{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Michele R Gauvin","gend":1,"currentgend":"","add":"40 E PRESQUE ISLE RD","city":"CARIBOU","state":"ME","zip":"04736","dob":"1972-05-28","age":"","mstatus":"","insh":"10000096284","cliId":"","pno":2074968869,"cno":"","email":"michele_gauvin@aol.com","ename":"","eno":"","pphy":"ROSSIGNOL, JARRYD","ppno":2074982356,"pcpadd":"Pines Health Services,11 Harmony Lane","pcpcity":"Fort Fairfield","pcpstate":"ME","pcpzip":"04742","pcpcounty":"","pcpid":"","pcpname":"PINES KIMBALL COMMUNITY HEALTH CENTER","plan":"Martin's Point","program":"MEDICARE","lob":"GA - 2025","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"40 E PRESQUE ISLE RD","madd2":"","madd3":"","mcity":"CARIBOU","mstate":"ME","mzip":"04736","pcpfaxno":2074926260,"pcpnpi":1063867489,"currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"7Q28XG1HX58","medicaidid":"","pcpFlag":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["E6601","R519","E119","M79672","M5416","G4733","M76899","R062","M25561","M25562","G8929","Z713","E1165","I10","M25572","M9903","M9904","M9905","M9902","Z466","J320","S233XXA","M9901","M25372","E785","N201","Z20822","R1011","R1031","J069","Z7982","K449","Z9884","Z1211","D125","Z86010","M7062","M722","M7051","M25861","T8131XA","F840","E782","Z6841","K824","N281","T8149XA","R6889","K2960","E669","Z6836","N179","S90852A","Z6833","J020","I2720","G4730","Z9989","Z9109","R0982","H6980","Z20818","J324","E1140","E113313","Z961","J0190","W458XXA","M19031","M25531","M25632","M19032","L03031","H43811","H35033","H26492","H04123","G5712","E11649","D135","Z1152","J0100","Z6831","Z6830","E7800","Z79899","R300","R1084","Z6839","Z0101","Z1231","H16223","J329","J343","E1169","S61211A","W260XXA","Y92009","Y998","Z01812","L03311","Y838","R2242","M79604","H35013","R110","S31825A","W540XXA","E1142","Z6832","L84","E1159","G629","E113311","I351","Z09","F419","E113393","M7052","T22212A","I2510","J208","S61432A","K5900","M7750","Z9049","J328","L03114","W268XXA","M79652","K219","R0600","S76112A","X58XXXA","Z01818","R12","E11311","E118","S93601A","S99911A","M67873","X501XXA","F5101","S6291XA","R2232","M778","M85842","R609","Z6842","H26491","Z98890","Z872","Z7189","H2511","S29012A","M5451"],"date":["2023-12-28","2025-04-25","2025-09-15","2024-11-01","2023-03-01","2023-12-28","2025-04-01","2025-03-20","2025-05-21","2025-05-21","2025-05-21","2024-04-24","2023-09-26","2023-07-17","2023-06-14","2025-07-18","2025-07-18","2025-07-18","2025-07-18","2024-04-10","2025-02-06","2024-10-11","2024-10-11","2024-04-17","2024-12-30","2024-05-09","2023-03-20","2024-04-10","2024-04-10","2025-03-04","2025-03-04","2023-06-06","2025-01-06","2024-08-02","2024-07-18","2024-07-18","2023-02-07","2025-05-01","2024-09-25","2024-05-22","2023-01-24","2025-02-06","2023-01-10","2023-01-10","2023-03-24","2023-03-01","2023-01-20","2023-11-02","2023-12-26","2024-04-24","2023-02-21","2022-12-29","2024-10-25","2023-04-04","2023-05-09","2023-06-28","2023-06-28","2022-12-29","2023-05-11","2025-05-14","2023-05-11","2023-05-11","2023-10-19","2023-11-27","2025-04-17","2024-11-04","2023-11-08","2024-10-23","2022-11-11","2022-10-04","2022-10-04","2022-11-11","2025-08-18","2024-09-30","2024-09-30","2025-04-17","2025-08-05","2023-02-01","2022-12-31","2023-03-13","2023-03-13","2025-01-07","2023-12-28","2023-09-28","2023-03-24","2022-12-31","2024-02-07","2023-03-24","2023-01-23","2024-11-04","2024-07-11","2025-06-10","2023-12-11","2023-07-19","2023-07-31","2023-03-15","2023-03-15","2023-03-15","2023-03-15","2023-03-14","2023-01-20","2023-01-20","2023-11-17","2025-02-10","2023-05-22","2025-01-15","2023-05-24","2023-05-24","2024-06-26","2023-05-04","2024-06-26","2024-06-26","2023-04-26","2023-02-14","2024-12-18","2023-07-12","2023-07-12","2024-11-04","2024-10-21","2023-10-17","2023-03-23","2025-03-06","2023-02-06","2024-04-24","2024-11-07","2023-03-24","2024-08-27","2023-02-06","2023-02-06","2022-09-24","2022-09-24","2022-09-28","2022-09-26","2022-09-19","2022-07-13","2022-07-13","2022-07-01","2022-06-14","2022-06-09","2022-06-09","2022-06-09","2022-06-09","2022-06-10","2022-06-01","2022-06-02","2022-06-01","2022-06-01","2022-05-18","2022-05-23","2022-05-09","2022-05-08","2022-05-08","2022-04-28","2022-04-12","2022-04-04","2022-04-01"],"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":[["","","LOSARTAN