{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Heather H Page","gend":1,"currentgend":"","add":"3 TURNBERRY CIR","city":"SCARBOROUGH","state":"ME","zip":"04074","dob":"1954-12-23","age":"","mstatus":"","insh":"10000086023","cliId":"","pno":2074155549,"cno":"","email":"Heather.page1@yahoo.com","ename":"","eno":"","pphy":"STATON, MEGAN","ppno":2078741489,"pcpadd":"100 FODEN RD. WEST,SUITE 203","pcpcity":"SOUTH PORTLAND","pcpstate":"ME","pcpzip":"41062327","pcpcounty":"","pcpid":"","pcpname":"INTERMED","plan":"Martin's Point","program":"MEDICARE","lob":"GA - 2025","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"3 TURNBERRY CIR","madd2":"","madd3":"","mcity":"SCARBOROUGH","mstate":"ME","mzip":"04074","pcpfaxno":2078741483,"pcpnpi":1235249137,"currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"4V12EN1TD01","medicaidid":"","pcpFlag":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["J95811","H16223","H0288A","H0288B","J939","J479","M542","J918","J9383","A310","M0579","Z79899","Z0001","A319","M069","Z1231","J470","R058","N904","N952","Z0000","J948","R918","E049","R0609","Z4682","N907","J984","N763","E010","R4182","H903","J181","J90","R6889","J9811","E041","Z8262","Z0100","Z0101","E042","H35343","J8489","D23121","R634","M9901","M9903","M9905","Z01419","Z1151","Z124","R768","R7303","M7741","M2011","M79671","M65872","M79672"],"date":["2024-10-18","2023-12-20","2023-12-20","2023-12-20","2024-11-07","2025-09-12","2025-05-14","2024-10-07","2024-11-11","2024-10-09","2025-03-17","2024-12-09","2024-11-25","2025-06-03","2024-10-09","2025-08-19","2022-12-19","2023-03-07","2025-05-06","2025-05-06","2024-03-11","2024-10-18","2025-08-18","2023-02-03","2025-01-29","2024-10-09","2025-07-08","2024-10-07","2025-07-08","2024-10-02","2024-10-02","2025-01-31","2023-10-09","2024-10-06","2023-06-14","2024-11-07","2025-03-17","2025-03-17","2023-07-24","2025-07-30","2023-02-03","2024-07-29","2022-09-27","2022-08-25","2022-08-02","2022-06-17","2022-06-17","2022-06-17","2022-05-10","2022-05-10","2022-05-10","2022-03-28","2022-03-28","2021-12-28","2021-12-28","2022-02-08","2022-02-08","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":[["","","METHOTREXATE","","","Select","Select",""],["","","RIFAMPIN","","","Select","Select",""],["","","CLOBETASOL PROPIONATE","","","Select","Select",""],["","","RESTASIS","","","Select","Select",""],["","","PFIZER COVID BIVAL (12Y UP)EUA","","","Select","Select",""],["","","COMIRNATY 2024-2025","","","Select","Select",""],["","","AZITHROMYCIN","","","Select","Select",""],["","","FLUZONE HIGH-DOSE QUAD 2023-24","","","Select","Select",""],["","","ALBUTEROL SULFATE HFA","","","Select","Select",""],["","","HYDROXYCHLOROQUINE SULFATE","","","Select","Select",""],["","","ARIKAYCE","","","Select","Select",""],["","","FLUZONE HIGH-DOSE QUAD 2022-23","","","Select","Select",""],["","","FLUAD TRIVALENT 2024-2025","","","Select","Select",""],["","","COMIRNATY 2023-2024","","","Select","Select",""],["","","FLUOROMETHOLONE","","","Select","Select",""],["","","ETHAMBUTOL HCL","","","Select","Select",""],["","","MELOXICAM","","","Select","Select",""],["","","EYSUVIS","","","Select","Select",""],["","","FLUZONE HIGH-DOSE 2025-2026","","","Select","Select",""],["","","AREXVY","","","Select","Select",""],["","","ESTRADIOL","","","Select","Select",""],["","","MIEBO","","","Select","Select",""],["","","COMIRNATY 2025-2026 (12Y UP)","","","Select","Select",""],["","","ERYTHROMYCIN","","","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":""}]}]}