{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Timothy J Prouty","gend":0,"currentgend":"","add":"51 CONTINENTAL DR","city":"PORTLAND","state":"ME","zip":"04103","dob":"1956-05-01","age":"","mstatus":"","insh":"10000085095","cliId":"","pno":2073299021,"cno":"","email":"tprouty@maine.rr.com","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":"51 CONTINENTAL DR","madd2":"","madd3":"","mcity":"PORTLAND","mstate":"ME","mzip":"04103","pcpfaxno":2078282425,"pcpnpi":1952351223,"currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"4HF8X74ER65","medicaidid":"","pcpFlag":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["G4733","I480","Z713","E6601","R030","I5189","R931","R9439","I5030","Z0101","H6983","I77810","I517","I7789","E66813","E785","Z0000","M109","I2510","I519","I7121","Z6838","Z23","I10","R6889","R0609","E7800","I351","M7631","Z96641","Z471","I5032","Z6835","R051","Z6836","Z1159","Z125","N529","R052","R319","R310"],"date":["2025-11-13","2025-11-10","2025-01-22","2025-02-19","2024-11-01","2025-01-28","2025-10-08","2023-07-25","2023-07-25","2025-06-02","2023-03-31","2025-01-28","2025-01-28","2024-07-11","2025-08-15","2024-11-08","2024-12-05","2024-11-08","2023-06-20","2025-01-28","2024-08-01","2025-01-22","2024-11-15","2025-08-15","2023-01-01","2023-07-21","2023-10-11","2023-05-22","2025-05-22","2023-01-11","2023-01-11","2023-10-11","2025-08-15","2024-09-08","2025-06-27","2022-11-18","2022-11-18","2022-11-09","2022-10-19","2022-06-07","2022-06-07"],"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":[["","","FLUZONE HIGH-DOSE 2025-2026","","","Select","Select",""],["","","COMIRNATY 2025-2026 (12Y UP)","","","Select","Select",""],["","","TOPIRAMATE","","","Select","Select",""],["","","TRAZODONE HCL","","","Select","Select",""],["","","METOPROLOL SUCCINATE","","","Select","Select",""],["","","ZEPBOUND","","","Select","Select",""],["","","DOXYCYCLINE MONOHYDRATE","","","Select","Select",""],["","","FUROSEMIDE","","","Select","Select",""],["","","LISINOPRIL","","","Select","Select",""],["","","ATORVASTATIN CALCIUM","","","Select","Select",""],["","","ALLOPURINOL","","","Select","Select",""],["","","PAXLOVID","","","Select","Select",""],["","","ELIQUIS","","","Select","Select",""],["","","SPIRONOLACTONE","","","Select","Select",""],["","","PAXLOVID (EUA)","","","Select","Select",""],["","","SULFAMETHOXAZOLE-TRIMETHOPRIM","","","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":""}]}]}