{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Suraya Jebin","gend":1,"currentgend":"","add":"330 RUTHERFORD AVE","city":"CHARLESTOWN","state":"MA","zip":"02129","dob":"1984-06-01","age":"","mstatus":"","insh":"C0034254200","cliId":"","pno":3479018913,"cno":"","email":"","ename":"","eno":"","pphy":"Erin A Peters","ppno":6177342433,"pcpadd":"1180 Beacon St,Ste 8A","pcpcity":"Brookline","pcpstate":"MA","pcpzip":"02446","pcpcounty":"","pcpid":"","pcpname":"Medical Care of Boston Management Corp.","plan":"Wellsense Health Plan","program":"ACA","lob":"Commercial - MA - Wave 1","region":"","aligned":"","ano":"","add2":"APT 105","add3":"","madd1":"330 RUTHERFORD AVE","madd2":"APT 105","madd3":"","mcity":"CHARLESTOWN","mstate":"MA","mzip":"02129","pcpfaxno":"","pcpnpi":1013238963,"currentgendcomment":"","pphycomment":"","uniqueid":146656150,"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":["J310","L299","R059","R000","R0989","Z1331","Z1339","Z0001","K219","M5450","G8929","M79641","M79642","R739","R1084","B001","G4700","R519","R079","R195","R52","R030","N644","R109","Z833","R058","Z823","R202","I498","J370","J383","M542","R99","Z0000","D72829","I10","G629","B029","R002"],"date":["2026-01-29","2026-01-29","2026-02-05","2026-01-29","2026-02-05","2026-01-20","2026-01-20","2026-01-20","2026-02-06","2025-01-16","2025-01-16","2025-01-16","2025-01-16","2026-01-05","2026-01-06","2026-01-05","2026-01-20","2026-01-08","2026-01-09","2026-01-08","2026-01-13","2026-01-20","2026-01-20","2026-01-21","2026-01-20","2026-02-05","2026-01-20","2026-01-09","2026-01-09","2026-02-05","2026-02-05","2025-03-24","2026-02-22","2026-01-20","2026-01-05","2026-01-08","2026-01-09","2026-01-09","2026-01-21"],"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":[["","","IBUPROFEN","","","Select","Select",""],["","","CYCLOBENZAPRINE HCL","","","Select","Select",""],["","","VALACYCLOVIR","","","Select","Select",""],["","","DICYCLOMINE HCL","","","Select","Select",""],["","","GABAPENTIN","","","Select","Select",""],["","","PANTOPRAZOLE SODIUM","","","Select","Select",""],["","","ARNUITY ELLIPTA","","","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":""}]}]}