{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Charlene M Kiss","gend":1,"currentgend":"","add":"79 EASTSIDE TRAIL","city":"OAKLAND","state":"ME","zip":"04963","dob":"1947-05-06","age":"","mstatus":"","insh":"10000082276","cliId":"","pno":2078738243,"cno":"","email":"Beanie.5647@gmail.com","ename":"","eno":"","pphy":"LEBLANC, CHRISTINA","ppno":2078731098,"pcpadd":"MaineGeneral Medical Center,149 North St","pcpcity":"Waterville","pcpstate":"ME","pcpzip":"04901","pcpcounty":"","pcpid":"","pcpname":"THAYER INTERNAL MEDICINE","plan":"Martin's Point","program":"MEDICARE","lob":"GA - 2025","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"79 EASTSIDE TRAIL","madd2":"","madd3":"","mcity":"OAKLAND","mstate":"ME","mzip":"04963","pcpfaxno":2078615461,"pcpnpi":1154773935,"currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"5MJ2RG2VJ92","medicaidid":"","pcpFlag":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["C50912","J3489","Z0101","C50412","Z86000","Z923","Z170","M461","M1990","Z1283","M810","M8589","N6321","I361","R921","Z1211","D123","R6889","D120","D122","D0512","N6342","Z1231","D709","J0190","Z87891","S2096XA","D242","N6489","N62","I071","J9811","I517","J029","R062","R928","N649","Z0000","Z483","M8580","M479","E669","L821","Z08","K635","Z98890","S40862A","W57XXXA","M9903","M5430","M9904","M9902","Z0100","B351","Z853","Z0001","D493","N6032","R3915","R350","R300","L814","L720","I8393","L03012","S20161A","B079"],"date":["2024-02-12","2023-02-22","2023-11-20","2024-02-12","2024-09-09","2024-03-08","2024-02-23","2023-12-11","2023-12-11","2024-08-20","2024-03-04","2024-03-04","2024-02-08","2025-10-07","2022-12-19","2024-09-27","2024-09-27","2023-09-22","2024-09-27","2024-09-27","2024-03-08","2023-12-13","2024-12-02","2023-05-15","2024-04-08","2024-04-08","2022-11-28","2024-01-04","2022-12-19","2022-12-19","2025-05-30","2024-02-12","2024-02-12","2023-02-22","2023-02-22","2022-11-30","2024-02-12","2024-05-09","2024-02-23","2024-02-23","2023-04-20","2023-04-20","2025-08-25","2024-09-09","2024-09-27","2024-03-08","2024-10-04","2024-10-04","2025-11-18","2025-11-18","2025-11-18","2025-11-18","2024-11-25","2024-12-17","2023-11-29","2025-05-15","2024-01-04","2022-12-19","2025-10-15","2025-10-15","2025-10-15","2023-08-15","2023-08-15","2023-08-15","2022-11-03","2022-11-09","2022-08-08"],"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":[["","","FLUAD 2025-2026","","","Select","Select",""],["","","NITROFURANTOIN MONO-MACRO","","","Select","Select",""],["","","TERBINAFINE HCL","","","Select","Select",""],["","","DOXYCYCLINE MONOHYDRATE","","","Select","Select",""],["","","AMOXICILLIN-CLAVULANATE POTASS","","","Select","Select",""],["","","CEPHALEXIN","","","Select","Select",""],["","","ALBUTEROL SULFATE HFA","","","Select","Select",""],["","","FLUAD TRIVALENT 2024-2025","","","Select","Select",""],["","","PEG 3350-ELECTROLYTE","","","Select","Select",""],["","","PREDNISONE","","","Select","Select",""],["","","AREXVY","","","Select","Select",""],["","","FLUAD QUAD 2023-2024","","","Select","Select",""],["","","PFIZER COVID BIVAL (12Y UP)EUA","","","Select","Select",""],["","","FLUZONE HIGH-DOSE QUAD 2022-23","","","Select","Select",""],["","","FLUAD QUAD 2022-2023","","","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":""}]}]}