{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Nancy L Bouthot","gend":1,"currentgend":"","add":"236 SALMON FALLS RD","city":"Hollis Center","state":"ME","zip":"04042","dob":"1950-06-26","age":"","mstatus":"","insh":"10000050049","cliId":"","pno":2072299679,"cno":"","email":"Nbouthot5@gmail.com","ename":"","eno":"","pphy":"BABU, PREMALATHA","ppno":"","pcpadd":"Intermed,100 Foden Rd Ste 203","pcpcity":"South Portland","pcpstate":"ME","pcpzip":"04106","pcpcounty":"","pcpid":"","pcpname":"INTERMED","plan":"Martin's Point","program":"MEDICARE","lob":"GA - 2025","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"236 SALMON FALLS RD","madd2":"","madd3":"","mcity":"Hollis Center","mstate":"ME","mzip":"04042","pcpfaxno":"","pcpnpi":1811573900,"currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"5PV4NW6XR98","medicaidid":"","pcpFlag":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z1231","E6609","Z6838","Z0101","M25511","Z6839","K760","R109","K8020","K7400","Z860100","R030","N289","R932","G5601","L720","R1010","R059","E6601","Z6841","N1831","M65331","K5730","Z1389","K3189","K449","K7402","M8588","M65352","E669","I10","E785","Z124","N9411","N952","R6889","Z0000","Z0001","I129","E063","K7689","Z48811","R7989","E782","M810","L853","D225","L821","L570","N281","Z23"],"date":["2025-06-05","2025-08-18","2025-08-18","2025-06-03","2025-09-02","2025-06-19","2025-06-19","2024-10-17","2025-11-18","2025-11-18","2025-11-18","2023-07-05","2024-11-21","2024-11-21","2023-11-21","2025-09-09","2024-09-26","2023-01-06","2024-12-10","2024-12-10","2023-01-06","2024-10-07","2025-05-16","2025-08-20","2024-12-11","2024-12-11","2024-12-11","2024-05-29","2023-12-05","2024-12-11","2025-01-03","2024-12-11","2025-08-20","2025-08-20","2025-08-20","2023-11-04","2025-07-24","2025-07-24","2024-12-10","2025-08-27","2025-07-18","2024-06-05","2025-07-24","2024-07-23","2023-05-22","2023-05-15","2023-05-15","2023-05-15","2023-05-15","2025-07-18","2022-10-17"],"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":[["","","LEVOTHYROXINE SODIUM","","","Select","Select",""],["","","FLUAD 2025-2026","","","Select","Select",""],["","","LISINOPRIL","","","Select","Select",""],["","","SIMVASTATIN","","","Select","Select",""],["","","ESTRADIOL","","","Select","Select",""],["","","ALBUTEROL SULFATE HFA","","","Select","Select",""],["","","FLUAD TRIVALENT 2024-2025","","","Select","Select",""],["","","BOOSTRIX TDAP","","","Select","Select",""],["","","COMIRNATY 2024-2025","","","Select","Select",""],["","","TOBRAMYCIN-DEXAMETHASONE","","","Select","Select",""],["","","AZITHROMYCIN","","","Select","Select",""],["","","SPIKEVAX 2023-2024","","","Select","Select",""],["","","FLUZONE HIGH-DOSE QUAD 2023-24","","","Select","Select",""],["","","PFIZER COVID (12Y UP) VAC(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":""}]}]}