{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Blaine A Chapman","gend":0,"currentgend":"","add":"814 SOUTH HIGH ST","city":"BRIDGTON","state":"ME","zip":"04009","dob":"1957-07-08","age":"","mstatus":"","insh":"10000098939","cliId":"","pno":2076475255,"cno":"","email":"","ename":"","eno":"","pphy":"MATUSOVICH, CHARLES S","ppno":2078566010,"pcpadd":"North Bridgton Family Practice,14 Wyonegonic Rd","pcpcity":"North Bridgton","pcpstate":"ME","pcpzip":"04057","pcpcounty":"","pcpid":"","pcpname":"NORTH BRIDGTON FAMILY PRACTICE AND WALK IN CLINIC","plan":"Martin's Point","program":"MEDICARE","lob":"GA - 2025","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"814 SOUTH HIGH ST","madd2":"","madd3":"","mcity":"BRIDGTON","mstate":"ME","mzip":"04009","pcpfaxno":2078579324,"pcpnpi":1134143514,"currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"2W57HQ1NG79","medicaidid":"","pcpFlag":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z0101","S52592D","M1712","Z96652","I2510","I255","I10","E785","Z87891","S52532A","S52502A","R4182","Z09","S2231XA","Z7901","M0579","M170","Z79899","Z0000","M25562","S52532D","M1711","G8918","M25561","M25462","S52572A","E119","Z01812","I119","D84821","M069","M75121","Z471","R0789","I429","I517","M25762","R202","Z1212","Z1211","B353","S52592A","S52352A","M1239"],"date":["2025-10-23","2023-02-27","2025-04-08","2025-04-08","2025-10-24","2023-08-23","2025-09-22","2023-08-23","2024-12-02","2022-11-30","2022-11-28","2022-11-30","2023-08-23","2024-11-01","2024-04-25","2025-10-15","2025-04-23","2025-10-15","2024-03-19","2024-12-02","2023-02-27","2025-10-15","2024-12-02","2025-01-29","2024-03-27","2022-11-30","2022-11-30","2024-11-20","2024-05-16","2024-05-16","2024-05-16","2025-04-23","2025-02-20","2024-11-01","2024-10-30","2023-08-23","2024-02-21","2025-03-31","2024-04-08","2024-04-08","2025-03-20","2022-11-25","2022-11-25","2022-10-10"],"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":[["","","PREDNISONE","","","Select","Select",""],["","","ATORVASTATIN CALCIUM","","","Select","Select",""],["","","FARXIGA","","","Select","Select",""],["","","ECONAZOLE NITRATE","","","Select","Select",""],["","","CLOPIDOGREL","","","Select","Select",""],["","","LOSARTAN POTASSIUM","","","Select","Select",""],["","","METOPROLOL SUCCINATE","","","Select","Select",""],["","","METHOTREXATE","","","Select","Select",""],["","","VALACYCLOVIR","","","Select","Select",""],["","","DAPAGLIFLOZIN","","","Select","Select",""],["","","AMOXICILLIN","","","Select","Select",""],["","","ONDANSETRON HCL","","","Select","Select",""],["","","CEFADROXIL","","","Select","Select",""],["","","TRAMADOL HCL","","","Select","Select",""],["","","CHLORHEXIDINE GLUCONATE","","","Select","Select",""],["","","DIAZEPAM","","","Select","Select",""],["","","OXYCODONE 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":[]}},{"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":""}]}]}