6 PODS (GEN 5)","","","Select","Select",""],["","","NOVOLOG","","","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":""}]}]}