{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Mary A Larson","gend":1,"currentgend":"","add":"7 ORCHARD HILLS PARKWAY","city":"BANGOR","state":"ME","zip":"04401","dob":"1947-09-21","age":"","mstatus":"","insh":"10000019476","cliId":"","pno":2078907310,"cno":"","email":"LARSONMA47@GMAIL.COM","ename":"","eno":"","pphy":"DUDZIK, MARY E","ppno":2074975614,"pcpadd":"PO BOX 1599,","pcpcity":"BANGOR","pcpstate":"ME","pcpzip":"44021599","pcpcounty":"","pcpid":"","pcpname":"BREWER MEDICAL CENTER","plan":"Martin's Point","program":"MEDICARE","lob":"GA - 2025","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"7 ORCHARD HILLS PARKWAY","madd2":"","madd3":"","mcity":"BANGOR","mstate":"ME","mzip":"04401","pcpfaxno":"","pcpnpi":1598735722,"currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"6VC1WN6UR23","medicaidid":"","pcpFlag":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["F331","H6121","Z0000","H00019","Z13220","M810","Z136","L209","R6889","L500","S0181XA","S61011A","S0081XA","Z0100","H6123","H25813","Z1231","H25012","F325","S0006XA","W57XXXA","M79641","U071","L821","I781"],"date":["2025-03-04","2023-04-05","2025-08-25","2024-11-22","2023-05-24","2023-05-24","2023-05-24","2023-05-11","2023-11-28","2023-04-21","2024-11-29","2024-11-29","2024-11-29","2023-04-12","2023-06-20","2024-05-06","2023-06-02","2023-08-02","2024-01-08","2024-10-14","2024-10-14","2024-07-22","2022-08-16","2022-07-21","2022-07-21"],"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":[["","","FLUZONE HIGH-DOSE TRIV 2024-25","","","Select","Select",""],["","","NORTRIPTYLINE HCL","","","Select","Select",""],["","","PREDNISONE","","","Select","Select",""],["","","COMIRNATY 2023-2024","","","Select","Select",""],["","","GABAPENTIN","","","Select","Select",""],["","","FLUZONE HIGH-DOSE QUAD 2023-24","","","Select","Select",""],["","","TRIAMCINOLONE ACETONIDE","","","Select","Select",""],["","","COMIRNATY 2024-2025","","","Select","Select",""],["","","PERMETHRIN","","","Select","Select",""],["","","DOXYCYCLINE MONOHYDRATE","","","Select","Select",""],["","","PREVNAR 20","","","Select","Select",""],["","","AREXVY","","","Select","Select",""],["","","PFIZER COVID BIVAL (12Y UP)EUA","","","Select","Select",""],["","","COMIRNATY 2025-2026 (12Y UP)","","","Select","Select",""],["","","FLUAD QUAD 2022-2023","","","Select","Select",""],["","","PAXLOVID (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":""}]}]}