{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Samantha Taylor","gend":1,"currentgend":"","add":"10 JEFFERSON ST","city":"TAUNTON","state":"MA","zip":"02780","dob":"1989-07-16","age":"","mstatus":"","insh":"C0017070700","cliId":"","pno":5085621747,"cno":"","email":"","ename":"","eno":"","pphy":"Syed 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 1","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"10 JEFFERSON ST","madd2":"","madd3":"","mcity":"TAUNTON","mstate":"MA","mzip":"02780","pcpfaxno":"","pcpnpi":1972789592,"currentgendcomment":"","pphycomment":"","uniqueid":92628150,"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":["M9901","M50220","M9902","S29012A","M9903","R109","Z01419","Z9049","Z803","N809","E282","E669","Z6832","N898","J0100","R519","R0981","R0982","R498","H6593","R200","R202","G43909","E66811","Z6834","Z91018","Z9089","Z8041","Z0000","Z6831","R059","Z9189","J45909","R0602","Z1231","G44209","N6489","R99","Z3046","R350","R319","R928"],"date":["2026-01-29","2026-01-29","2026-01-29","2026-01-29","2026-01-29","2024-06-11","2024-06-21","2024-06-21","2025-12-05","2024-09-10","2024-09-10","2025-12-12","2025-08-28","2024-09-10","2024-12-31","2025-11-13","2024-12-31","2024-12-31","2024-12-31","2024-12-31","2025-11-13","2025-11-13","2025-12-12","2025-12-12","2025-07-29","2025-07-29","2025-07-29","2025-09-19","2025-10-24","2025-12-12","2025-10-31","2025-10-24","2025-10-24","2025-10-31","2025-12-05","2025-11-13","2025-12-24","2026-01-28","2024-04-11","2024-06-11","2024-06-11","2025-12-05"],"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":[["","","NEXPLANON","","","Select","Select",""],["","","FLUCONAZOLE","","","Select","Select",""],["","","AMOXICILLIN","","","Select","Select",""],["","","LORAZEPAM","","","Select","Select",""],["","","VENLAFAXINE HCL ER","","","Select","Select",""],["","","PHENTERMINE HCL","","","Select","Select",""],["","","METHYLPREDNISOLONE","","","Select","Select",""],["","","AZITHROMYCIN","","","Select","Select",""],["","","TIZANIDINE HCL","","","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":""}]}]}