{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Nancy L Wallerstein","gend":1,"currentgend":"","add":"25 HENLEY ST UNIT 10","city":"S PORTLAND","state":"ME","zip":"04106","dob":"1952-09-09","age":"","mstatus":"","insh":"10000056356","cliId":"","pno":2073181525,"cno":"","email":"nwallerstein@gmail.com","ename":"","eno":"","pphy":"KLAYMAN, ANDREA S","ppno":2077745816,"pcpadd":"InterMed,84 Marginal Way Ste 800","pcpcity":"Portland","pcpstate":"ME","pcpzip":"04101","pcpcounty":"","pcpid":"","pcpname":"INTERMED","plan":"Martin's Point","program":"MEDICARE","lob":"GA - 2025","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"25 HENLEY ST UNIT 10","madd2":"","madd3":"","mcity":"S PORTLAND","mstate":"ME","mzip":"04106","pcpfaxno":2078741483,"pcpnpi":1780856963,"currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"4HY3AD2EJ15","medicaidid":"","pcpFlag":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R059","Z23","M7662","J189","Z1211","D128","K648","K6389","Z0100","R42","E663","E039","Z0000","M79672","M899","Z0101","M25552","Z1231","R6889","Z13220","H02821","M7660","D23111","M25572","L900","N814","H02824","M79675","D48110","H02831","H02834","M25551","M7732","R0982","R053","Z780","S86012A","K621","R0602","R002","N9089","U071","R062","J40","Z09","K4090","R4182","Z20822","Z01812","N9489","H2512","H259","H2511","R1905","H25813"],"date":["2023-03-11","2025-09-16","2023-10-10","2023-03-11","2024-02-01","2024-02-01","2024-02-01","2024-02-01","2024-06-20","2024-12-06","2025-01-13","2025-03-11","2025-01-13","2023-03-07","2024-09-14","2025-06-25","2023-03-06","2025-10-16","2023-03-09","2024-01-09","2025-01-09","2022-12-14","2024-12-16","2023-06-02","2025-03-17","2024-03-21","2025-03-20","2025-06-07","2025-01-09","2025-01-09","2025-01-09","2024-09-14","2022-12-14","2023-12-19","2023-12-19","2023-05-31","2023-06-02","2024-02-01","2022-10-31","2022-10-31","2022-08-26","2022-08-12","2022-08-12","2022-08-12","2022-06-14","2022-05-31","2022-05-31","2022-05-28","2022-05-28","2022-05-31","2022-04-11","2022-04-11","2022-03-28","2022-03-10","2021-12-07"],"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":[["","","VALACYCLOVIR","","","Select","Select",""],["","","LEVOTHYROXINE SODIUM","","","Select","Select",""],["","","FLUAD 2025-2026","","","Select","Select",""],["","","SCOPOLAMINE","","","Select","Select",""],["","","NEOMYCIN-POLYMYXIN-DEXAMETH","","","Select","Select",""],["","","CHLORHEXIDINE GLUCONATE","","","Select","Select",""],["","","AMOXICILLIN","","","Select","Select",""],["","","ALBUTEROL SULFATE HFA","","","Select","Select",""],["","","COMIRNATY 2023-2024","","","Select","Select",""],["","","FLUAD QUAD 2023-2024","","","Select","Select",""],["","","COMIRNATY 2024-2025","","","Select","Select",""],["","","FLUAD TRIVALENT 2024-2025","","","Select","Select",""],["","","PFIZER COVID BIVAL (12Y UP)EUA","","","Select","Select",""],["","","CLOBETASOL PROPIONATE","","","Select","Select",""],["","","AREXVY","","","Select","Select",""],["","","ABRYSVO","","","Select","Select",""],["","","DOXYCYCLINE HYCLATE","","","Select","Select",""],["","","IPRATROPIUM BROMIDE","","","Select","Select",""],["","","FLUAD QUAD 2022-2023","","","Select","Select",""],["","","FLUCONAZOLE","","","Select","Select",""],["","","PREDNISONE","","","Select","Select",""],["","","METRONIDAZOLE","","","Select","Select",""],["","","PAXLOVID (EUA)","","","Select","Select",""],["","","OXYCODONE HCL","","","Select","Select",""],["","","PFIZER COVID (12Y UP) VAC(EUA)","","","Select","Select",""],["","","PREDNISOLONE ACETATE","","","Select","Select",""],["","","KETOROLAC TROMETHAMINE","","","Select","Select",""],["","","OFLOXACIN","","","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":""}]}]}