{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Forrest L Leslie","gend":0,"currentgend":"","add":"761 WESTSHORE DR","city":"Acton","state":"ME","zip":"04001","dob":"1946-09-25","age":"","mstatus":"","insh":"10000014271","cliId":"","pno":2076510938,"cno":"","email":"FNLESLIE@METROCAST.NET","ename":"","eno":"","pphy":"HARYADI, YULIUS L","ppno":6036096800,"pcpadd":"Strafford Medical Associates,10 Members Way Ste 500","pcpcity":"Dover","pcpstate":"NH","pcpzip":"03820","pcpcounty":"","pcpid":"","pcpname":"WHP INTERNAL MEDICINE","plan":"Martin's Point","program":"MEDICARE","lob":"GA - 2025","region":"","aligned":"","ano":2076361020,"add2":"","add3":"","madd1":"761 WESTSHORE DR","madd2":"","madd3":"","mcity":"Acton","mstate":"ME","mzip":"04001","pcpfaxno":6037429863,"pcpnpi":1164943635,"currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"2FP0UP2EM20","medicaidid":"","pcpFlag":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["N401","R351","I10","E785","Z1211","R6889","K5730","C44319","S80861A","Z0000","M1A00X0","L578","X32XXXA","Z08","Z85828","S2242XA","L570","S2242XD","Z0101","S2249XD","D120","J9811","S299XXA","H5203","Z87891","D485","Z860101","M1A09X0","S2249XS","N529","K5750","Z09","Z538","Z0100"],"date":["2025-08-01","2025-08-01","2025-08-01","2025-08-01","2025-04-08","2022-12-20","2025-04-08","2024-05-02","2025-05-23","2023-07-07","2024-01-03","2024-04-16","2024-04-16","2024-04-16","2024-04-16","2025-06-28","2024-05-02","2025-07-14","2025-11-06","2025-07-08","2024-12-09","2025-07-01","2025-07-01","2025-11-06","2025-06-28","2024-04-16","2025-04-07","2023-07-05","2025-07-14","2024-09-11","2024-12-09","2025-04-07","2025-04-07","2022-11-03"],"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":[["","","HYDROCODONE-ACETAMINOPHEN","","","Select","Select",""],["","","TAMSULOSIN HCL","","","Select","Select",""],["","","SULINDAC","","","Select","Select",""],["","","LOSARTAN POTASSIUM","","","Select","Select",""],["","","FLUAD 2025-2026","","","Select","Select",""],["","","PEG-3350 AND ELECTROLYTES","","","Select","Select",""],["","","GAVILYTE-G","","","Select","Select",""],["","","COMIRNATY 2025-2026 (12Y UP)","","","Select","Select",""],["","","COMIRNATY 2024-2025","","","Select","Select",""],["","","AMOXICILLIN","","","Select","Select",""],["","","SPIKEVAX 2023-2024","","","Select","Select",""],["","","FLUZONE HIGH-DOSE TRIV 2024-25","","","Select","Select",""],["","","SHINGRIX","","","Select","Select",""],["","","FLUAD QUAD 2023-2024","","","Select","Select",""],["","","FLUAD QUAD 2022-2023","","","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":""}]}]}