{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Nancy C Capps","gend":1,"currentgend":"","add":"37 INTERVALE RD","city":"NEW GLOUCESTER","state":"ME","zip":"04260","dob":"1956-03-01","age":"","mstatus":"","insh":"10000087156","cliId":"","pno":2072403972,"cno":"","email":"declined@103125.com","ename":"","eno":"","pphy":"BUSTAMANTE, ANTHONY","ppno":2078469013,"pcpadd":"InterMed,259 Main St","pcpcity":"Yarmouth","pcpstate":"ME","pcpzip":"04096","pcpcounty":"","pcpid":"","pcpname":"INTERMED","plan":"Martin's Point","program":"MEDICARE","lob":"GA - 2025","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"PO BOX 510","madd2":"","madd3":"","mcity":"NEW GLOUCESTR","mstate":"ME","mzip":"04260","pcpfaxno":2075238586,"pcpnpi":1306229521,"currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"1YH2GC2QY84","medicaidid":"","pcpFlag":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["R748","E7800","Z0000","I10","Z124","Z0001","M25811","M2560","M6281","M62838","M25519","Z0101","R29898","M25511","M19011","L821","M25512","M25551","B351","D649","L570","S1096XA","W57XXXA","M19012","S59902A","M7502","M7541","M79631","L282","Z23","M8589","M810","F32A","F329","E559","R899","Z13220"],"date":["2024-06-14","2024-06-14","2024-01-02","2024-01-02","2025-04-28","2025-01-06","2023-07-25","2023-07-25","2023-07-25","2023-07-25","2023-08-01","2022-12-13","2024-06-18","2024-06-18","2023-06-13","2023-08-01","2025-10-10","2025-10-10","2025-10-10","2023-09-14","2023-09-14","2023-10-30","2023-10-30","2025-10-10","2023-04-26","2025-10-22","2024-08-08","2024-08-08","2024-05-10","2025-01-06","2022-11-08","2022-11-08","2022-05-10","2021-12-01","2021-12-01","2021-12-01","2021-12-01"],"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":[["","","TERBINAFINE HCL","","","Select","Select",""],["","","ALBUTEROL SULFATE HFA","","","Select","Select",""],["","","PREDNISONE","","","Select","Select",""],["","","JUBLIA","","","Select","Select",""],["","","VARENICLINE TARTRATE","","","Select","Select",""],["","","DIAZEPAM","","","Select","Select",""],["","","COMIRNATY 2025-2026 (12Y UP)","","","Select","Select",""],["","","BUPROPION XL","","","Select","Select",""],["","","KETOCONAZOLE","","","Select","Select",""],["","","AMOXICILLIN","","","Select","Select",""],["","","FLUCONAZOLE","","","Select","Select",""],["","","FLUCELVAX QUAD 2023-2024","","","Select","Select",""],["","","COMIRNATY 2023-2024","","","Select","Select",""],["","","AREXVY","","","Select","Select",""],["","","FLUZONE HIGH-DOSE QUAD 2023-24","","","Select","Select",""],["","","NABUMETONE","","","Select","Select",""],["","","DOXYCYCLINE HYCLATE","","","Select","Select",""],["","","FLUAD QUAD 2022-2023","","","Select","Select",""],["","","PFIZER COVID BIVAL (12Y UP)EUA","","","Select","Select",""],["","","PFIZER COVID (12Y UP) VAC(EUA)","","","Select","Select",""],["","","CLOTRIMAZOLE","","","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":{"indx":[["","","","",""],[],[""],[""],[""],[""],[""]],"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":""}]}]}