{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Jean Nichols","gend":1,"currentgend":"","add":"16 ALLAGASH WAY","city":"WINDHAM","state":"ME","zip":"04062","dob":"1958-01-31","age":"","mstatus":"","insh":"10000104662","cliId":"","pno":2078927077,"cno":2077761107,"email":"jea.nichols@gmail.com","ename":"","eno":"","pphy":"ROTE, JOSEPH BENJAMIN","ppno":2077811600,"pcpadd":"5 Bucknam Rd Ste 2B,","pcpcity":"Falmouth","pcpstate":"ME","pcpzip":"04105","pcpcounty":"","pcpid":"","pcpname":"MAINEHEALTH PRIMARY CARE INTERNAL MEDICINE","plan":"Martin's Point","program":"MEDICARE","lob":"GA - 2025","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"16 ALLAGASH WAY","madd2":"","madd3":"","mcity":"WINDHAM","mstate":"ME","mzip":"04062","pcpfaxno":2077811609,"pcpnpi":1407315302,"currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"4M97UH0UA20","medicaidid":"","pcpFlag":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["M79672","M79671","M810","L233","L600","S42222D","M170","M25561","S42252D","M2352","S83241A","S83231D","M25461","M25462","M25562","Z0000","M25522","W19XXXA","X58XXXA","F419","M25511","Z1211","Z1231","R928","L570","L720","Z85828","Z808","S42222A","D0439","M1711","S2002XA","H2513","H5213","Z780","E7800","S42212A","M2141","M2142","Z1239","G8929","D122","Z860101","R922","S42252A","Z9181","S42292D","H00015","Z7722","S42212D","S83231A","K219","R4182","M1712","E559","L853","L578","H02889","M25512"],"date":["2023-05-08","2025-01-13","2025-07-07","2023-04-14","2025-11-19","2025-03-13","2024-12-17","2024-10-31","2024-12-27","2024-11-15","2023-12-05","2023-09-20","2024-08-08","2023-08-17","2024-08-08","2025-07-24","2024-12-19","2024-12-19","2023-12-05","2023-12-05","2024-10-10","2024-11-22","2025-10-28","2023-08-21","2025-10-27","2023-10-19","2025-10-27","2023-10-19","2025-01-02","2023-02-01","2024-07-16","2023-09-25","2025-05-12","2025-05-12","2025-04-25","2025-06-23","2024-12-19","2025-11-19","2025-11-19","2023-09-25","2024-10-10","2024-11-22","2024-11-22","2023-08-21","2024-12-19","2024-07-22","2025-01-30","2024-11-01","2024-12-19","2025-03-06","2023-12-05","2023-12-05","2023-12-05","2024-07-18","2025-07-07","2025-10-27","2025-10-27","2025-04-21","2024-10-10"],"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":[["","","HYDROXYZINE HCL","","","Select","Select",""],["","","ERYTHROMYCIN","","","Select","Select",""],["","","FLUZONE HIGH-DOSE TRIV 2024-25","","","Select","Select",""],["","","OXYCODONE HCL","","","Select","Select",""],["","","PREDNISONE","","","Select","Select",""],["","","DOXYCYCLINE HYCLATE","","","Select","Select",""],["","","TRETINOIN","","","Select","Select",""],["","","TRAMADOL HCL","","","Select","Select",""],["","","AZITHROMYCIN","","","Select","Select",""],["","","FLUOROURACIL","","","Select","Select",""],["","","COMIRNATY 2023-2024","","","Select","Select",""],["","","FLUZONE HIGH-DOSE QUAD 2023-24","","","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":{"indx":[["","","",""],[],[""],[""],[""],[""],[""],[""]],"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":""}]}]}