{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Gloria L Goulet","gend":1,"currentgend":"","add":"3 NICKERSON DR APT 12","city":"Greenville","state":"ME","zip":"04441","dob":"1947-07-20","age":"","mstatus":"","insh":"10000009660","cliId":"","pno":2076952731,"cno":"","email":"declined@02282024.com","ename":"","eno":"","pphy":"ROOPE, SHELLY L","ppno":2076955220,"pcpadd":"22 HALEY CT,","pcpcity":"SANGERVILLE","pcpstate":"ME","pcpzip":"44793000","pcpcounty":"","pcpid":"","pcpname":"NORTHERN LIGHT PRIMARY CARE SANGERVILLE","plan":"Martin's Point","program":"MEDICARE","lob":"GA - 2025","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"3 NICKERSON DR APT 12","madd2":"","madd3":"","mcity":"Greenville","mstate":"ME","mzip":"04441","pcpfaxno":2078764302,"pcpnpi":1487021259,"currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"2YK4WW2TY76","medicaidid":"","pcpFlag":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["K219","I252","M0579","M069","I2510","G4733","R0602","R0609","I517","E785","E876","R197","G4719","K760","M549","R9439","K7460","K766","G9332","M5136","K3189","K449","N289","L814","D225","Z08","Z85828","D485","L570","Z79899","Z7952","M8580","R109","K5730","F331","H539","Z23","R110","Z780","D2371","R778","G8929","M5450","R1011","R7303","Z0000","B349","L821","I10","L659","R059","M47817","Z0101","Z7189","M8589","K529","F32A","J449","R0989","M9903","M5386","M9904","M1711","M25561"],"date":["2025-08-15","2025-07-30","2025-07-01","2025-08-28","2025-09-08","2025-09-11","2025-05-18","2024-05-15","2024-05-15","2024-07-03","2023-07-07","2023-03-13","2023-08-03","2023-04-26","2024-11-16","2025-08-27","2025-09-22","2025-04-29","2022-12-22","2024-07-09","2025-04-29","2025-04-29","2024-04-24","2024-12-04","2024-12-04","2023-09-21","2023-02-14","2023-02-14","2023-02-14","2024-08-27","2023-11-08","2023-11-08","2024-10-31","2024-10-31","2025-09-02","2025-01-21","2023-10-21","2024-08-27","2023-11-29","2023-02-14","2024-10-17","2024-11-05","2024-11-08","2023-03-13","2025-03-26","2024-06-26","2025-05-29","2024-12-04","2023-06-27","2024-02-22","2025-05-18","2024-07-09","2025-07-02","2024-12-04","2023-11-29","2023-04-03","2025-02-04","2024-10-04","2024-10-04","2022-08-31","2022-08-31","2022-08-31","2022-07-11","2022-07-12"],"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":[["","","LISINOPRIL","","","Select","Select",""],["","","PREDNISONE","","","Select","Select",""],["","","BUPROPION HCL","","","Select","Select",""],["","","PANTOPRAZOLE SODIUM","","","Select","Select",""],["","","FLUAD QUAD 2022-2023","","","Select","Select",""],["","","BETAMETHASONE DIPROPIONATE","","","Select","Select",""],["","","FLUARIX QUAD 2022-2023","","","Select","Select",""],["","","METOPROLOL TARTRATE","","","Select","Select",""],["","","MUPIROCIN","","","Select","Select",""],["","","SERTRALINE HCL","","","Select","Select",""],["","","GABAPENTIN","","","Select","Select",""],["","","CLOTRIMAZOLE","","","Select","Select",""],["","","SPIRONOLACTONE","","","Select","Select",""],["","","DOXAZOSIN MESYLATE","","","Select","Select",""],["","","POTASSIUM CHLORIDE","","","Select","Select",""],["","","BUPROPION XL","","","Select","Select",""],["","","IBUPROFEN","","","Select","Select",""],["","","ONDANSETRON ODT","","","Select","Select",""],["","","ATORVASTATIN CALCIUM","","","Select","Select",""],["","","ONDANSETRON HCL","","","Select","Select",""],["","","HYDROCODONE-ACETAMINOPHEN","","","Select","Select",""],["","","MODERNA COVID BIVAL(6MO UP)EUA","","","Select","Select",""],["","","NITROGLYCERIN","","","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":""}]}]}