{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Carol A Betsch Larkins","gend":1,"currentgend":"","add":"15 ATWOOD RD","city":"NEW GLOUCESTER","state":"ME","zip":"04260","dob":"1957-06-20","age":"","mstatus":"","insh":"10000097785","cliId":"","pno":2073199175,"cno":"","email":"carolabetsch@gmail.com","ename":"","eno":"","pphy":"HEATH, WAYNE A","ppno":2075826608,"pcpadd":"Gardiner Family Medicine,5 Central Maine Crossing","pcpcity":"Gardiner","pcpstate":"ME","pcpzip":"43452615","pcpcounty":"","pcpid":"","pcpname":"GARDINER FAMILY MEDICINE","plan":"Martin's Point","program":"MEDICARE","lob":"GA - 2025","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"15 ATWOOD RD","madd2":"","madd3":"","mcity":"NEW GLOUCESTER","mstate":"ME","mzip":"04260","pcpfaxno":2075822258,"pcpnpi":1518489095,"currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"8RE2T18AH90","medicaidid":"","pcpFlag":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["H5712","R220","S61311D","Y990","M65341","R0683","N3001","B9689","M19012","S61211A","T1490XA","M25512","C880","K219","H6993","C8800","N390","L729","M720","K449","R6889","L578","S8992XA","Z96652","U071","R0981","R519","J029","K529","K5730","T23201A","X100XXA","K143","B009","G4733","Z872","R350","R300","R635","R194","Z538","G5790","R0902","R258","R1030","I700","K429","R935","S060X0A","S0512XA","S86912A","E538","M79642","M1812","Z23","S80261A","D485","Z0000","M5450","K649","S6982XA","W298XXA","R2232","G6289","G5603","M79671","L700","S0990XA","R930","R29898","R2689","R202","Z9189","R195","B957","Z4801","S61211D","X58XXXD","Z1231","M24541","M25841","L814","L658","J4520","M159","I6782","R9082","G319","S61311A","W270XXA","Y93H3","L853","L810","H8110","Z4800","M48061","M79672","L820","R2231","M25511","G8929","L728","R5383","G5602","K2100","F419","R109","K921","Z8719","H5203","H52223","H524","H2513","H43813","R197","S6992XA","M19042","M6530","W230XXA","K2270","Z6826","M19011"],"date":["2025-10-15","2025-10-15","2024-04-03","2024-04-03","2024-02-29","2024-06-20","2025-05-09","2025-05-09","2025-08-01","2024-04-08","2024-04-08","2025-08-01","2024-09-24","2024-10-09","2025-10-27","2025-08-18","2023-01-04","2025-03-13","2024-02-29","2024-11-08","2023-12-28","2024-11-13","2025-10-15","2025-10-15","2023-01-15","2023-01-15","2023-10-03","2023-01-15","2024-02-22","2024-02-22","2024-03-01","2024-03-01","2025-06-10","2025-06-10","2024-06-20","2023-10-16","2025-06-22","2025-06-22","2024-02-29","2023-12-13","2023-12-13","2024-05-07","2024-06-20","2024-06-20","2023-07-24","2023-07-24","2023-07-24","2023-07-24","2025-10-15","2025-10-15","2025-10-15","2024-05-15","2023-12-20","2023-12-20","2025-03-12","2025-09-11","2025-03-13","2023-06-30","2023-06-30","2023-06-30","2024-04-05","2024-04-05","2024-01-18","2024-11-13","2024-12-10","2024-05-30","2024-07-24","2025-10-15","2025-10-15","2024-08-20","2024-04-25","2024-08-20","2024-04-25","2023-12-13","2023-01-04","2024-04-04","2024-04-10","2024-04-10","2024-12-03","2024-07-25","2024-07-25","2024-11-13","2023-10-25","2024-12-18","2024-12-18","2024-07-01","2024-07-01","2024-07-01","2024-03-31","2024-03-31","2024-03-31","2023-08-16","2025-02-05","2025-10-27","2024-04-02","2023-11-02","2023-11-02","2025-03-13","2023-03-07","2025-08-01","2025-06-18","2025-10-24","2023-10-03","2025-02-06","2024-10-09","2024-10-09","2023-07-24","2023-07-24","2024-02-22","2024-02-29","2024-02-29","2024-02-29","2024-02-29","2024-02-29","2024-10-22","2024-04-05","2024-04-05","2023-12-20","2023-12-20","2024-07-10","2024-02-29","2025-08-01"],"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":[["","","MECLIZINE HCL","","","Select","Select",""],["","","ONDANSETRON HCL","","","Select","Select",""],["","","TRETINOIN","","","Select","Select",""],["","","CLINDAMYCIN PHOSPHATE","","","Select","Select",""],["","","MONTELUKAST SODIUM","","","Select","Select",""],["","","FAMOTIDINE","","","Select","Select",""],["","","FLUOROURACIL","","","Select","Select",""],["","","NITROFURANTOIN","","","Select","Select",""],["","","SULFAMETHOXAZOLE-TRIMETHOPRIM","","","Select","Select",""],["","","ERYTHROMYCIN","","","Select","Select",""],["","","DESONIDE","","","Select","Select",""],["","","CELECOXIB","","","Select","Select",""],["","","OMEPRAZOLE","","","Select","Select",""],["","","ALBUTEROL SULFATE HFA","","","Select","Select",""],["","","NITROFURANTOIN MONO-MACRO","","","Select","Select",""],["","","PEG-3350 AND ELECTROLYTES","","","Select","Select",""],["","","CHLORHEXIDINE GLUCONATE","","","Select","Select",""],["","","DOXYCYCLINE MONOHYDRATE","","","Select","Select",""],["","","EPINEPHRINE","","","Select","Select",""],["","","FLUTICASONE PROPIONATE","","","Select","Select",""],["","","HYDROCODONE-ACETAMINOPHEN","","","Select","Select",""],["","","ONDANSETRON ODT","","","Select","Select",""],["","","METRONIDAZOLE","","","Select","Select",""],["","","CIPROFLOXACIN HCL","","","Select","Select",""],["","","AMOXICILLIN","","","Select","Select",""],["","","AZITHROMYCIN","","","Select","Select",""],["","","TRIAMCINOLONE ACETONIDE","","","Select","Select",""],["","","OZEMPIC","","","Select","Select",""],["","","PAXLOVID (EUA)","","","Select","Select",""],["","","GABAPENTIN","","","Select","Select",""],["","","TOPIRAMATE","","","Select","Select",""],["","","VALACYCLOVIR","","","Select","Select",""],["","","ULTRA-FINE MINI PEN NEEDLE","","","Select","Select",""],["","","OXYCODONE HCL","","","Select","Select",""],["","","DOXYCYCLINE HYCLATE","","","Select","Select",""],["","","SSD","","","Select","Select",""],["","","SILVER SULFADIAZINE","","","Select","Select",""],["","","AREXVY","","","Select","Select",""],["","","PFIZER COVID BIVAL (12Y UP)EUA","","","Select","Select",""],["","","FLUZONE HIGH-DOSE QUAD 2022-23","","","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":""}]}]}