{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Teresa A Nacelewicz","gend":1,"currentgend":"","add":"25 ROBINSON ST","city":"SOUTH PORTLAND","state":"ME","zip":"04106","dob":"1952-12-31","age":"","mstatus":"","insh":"10000070308","cliId":"","pno":2077671609,"cno":"","email":"tessn@gwi.net","ename":"","eno":"","pphy":"BOBZIEN, ELIZABETH R","ppno":2078741489,"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":"25 ROBINSON ST","madd2":"","madd3":"","mcity":"SOUTH PORTLAND","mstate":"ME","mzip":"04106","pcpfaxno":2075238590,"pcpnpi":1144549320,"currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"2F75Y67MD58","medicaidid":"","pcpFlag":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["M5450","M546","M2560","M6281","R2232","M1712","R21","Z1231","R9389","Z124","L570","D225","L821","L578","Z23","R300","E785","R7989","J069","J45909","Z0100","M62830","M5134","M47814","M4185","M62838","M79671","M19071","R059","K644","Z0001","R309","D492","K625","M84374A","K648","K5730","Z860101","M5136","M7061","G8929","J4530","L219","Z872","M25462","B029","M48061","M5127","M47817","D2361","J40","Z780","L309","R1310","K219","Z01812","Z20822","J45990","R0600","R062","R0981","Z03818","J439","M25562","R5382"],"date":["2024-06-26","2024-06-26","2024-06-26","2024-06-26","2024-07-19","2023-08-15","2024-12-07","2025-09-10","2024-03-21","2023-11-27","2023-01-12","2024-01-25","2024-01-25","2023-01-12","2025-01-10","2024-12-30","2025-01-10","2025-01-10","2024-08-06","2024-08-06","2025-08-14","2024-02-12","2024-03-21","2024-03-21","2024-03-21","2024-02-12","2025-04-12","2025-11-12","2023-04-05","2024-01-19","2024-12-11","2024-12-11","2025-01-30","2024-10-30","2025-04-12","2024-10-30","2024-10-30","2024-10-30","2024-06-25","2024-06-25","2024-06-25","2024-02-16","2024-01-25","2024-01-25","2023-07-10","2024-12-07","2024-02-12","2024-02-12","2024-02-12","2025-01-30","2023-04-05","2024-10-23","2022-08-10","2022-05-13","2022-05-13","2022-05-10","2022-05-10","2022-04-14","2022-04-01","2022-04-01","2022-04-01","2022-04-01","2022-04-01","2021-11-19","2021-12-02"],"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":[["","","SPIKEVAX 2025-2026 (12Y UP)","","","Select","Select",""],["","","FLUZONE HIGH-DOSE 2025-2026","","","Select","Select",""],["","","NITROFURANTOIN MONO-MACRO","","","Select","Select",""],["","","BREO ELLIPTA","","","Select","Select",""],["","","VALACYCLOVIR","","","Select","Select",""],["","","SHINGRIX","","","Select","Select",""],["","","PAXLOVID","","","Select","Select",""],["","","MELOXICAM","","","Select","Select",""],["","","FLUTICASONE PROPIONATE","","","Select","Select",""],["","","CYCLOBENZAPRINE HCL","","","Select","Select",""],["","","DULERA","","","Select","Select",""],["","","ALBUTEROL SULFATE HFA","","","Select","Select",""],["","","PREDNISONE","","","Select","Select",""],["","","SYMBICORT","","","Select","Select",""],["","","TIZANIDINE HCL","","","Select","Select",""],["","","DOXYCYCLINE HYCLATE","","","Select","Select",""],["","","TRIAMCINOLONE ACETONIDE","","","Select","Select",""],["","","VENTOLIN HFA","","","Select","Select",""],["","","MODERNA COVID BIVAL(6MO UP)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":""}]}]}