{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Kim E Provencher","gend":1,"currentgend":"","add":"704 COLLEGE ST","city":"Lewiston","state":"ME","zip":"04240","dob":"1956-05-30","age":"","mstatus":"","insh":"00008370400","cliId":"","pno":2077131827,"cno":"","email":"KIMLIZ0530@MSN.COM","ename":"","eno":"","pphy":"HILARY, MANJU","ppno":2076573308,"pcpadd":"126 SHAKER RD,","pcpcity":"GRAY","pcpstate":"ME","pcpzip":"40399629","pcpcounty":"","pcpid":"","pcpname":"GRAY FAMILY HEALTH CENTER","plan":"Martin's Point","program":"MEDICARE","lob":"GA - 2025","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"704 COLLEGE ST","madd2":"","madd3":"","mcity":"Lewiston","mstate":"ME","mzip":"04240","pcpfaxno":2076573309,"pcpnpi":1710066410,"currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"6XQ3FC8XJ78","medicaidid":"","pcpFlag":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["M79671","C50411","C50912","K909","H35363","S92501A","F4323","M79674","M7521","K224","K900","G894","W19XXXA","M10072","R2233","E6609","R10811","S0502XA","C50919","G8929","Z79899","S92919A","S92514A","U071","M79601","J4540","J342","K219","R21","R0789","Z79810","Z170","K5730","M109","R053","J309","Z0000","F4310","R600","Z880","Z881","L0390","K5790","F329","F4320","M7551","G43709","C50911","M4316","Z98890","T7840XA","J45909","M1712","M1711","M25562"],"date":["2025-01-02","2024-10-02","2023-11-29","2024-08-08","2025-03-06","2022-12-16","2025-11-17","2022-12-01","2025-03-18","2023-01-06","2024-08-08","2025-06-18","2025-06-18","2025-06-11","2025-06-11","2023-10-04","2024-12-05","2025-05-26","2023-11-29","2025-01-20","2024-10-24","2025-01-02","2022-12-01","2023-12-04","2024-11-26","2025-07-28","2023-06-20","2025-08-08","2023-09-27","2023-09-27","2023-09-27","2024-10-02","2024-12-05","2025-06-16","2023-07-05","2023-07-05","2024-08-26","2025-01-20","2025-06-16","2025-07-28","2024-08-13","2024-06-14","2023-05-19","2025-04-29","2025-10-02","2025-01-21","2024-07-26","2024-07-26","2024-06-20","2023-03-21","2022-10-24","2022-09-26","2022-08-15","2022-08-15","2022-08-15"],"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":[["","","BOOSTRIX TDAP","","","Select","Select",""],["","","FLUZONE HIGH-DOSE 2025-2026","","","Select","Select",""],["","","COMIRNATY 2025-2026 (12Y UP)","","","Select","Select",""],["","","FAMOTIDINE","","","Select","Select",""],["","","VENLAFAXINE HCL","","","Select","Select",""],["","","MONTELUKAST SODIUM","","","Select","Select",""],["","","ROSUVASTATIN CALCIUM","","","Select","Select",""],["","","TRAMADOL HCL","","","Select","Select",""],["","","TAMOXIFEN CITRATE","","","Select","Select",""],["","","CREON","","","Select","Select",""],["","","ADVAIR HFA","","","Select","Select",""],["","","LANSOPRAZOLE","","","Select","Select",""],["","","ERYTHROMYCIN","","","Select","Select",""],["","","ALBUTEROL SULFATE HFA","","","Select","Select",""],["","","DULOXETINE HCL","","","Select","Select",""],["","","DOXYCYCLINE MONOHYDRATE","","","Select","Select",""],["","","AREXVY","","","Select","Select",""],["","","FLUZONE HIGH-DOSE TRIV 2024-25","","","Select","Select",""],["","","ONDANSETRON ODT","","","Select","Select",""],["","","AZELASTINE HCL","","","Select","Select",""],["","","COMIRNATY 2024-2025","","","Select","Select",""],["","","ADACEL TDAP","","","Select","Select",""],["","","TRELEGY ELLIPTA","","","Select","Select",""],["","","PAXLOVID (EUA)","","","Select","Select",""],["","","FLUZONE HIGH-DOSE QUAD 2023-24","","","Select","Select",""],["","","COMIRNATY 2023-2024","","","Select","Select",""],["","","PFIZER COVID BIVAL (12Y UP)EUA","","","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":""}]}]}