{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Fonda J Violette","gend":1,"currentgend":"","add":"54 LEDGE LANE","city":"Fayette","state":"ME","zip":"04349","dob":"1952-07-03","age":"","mstatus":"","insh":"10000060555","cliId":"","pno":2079319440,"cno":"","email":"paulandfonda@gmail.com","ename":"","eno":"","pphy":"ABRELL, ANDREA C","ppno":2076261561,"pcpadd":"Family Medicine Institute,15 E Chestnut St","pcpcity":"Augusta","pcpstate":"ME","pcpzip":"04330","pcpcounty":"","pcpid":"","pcpname":"FAMILY MEDICINE INSTITUTE","plan":"Martin's Point","program":"MEDICARE","lob":"GA - 2025","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"54 LEDGE LANE","madd2":"","madd3":"","mcity":"Fayette","mstate":"ME","mzip":"04349","pcpfaxno":2076261849,"pcpnpi":1558525188,"currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"2TN0Q11UP49","medicaidid":"","pcpFlag":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":{"indx":["1",""],"comment":["",""],"sub":[]}},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["H401131","E1122","E119","E785","Z7984","M5450","Z1211","Z13820","E1121","M810","Z780","M25561","D123","E1142","M4316","M47816","M4317","H04123","L989","R6889","H1012","S8391XA","M25461","E83110","M5136","R0982","H02055","H02054","Z0100","R059","Z0000","I129","N1830","Z961","Z1231","D125","E039","Z8349","Z0001","H43813","Z23","H40011","H401121","N390"],"date":["2025-07-21","2024-10-31","2025-09-23","2025-09-23","2025-09-23","2023-07-06","2023-08-23","2025-08-28","2025-04-10","2025-07-16","2025-08-28","2025-05-28","2023-08-23","2024-10-31","2023-05-01","2023-05-01","2023-05-01","2025-11-06","2024-07-16","2023-10-25","2022-12-28","2025-05-28","2025-05-28","2023-07-06","2023-05-01","2024-12-06","2025-11-06","2025-11-06","2025-07-21","2024-12-06","2025-03-27","2024-10-31","2024-10-31","2023-10-25","2024-10-09","2023-08-23","2023-02-20","2023-06-26","2022-11-16","2022-11-14","2022-10-25","2022-10-12","2022-10-12","2022-08-10"],"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":[["","","VYZULTA","","","Select","Select",""],["","","TRULICITY","","","Select","Select",""],["","","SPIKEVAX 2025-2026 (12Y UP)","","","Select","Select",""],["","","FLUAD 2025-2026","","","Select","Select",""],["","","METFORMIN HCL","","","Select","Select",""],["","","LOSARTAN POTASSIUM","","","Select","Select",""],["","","COMIRNATY 2025-2026 (12Y UP)","","","Select","Select",""],["","","LEVOTHYROXINE SODIUM","","","Select","Select",""],["","","BRIMONIDINE TARTRATE","","","Select","Select",""],["","","SERTRALINE HCL","","","Select","Select",""],["","","ATORVASTATIN CALCIUM","","","Select","Select",""],["","","TIMOLOL MALEATE","","","Select","Select",""],["","","DORZOLAMIDE-TIMOLOL","","","Select","Select",""],["","","ABRYSVO","","","Select","Select",""],["","","SPIKEVAX 2023-2024","","","Select","Select",""],["","","FLUAD QUAD 2023-2024","","","Select","Select",""],["","","LATANOPROST","","","Select","Select",""],["","","PREVNAR 20","","","Select","Select",""],["","","PEG 3350-ELECTROLYTE","","","Select","Select",""],["","","FLUAD TRIVALENT 2024-2025","","","Select","Select",""],["","","SPIKEVAX 2024-2025","","","Select","Select",""],["","","COMIRNATY 2024-2025","","","Select","Select",""],["","","ERYTHROMYCIN","","","Select","Select",""],["","","SULFAMETHOXAZOLE-TRIMETHOPRIM","","","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":{"indx":[["","","","",""],[""],[""],[""],[""],[""]],"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":""}]}]}