{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Karen D Cevallos","gend":1,"currentgend":"","add":"12 POPE ST","city":"SALEM","state":"MA","zip":"01970","dob":"1997-09-29","age":"","mstatus":"","insh":"C0033069900","cliId":"","pno":9786526367,"cno":"","email":"","ename":"","eno":"","pphy":"Marina Joseph","ppno":9787419500,"pcpadd":"400 Highland Ave,Ste 1","pcpcity":"Salem","pcpstate":"MA","pcpzip":"01970","pcpcounty":"","pcpid":"","pcpname":"North Shore Physicians Group, Inc.","plan":"Wellsense Health Plan","program":"ACA","lob":"Commercial - MA - Wave 1","region":"","aligned":"","ano":"","add2":"APT B1011","add3":"","madd1":"12 POPE ST","madd2":"APT B1011","madd3":"","mcity":"SALEM","mstate":"MA","mzip":"01970","pcpfaxno":"","pcpnpi":1275729428,"currentgendcomment":"","pphycomment":"","uniqueid":144676350,"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":["E538","R0683","J4520","B3731","H40002","M79671","M79672","J3089","T7803XA","T7802XA","J302","E282","Z0000","G43009","E785","T7840XS","E669","M778","S93529A","M79675","Z01419","E7800","Z6832","R059","R238","R99","Z309","H6690","R5381","R5383","G43909","K219","Z79899","Z6831","F4310","F411","R0981","J069","Z20822"],"date":["2025-11-12","2025-05-12","2025-11-12","2025-03-11","2025-04-14","2025-05-21","2025-09-30","2025-07-09","2025-07-09","2025-07-09","2025-07-09","2025-11-17","2025-11-12","2025-11-12","2025-11-18","2025-11-12","2025-11-25","2025-09-30","2025-11-17","2025-11-17","2025-11-17","2025-11-17","2025-11-17","2025-12-29","2026-01-14","2026-02-26","2026-01-24","2024-12-26","2024-11-06","2024-11-06","2024-11-06","2024-11-06","2024-11-06","2024-11-06","2024-10-16","2025-11-05","2024-11-29","2024-12-17","2024-12-17"],"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":[["","","FAMOTIDINE","","","Select","Select",""],["","","ALYACEN","","","Select","Select",""],["","","AZELASTINE HCL","","","Select","Select",""],["","","FLUCELVAX TRIVALENT 2024-2025","","","Select","Select",""],["","","VENTOLIN HFA","","","Select","Select",""],["","","BUDESONIDE-FORMOTEROL FUMARATE","","","Select","Select",""],["","","AMOXICILLIN-CLAVULANATE POTASS","","","Select","Select",""],["","","NYLIA","","","Select","Select",""],["","","FLUCONAZOLE","","","Select","Select",""],["","","EPINEPHRINE","","","Select","Select",""],["","","FLUCELVAX 2025-2026","","","Select","Select",""],["","","ZEPBOUND","","","Select","Select",""],["","","OSELTAMIVIR PHOSPHATE","","","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":""}]}]}