{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Raelene F Fasulo","gend":1,"currentgend":"","add":"25 MITCHELLWOOD DRIVE","city":"FALMOUTH","state":"ME","zip":"04105","dob":"1957-10-30","age":"","mstatus":"","insh":"10000099780","cliId":"","pno":2077491808,"cno":"","email":"RAEFASULO@ME.COM","ename":"","eno":"","pphy":"HEARD CUSHING, KAREN S","ppno":2077745816,"pcpadd":"InterMed,84 Marginal Way Ste 800","pcpcity":"Portland","pcpstate":"ME","pcpzip":"04101","pcpcounty":"","pcpid":"","pcpname":"INTERMED","plan":"Martin's Point","program":"MEDICARE","lob":"GA - 2025","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"25 MITCHELLWOOD DRIVE","madd2":"","madd3":"","mcity":"FALMOUTH","mstate":"ME","mzip":"04105","pcpfaxno":2075238597,"pcpnpi":1720421217,"currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"2J08FX7EW26","medicaidid":"","pcpFlag":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["E042","Z0000","N2581","L649","D225","L821","L601","H0259","E8352","Z1231","E785","I10","R6889","M8580","E038","M8588","Z1211","H16223","H2513","T148XXA","L0390","D122","R7309","R7303","E049","E041","Z124"],"date":["2025-08-06","2025-01-22","2025-08-06","2023-07-18","2023-07-18","2023-07-18","2023-07-18","2024-05-20","2025-05-16","2024-08-19","2025-05-16","2025-01-16","2023-08-28","2025-01-16","2025-01-16","2023-08-17","2025-06-02","2025-04-22","2025-04-22","2024-12-17","2024-12-17","2025-06-02","2024-01-18","2022-11-01","2022-11-01","2022-11-08","2022-11-09"],"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":[["","","RIZATRIPTAN","","","Select","Select",""],["","","SPIRONOLACTONE","","","Select","Select",""],["","","ROSUVASTATIN CALCIUM","","","Select","Select",""],["","","AMITRIPTYLINE HCL","","","Select","Select",""],["","","OMEPRAZOLE","","","Select","Select",""],["","","ESTRING","","","Select","Select",""],["","","FLUAD 2025-2026","","","Select","Select",""],["","","LORAZEPAM","","","Select","Select",""],["","","COMIRNATY 2024-2025","","","Select","Select",""],["","","ERYTHROMYCIN","","","Select","Select",""],["","","PRAVASTATIN SODIUM","","","Select","Select",""],["","","FLUCONAZOLE","","","Select","Select",""],["","","OSELTAMIVIR PHOSPHATE","","","Select","Select",""],["","","FLUZONE HIGH-DOSE TRIV 2024-25","","","Select","Select",""],["","","TRIAMCINOLONE ACETONIDE","","","Select","Select",""],["","","CEPHALEXIN","","","Select","Select",""],["","","PFIZER COVID BIVAL (12Y UP)EUA","","","Select","Select",""],["","","FLUAD QUAD 2023-2024","","","Select","Select",""],["","","COMIRNATY 2023-2024","","","Select","Select",""],["","","FLUCELVAX QUAD 2022-2023","","","Select","Select",""],["","","PREVNAR 20","","","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":""}]}]}