{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Roger L Fortin","gend":0,"currentgend":"","add":"386 CAPISIC ST","city":"PORTLAND","state":"ME","zip":"04102","dob":"1941-11-20","age":"","mstatus":"","insh":"10000082326","cliId":"","pno":2074159107,"cno":"","email":"rfortin@maine.rr.com","ename":"","eno":"","pphy":"FRASER, ROBERT J","ppno":2077745816,"pcpadd":"100 FODEN RD. W,SUITE 203","pcpcity":"SOUTH PORTLAND","pcpstate":"ME","pcpzip":"41066143","pcpcounty":"","pcpid":"","pcpname":"INTERMED","plan":"Martin's Point","program":"MEDICARE","lob":"GA - 2025","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"386 CAPISIC ST","madd2":"","madd3":"","mcity":"PORTLAND","mstate":"ME","mzip":"04102","pcpfaxno":2078741483,"pcpnpi":1134206352,"currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"5CF0T93CE16","medicaidid":"","pcpFlag":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R112","Z86711","Z7901","R066","S82842A","R6889","S82842D","M25572","I480","H903","Z86718","I2510","E785","Z0000","D6859","L570","Z0001","K219","D6862","R21","M2042","M79672","M2011","I10","Z87891","M720","Z23","M5450","M79644","M65312","L578","L814","Z0101","Z961","H35363","H02839","H33192","D72810","H9193","J300"],"date":["2025-03-10","2025-10-22","2025-09-10","2025-03-12","2022-12-07","2023-06-12","2023-05-01","2023-05-01","2025-06-25","2023-06-16","2025-10-22","2024-01-04","2025-01-08","2025-01-14","2023-01-03","2023-08-22","2023-01-09","2023-01-09","2023-01-09","2023-01-09","2023-05-10","2023-05-10","2023-05-10","2022-12-04","2022-12-04","2025-10-17","2024-10-16","2024-05-19","2024-04-19","2025-08-22","2023-08-22","2023-08-22","2022-03-01","2022-03-01","2022-03-01","2022-03-01","2022-03-01","2022-01-10","2021-11-29","2021-11-29"],"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":[["","","IMIPRAMINE HCL","","","Select","Select",""],["","","BACLOFEN","","","Select","Select",""],["","","ENOXAPARIN SODIUM","","","Select","Select",""],["","","COMIRNATY 2025-2026 (12Y UP)","","","Select","Select",""],["","","FLUAD 2025-2026","","","Select","Select",""],["","","ONDANSETRON ODT","","","Select","Select",""],["","","CARVEDILOL","","","Select","Select",""],["","","LISINOPRIL","","","Select","Select",""],["","","ATORVASTATIN CALCIUM","","","Select","Select",""],["","","WARFARIN SODIUM","","","Select","Select",""],["","","IPRATROPIUM BROMIDE","","","Select","Select",""],["","","PREDNISONE","","","Select","Select",""],["","","MUPIROCIN","","","Select","Select",""],["","","NYSTATIN","","","Select","Select",""],["","","CYCLOBENZAPRINE HCL","","","Select","Select",""],["","","CLOTRIMAZOLE-BETAMETHASONE","","","Select","Select",""],["","","FLUOROURACIL","","","Select","Select",""],["","","PFIZER COVID BIVAL (12Y UP)EUA","","","Select","Select",""],["","","FLUTICASONE PROPIONATE","","","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":""}]}]}