{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Susan J Burrows","gend":1,"currentgend":"","add":"600 LEWISTON RD","city":"NEW GLOUCESTER","state":"ME","zip":"04260","dob":"1952-09-13","age":"","mstatus":"","insh":"10000062828","cliId":"","pno":2077708591,"cno":"","email":"Burrows0926@gmail.com","ename":"","eno":"","pphy":"FUCHS ERTMAN, DEBRA","ppno":2077745816,"pcpadd":"100 GANNETT DRIVE,SUITE C","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":"600 LEWISTON RD","madd2":"","madd3":"","mcity":"NEW GLOUCESTER","mstate":"ME","mzip":"04260","pcpfaxno":2078741483,"pcpnpi":1730158403,"currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"8U78KH0TR39","medicaidid":"","pcpFlag":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z0001","R053","Z23","R7303","R202","G4700","R413","J0100","R269","R2689","M6281","M2560","Z1231","T63484A","I6789","M8588","M47816","M25552","H6981","R430","H6591","H903","J069","T161XXA","R109","M5450","N200","K5730","H2513","M5416","M5442","D3131","H35373","M545","M8580","L819","D704","Z0000","H16223","Z03818","L255","L258","B028","Z853"],"date":["2025-05-12","2023-11-02","2025-10-08","2023-11-02","2023-11-02","2023-11-02","2025-10-07","2023-05-11","2023-05-30","2023-05-30","2023-05-30","2023-05-30","2025-05-12","2025-09-04","2025-10-14","2023-05-15","2025-09-30","2025-09-30","2024-05-01","2024-05-01","2024-05-01","2025-06-12","2024-04-25","2024-04-25","2025-09-16","2025-09-16","2025-09-16","2025-09-16","2024-10-16","2025-09-08","2025-09-08","2023-10-12","2023-10-12","2023-12-19","2023-06-05","2025-06-10","2022-10-21","2022-10-21","2022-10-07","2022-09-21","2022-05-17","2022-05-16","2022-05-15","2022-05-15"],"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":[["","","ZOLPIDEM TARTRATE","","","Select","Select",""],["","","GABAPENTIN","","","Select","Select",""],["","","AMOXICILLIN","","","Select","Select",""],["","","ATORVASTATIN CALCIUM","","","Select","Select",""],["","","OMEPRAZOLE","","","Select","Select",""],["","","TOLTERODINE TARTRATE","","","Select","Select",""],["","","PREDNISONE","","","Select","Select",""],["","","ALENDRONATE SODIUM","","","Select","Select",""],["","","AREXVY","","","Select","Select",""],["","","CIPROFLOXACIN HCL","","","Select","Select",""],["","","MONTELUKAST SODIUM","","","Select","Select",""],["","","AMOXICILLIN-CLAVULANATE POTASS","","","Select","Select",""],["","","IPRATROPIUM BROMIDE","","","Select","Select",""],["","","DICLOFENAC SODIUM","","","Select","Select",""],["","","RESTASIS","","","Select","Select",""],["","","CHLORHEXIDINE GLUCONATE","","","Select","Select",""],["","","VALACYCLOVIR","","","Select","Select",""],["","","TRIAMCINOLONE ACETONIDE","","","Select","Select",""],["","","HYDROCODONE-ACETAMINOPHEN","","","Select","Select",""],["","","MODERNA 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":{"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":[]}},{"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":""}]}]}