{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Raymond J Gallant","gend":0,"currentgend":"","add":"PO BOX 7 131 LOON COVE ROAD","city":"STETSON","state":"ME","zip":"04488","dob":"1947-08-23","age":"","mstatus":"","insh":"10000019315","cliId":"","pno":2072962249,"cno":2079447009,"email":"","ename":"","eno":"","pphy":"DOBROVOLNY, KATHRYN E","ppno":2079891567,"pcpadd":"Brewer Medical Center,735 Wilson St","pcpcity":"Brewer","pcpstate":"ME","pcpzip":"04412","pcpcounty":"","pcpid":"","pcpname":"BREWER MEDICAL CENTER","plan":"Martin's Point","program":"MEDICARE","lob":"GA - 2025","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"PO BOX 7 131 LOON COVE ROAD","madd2":"","madd3":"","mcity":"STETSON","mstate":"ME","mzip":"04488","pcpfaxno":2079892286,"pcpnpi":1922668466,"currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"1HW0HE5YG11","medicaidid":"","pcpFlag":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["E559","E1169","D649","E785","Z720","J449","Z87891","R911","R0602","L814","L821","D2371","Z08","D485","K760","R918","E119","H35371","J431","L918","L538","R208","D225","L708","L259","L820","Z789","I110","I5020","I25110","I214","K2100","D120","D124","H43813","M542","L501","Z1211","K5730","D126","K2270","Z961","Z452","L728","E538","L298","Z122","J181","Z48812","F17210","Z114","Z98890","K769","N400","D1723","Z136"],"date":["2025-07-01","2025-07-01","2025-07-01","2025-07-01","2024-03-28","2025-11-12","2025-11-12","2025-11-12","2023-07-07","2024-11-12","2024-11-12","2024-11-12","2024-11-12","2024-11-12","2024-02-28","2023-06-09","2025-06-12","2025-06-12","2024-08-12","2023-04-07","2024-05-14","2024-05-14","2023-10-27","2023-04-07","2023-01-05","2024-05-14","2024-09-05","2023-03-07","2023-03-07","2023-03-07","2023-03-07","2023-11-14","2023-11-14","2023-11-14","2025-06-12","2025-09-25","2023-02-08","2023-11-14","2023-11-14","2023-11-14","2023-11-14","2023-02-16","2023-03-06","2024-11-12","2024-12-04","2023-06-12","2024-03-28","2023-03-09","2023-03-09","2023-07-07","2024-09-05","2023-03-11","2024-09-05","2024-09-05","2022-10-07","2022-08-23"],"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":[["","","PANTOPRAZOLE SODIUM","","","Select","Select",""],["","","LISINOPRIL","","","Select","Select",""],["","","ATORVASTATIN CALCIUM","","","Select","Select",""],["","","METFORMIN HCL","","","Select","Select",""],["","","ANORO ELLIPTA","","","Select","Select",""],["","","ESCITALOPRAM OXALATE","","","Select","Select",""],["","","ALBUTEROL SULFATE HFA","","","Select","Select",""],["","","VARENICLINE TARTRATE","","","Select","Select",""],["","","PREDNISONE","","","Select","Select",""],["","","COMIRNATY 2023-2024","","","Select","Select",""],["","","AREXVY","","","Select","Select",""],["","","FLUAD QUAD 2023-2024","","","Select","Select",""],["","","FLUZONE HIGH-DOSE 2025-2026","","","Select","Select",""],["","","COMIRNATY 2025-2026 (12Y UP)","","","Select","Select",""],["","","ONETOUCH ULTRA TEST STRIP","","","Select","Select",""],["","","ONETOUCH DELICA PLUS LANCET","","","Select","Select",""],["","","DEXCOM G7 SENSOR","","","Select","Select",""],["","","DICLOFENAC SODIUM","","","Select","Select",""],["","","PREVNAR 20","","","Select","Select",""],["","","ONETOUCH ULTRA2","","","Select","Select",""],["","","DEXCOM G7 RECEIVER","","","Select","Select",""],["","","FLUZONE HIGH-DOSE TRIV 2024-25","","","Select","Select",""],["","","COMIRNATY 2024-2025","","","Select","Select",""],["","","EPINEPHRINE","","","Select","Select",""],["","","TRIAMCINOLONE ACETONIDE","","","Select","Select",""],["","","PFIZER COVID BIVAL (12Y UP)EUA","","","Select","Select",""],["","","FLUZONE HIGH-DOSE QUAD 2022-23","","","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":{"indx":[["","","","","",""],[],[""],[""],[""],[""],[""],[""],[""],[""],[""]],"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":""}]}]}