{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Carl A Brousseau","gend":0,"currentgend":"","add":"21 MOUNTAIN VIEW LN","city":"STANDISH","state":"ME","zip":"04084","dob":"1956-01-01","age":"","mstatus":"","insh":"10000080542","cliId":"","pno":2075768774,"cno":"","email":"","ename":"","eno":"","pphy":"BELCHER, MATTHEW","ppno":2078282402,"pcpadd":"100 GANNETT DRIVE,SUITE C","pcpcity":"SOUTH PORTLAND","pcpstate":"ME","pcpzip":"41065900","pcpcounty":"","pcpid":"","pcpname":"INTERMED","plan":"Martin's Point","program":"MEDICARE","lob":"GA - 2025","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"21 MOUNTAIN VIEW LN","madd2":"","madd3":"","mcity":"STANDISH","mstate":"ME","mzip":"04084","pcpfaxno":2078282425,"pcpnpi":1952351223,"currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"8D90TH2FR01","medicaidid":"","pcpFlag":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["J029","K219","R918","C9110","R319","J989","M19032","N529","E883","Z7189","Z856","D122","Z86010","K5730","D649","D701","D696","R911","Z5112","R079","R0600","T451X5A","Z0000","J45909","Z125","Z23","R1032","R6889","D709","D72828","M25532","N400","R3129","N281","K5790","I499","J4520","Z9189","Z136","C9190","E663","K5900","D72820","R438","Z8616"],"date":["2025-07-21","2025-07-21","2023-01-30","2025-08-07","2023-01-06","2025-06-15","2024-09-26","2023-12-14","2024-03-28","2023-12-14","2023-10-30","2023-06-27","2023-06-27","2023-06-27","2025-08-07","2025-02-07","2025-02-07","2024-07-29","2024-03-28","2023-11-09","2023-11-09","2023-11-09","2024-11-18","2023-11-15","2025-08-07","2023-10-27","2023-11-01","2023-01-17","2024-05-09","2023-11-13","2024-09-05","2023-01-06","2022-11-14","2022-11-14","2022-11-14","2022-10-21","2022-09-19","2022-09-30","2021-11-15","2021-12-10","2021-12-10","2021-12-10","2022-01-31","2022-01-31","2022-01-31"],"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":[["","","AZITHROMYCIN","","","Select","Select",""],["","","VENCLEXTA","","","Select","Select",""],["","","ALLOPURINOL","","","Select","Select",""],["","","VENCLEXTA STARTING PACK","","","Select","Select",""],["","","ALBUTEROL SULFATE HFA","","","Select","Select",""],["","","PROCHLORPERAZINE MALEATE","","","Select","Select",""],["","","ONDANSETRON ODT","","","Select","Select",""],["","","SEVELAMER CARBONATE","","","Select","Select",""],["","","FLUZONE HIGH-DOSE QUAD 2022-23","","","Select","Select",""],["","","PREVNAR 20","","","Select","Select",""],["","","SHINGRIX","","","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":""}]}]}