{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Judith R Burger Gossart","gend":1,"currentgend":"","add":"54 SPRUCEWIND DR","city":"BAR HARBOR","state":"ME","zip":"04609","dob":"1943-11-05","age":"","mstatus":"","insh":"10000076065","cliId":"","pno":2072884641,"cno":2076100633,"email":"sprucewind.gossart@gmail.com","ename":"","eno":"","pphy":"RENSENBRINK, KATHRYN","ppno":2076647780,"pcpadd":"Northern Light Primary Care Ellsworth,32 Resort Way","pcpcity":"Ellsworth","pcpstate":"ME","pcpzip":"04605","pcpcounty":"","pcpid":"","pcpname":"NORTHERN LIGHT PRIMARY CARE ELLSWORTH","plan":"Martin's Point","program":"MEDICARE","lob":"GA - 2025","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"PO BOX 119","madd2":"","madd3":"","mcity":"SALSBURY COVE","mstate":"ME","mzip":"04672","pcpfaxno":2076647721,"pcpnpi":1124067194,"currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"2YW1EC9AV22","medicaidid":"","pcpFlag":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["J189","J988","F17200","Z45018","I2510","H401131","H26492","H04123","I4891","S52501D","R911","I4892","I429","I2542","M810","L820","H0015","S52501A","E039","G4700","I480","I493","I495","I447","C4441","H903","U071","Z95818","F900","R918","L570","L821","L814","D225","B353","C50011","D485","Z7189","R110","J479","M79671","Z0000","R5383","Z5189","Z780","M8589","M79673","C4491","C44722","R112","R000","I454","R058","I517","Z86010","Z5181","S6291XA","B078","Z13820","I082","Z1211","D120","D125","Z789","L538","R208","D1801","J00","S52591A","S82002A","S80212A","S82009D","M79601","M79602","J069","R5381","R079","A6920"],"date":["2024-01-25","2024-01-25","2024-01-25","2025-07-13","2025-04-29","2025-05-12","2025-05-12","2025-05-12","2025-08-12","2024-09-17","2023-10-24","2025-05-05","2025-09-03","2025-05-05","2025-08-26","2023-12-14","2023-05-15","2024-08-24","2025-08-12","2025-08-12","2025-01-21","2024-05-06","2024-05-06","2024-05-06","2024-11-06","2024-01-15","2023-05-21","2025-03-18","2023-10-24","2023-10-05","2024-11-06","2024-11-06","2024-11-06","2024-11-06","2023-10-30","2022-10-28","2024-11-06","2024-11-06","2025-03-13","2025-03-31","2024-03-27","2024-12-03","2023-08-08","2025-03-05","2025-03-25","2025-03-25","2024-03-27","2022-12-05","2022-12-06","2025-01-26","2025-03-13","2023-03-18","2025-01-29","2024-12-11","2023-04-04","2024-02-13","2024-09-17","2024-03-26","2025-03-25","2025-03-17","2023-04-04","2023-04-04","2023-04-04","2022-10-31","2022-10-31","2022-10-31","2022-10-31","2023-05-21","2024-08-24","2022-08-25","2022-08-19","2022-08-25","2022-08-19","2022-08-19","2022-07-03","2022-07-03","2022-07-03","2022-06-13"],"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":[["","","CLOPIDOGREL","","","Select","Select",""],["","","METOPROLOL SUCCINATE","","","Select","Select",""],["","","LORAZEPAM","","","Select","Select",""],["","","ELIQUIS","","","Select","Select",""],["","","LEVOTHYROXINE SODIUM","","","Select","Select",""],["","","FLUZONE HIGH-DOSE TRIV 2024-25","","","Select","Select",""],["","","FLECAINIDE ACETATE","","","Select","Select",""],["","","DOXYCYCLINE HYCLATE","","","Select","Select",""],["","","SPIKEVAX 2023-2024","","","Select","Select",""],["","","FLUZONE HIGH-DOSE QUAD 2023-24","","","Select","Select",""],["","","ONDANSETRON ODT","","","Select","Select",""],["","","AZITHROMYCIN","","","Select","Select",""],["","","ONDANSETRON HCL","","","Select","Select",""],["","","ALENDRONATE SODIUM","","","Select","Select",""],["","","LOSARTAN POTASSIUM","","","Select","Select",""],["","","SHINGRIX","","","Select","Select",""],["","","SPIKEVAX 2024-2025","","","Select","Select",""],["","","FLUAD 2025-2026","","","Select","Select",""],["","","MODERNA COVID BIVAL(6MO UP)EUA","","","Select","Select",""],["","","ABRYSVO","","","Select","Select",""],["","","MNEXSPIKE 2025-2026 (12Y UP)","","","Select","Select",""],["","","DOXYCYCLINE MONOHYDRATE","","","Select","Select",""],["","","FLUZONE HIGH-DOSE QUAD 2022-23","","","Select","Select",""],["","","ALBUTEROL SULFATE HFA","","","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":""}]}]}