POTASSIUM","","","Select","Select",""],["","","FLUOROMETHOLONE","","","Select","Select",""],["","","MONTELUKAST SODIUM","","","Select","Select",""],["","","PANTOPRAZOLE SODIUM","","","Select","Select",""],["","","AMOXICILLIN-CLAVULANATE POTASS","","","Select","Select",""],["","","MUPIROCIN","","","Select","Select",""],["","","FREESTYLE TEST STRIPS","","","Select","Select",""],["","","OXYCODONE HCL","","","Select","Select",""],["","","ALBUTEROL SULFATE HFA","","","Select","Select",""],["","","PROCHLORPERAZINE MALEATE","","","Select","Select",""],["","","FLUTICASONE PROPIONATE","","","Select","Select",""],["","","FLUBLOK 2025-2026","","","Select","Select",""],["","","OZEMPIC","","","Select","Select",""],["","","DOXYCYCLINE HYCLATE","","","Select","Select",""],["","","AMOXICILLIN","","","Select","Select",""],["","","TAMSULOSIN HCL","","","Select","Select",""],["","","SILVER SULFADIAZINE","","","Select","Select",""],["","","LIDOCAINE HCL VISCOUS","","","Select","Select",""],["","","HYDROCORTISONE","","","Select","Select",""],["","","ONETOUCH DELICA PLUS LANCET","","","Select","Select",""],["","","DEXCOM G7 RECEIVER","","","Select","Select",""],["","","GABAPENTIN","","","Select","Select",""],["","","DEXCOM G7 SENSOR","","","Select","Select",""],["","","FLUZONE TRIVALENT 2024-2025","","","Select","Select",""],["","","GLIPIZIDE","","","Select","Select",""],["","","ONDANSETRON ODT","","","Select","Select",""],["","","INSULIN SYRINGE","","","Select","Select",""],["","","SPIKEVAX 2023-2024","","","Select","Select",""],["","","ONETOUCH ULTRA TEST STRIP","","","Select","Select",""],["","","FLUARIX QUAD 2023-2024","","","Select","Select",""],["","","AMLODIPINE BESYLATE","","","Select","Select",""],["","","CLINDAMYCIN HCL","","","Select","Select",""],["","","CHLORHEXIDINE GLUCONATE","","","Select","Select",""],["","","ONDANSETRON HCL","","","Select","Select",""],["","","TRAMADOL HCL","","","Select","Select",""],["","","TRIAMCINOLONE ACETONIDE","","","Select","Select",""],["","","TRULICITY","","","Select","Select",""],["","","MODERNA COVID BIVAL(6MO UP)EUA","","","Select","Select",""],["","","CEFDINIR","","","Select","Select",""],["","","ULTRA THIN LANCETS","","","Select","Select",""],["","","CEPHALEXIN","","","Select","Select",""],["","","DEXCOM G6 SENSOR","","","Select","Select",""],["","","IPRATROPIUM BROMIDE","","","Select","Select",""],["","","METHYLPREDNISOLONE","","","Select","Select",""],["","","DEXCOM G6 RECEIVER","","","Select","Select",""],["","","ULTRA-FINE MICRO PEN NEEDLE","","","Select","Select",""],["","","PAXLOVID","","","Select","Select",""],["","","ATORVASTATIN CALCIUM","","","Select","Select",""],["","","ONETOUCH ULTRA2","","","Select","Select",""],["","","PREDNISONE","","","Select","Select",""],["","","ACETAMINOPHEN-CODEINE","","","Select","Select",""],["","","VALACYCLOVIR","","","Select","Select",""],["","","LEVOFLOXACIN","","","Select","Select",""],["","","DEXCOM G6 TRANSMITTER","","","Select","Select",""],["","","BACLOFEN","","","Select","Select",""],["","","FARXIGA","","","Select","Select",""],["","","FLUARIX QUAD 2022-2023","","","Select","Select",""],["","","ONETOUCH VERIO TEST STRIP","","","Select","Select",""],["","","HUMALOG","","","Select","Select",""],["","","MELOXICAM","","","Select","Select",""],["","","CLOTRIMAZOLE","","","Select","Select",""],["","","ONETOUCH DELICA","","","Select","Select",""],["","","ONETOUCH VERIO REFLECT METER","","","Select","Select",""],["","","METFORMIN HCL ER","","","Select","Select",""],["","","TRESIBA FLEXTOUCH U-200","","","Select","Select",""],["","","GLIPIZIDE ER","","","Select","Select",""],["","","SHINGRIX","","","Select","Select",""],["","","HYDROCHLOROTHIAZIDE","","","Select","Select",""],["","","CYCLOBENZAPRINE HCL","","","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":{"indx":[["","","","","",""],[],[""],[""],[""],[""],[""]],"comment":[["","","","","",""],[],[""],[""],[""],[""],[""]],"sub":[]}}},{"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":{"indx":[["","","","","",""],[],[""],[""],[""],[""],[""],[""],[""],[""],[""]],"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":""}]}]}