{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Donna J Gagne","gend":1,"currentgend":"","add":"211 CYPRESS ST","city":"SCARBOROUGH","state":"ME","zip":"04074","dob":"1954-01-14","age":"","mstatus":"","insh":"10000064054","cliId":"","pno":2073293293,"cno":"","email":"donnagagne99@gmail.com","ename":"","eno":"","pphy":"BABU, PREMALATHA","ppno":2078469013,"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":"211 CYPRESS ST","madd2":"","madd3":"","mcity":"SCARBOROUGH","mstate":"ME","mzip":"04074","pcpfaxno":2078741483,"pcpnpi":1811573900,"currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"4A85EY9TA87","medicaidid":"","pcpFlag":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z1211","M810","L859","Z0100","S32030A","M5450","R053","F17200","M546","S22060S","M48061","M5126","M5136","K219","R059","C44212","S32000S","M818","R918","D485","J4520","Z720","M8589","Z0000","E785","Z1231","C4491","S22060D","H25811","K2289","J449","G4730","Z87891","Z0001","Z23","Z98890","M2560","M6281","M62838","H25813","J984","J4531","I10","R062","R6889","J069","Z122","M4854XD","Z13820","E559","L820","L570","L578","L814","S32010A","T148XXA","L089","D7589","R7989","M47817","J8489","R0982","E211"],"date":["2023-09-25","2025-05-01","2023-09-25","2025-01-29","2024-01-06","2024-02-09","2025-09-28","2023-10-19","2025-05-15","2025-05-15","2024-01-29","2024-01-29","2024-01-29","2023-01-10","2025-09-28","2024-05-13","2024-01-31","2025-06-17","2023-12-21","2023-11-28","2025-02-05","2025-02-05","2024-05-09","2023-09-07","2025-01-27","2025-01-18","2023-11-28","2025-05-08","2025-11-04","2023-01-10","2023-01-10","2023-01-10","2025-01-30","2025-01-14","2025-10-16","2025-06-23","2024-02-09","2024-02-09","2024-02-09","2025-10-22","2025-02-05","2025-08-21","2023-05-04","2025-09-28","2023-11-27","2025-09-28","2023-01-25","2025-04-08","2025-01-27","2025-01-27","2025-08-05","2025-08-05","2025-08-05","2025-08-05","2024-05-16","2022-12-17","2022-12-17","2024-05-09","2024-05-09","2024-01-06","2022-10-13","2022-08-12","2022-09-06"],"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":[["","","ALBUTEROL SULFATE HFA","","","Select","Select",""],["","","BREO ELLIPTA","","","Select","Select",""],["","","KETOROLAC TROMETHAMINE","","","Select","Select",""],["","","PREDNISOLONE ACETATE","","","Select","Select",""],["","","OLMESARTAN MEDOXOMIL","","","Select","Select",""],["","","TRAMADOL HCL","","","Select","Select",""],["","","CALCITONIN-SALMON","","","Select","Select",""],["","","PREDNISOLONE","","","Select","Select",""],["","","VARENICLINE TARTRATE","","","Select","Select",""],["","","METHOCARBAMOL","","","Select","Select",""],["","","LORAZEPAM","","","Select","Select",""],["","","PREDNISONE","","","Select","Select",""],["","","AZITHROMYCIN","","","Select","Select",""],["","","SHINGRIX","","","Select","Select",""],["","","AREXVY","","","Select","Select",""],["","","SULFAMETHOXAZOLE-TRIMETHOPRIM","","","Select","Select",""],["","","ROSUVASTATIN CALCIUM","","","Select","Select",""],["","","DOXYCYCLINE HYCLATE","","","Select","Select",""],["","","CYCLOBENZAPRINE HCL","","","Select","Select",""],["","","METHYLPREDNISOLONE","","","Select","Select",""],["","","VENTOLIN HFA","","","Select","Select",""],["","","OMEPRAZOLE","","","Select","Select",""],["","","IPRATROPIUM BROMIDE","","","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":[]}},{"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":""}]}]}