{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Elisio Gutierrez","gend":0,"currentgend":"","add":"27 KIMBALL ST","city":"SANFORD","state":"ME","zip":"04073","dob":"1956-06-07","age":"","mstatus":"","insh":"10000128257","cliId":"","pno":6037672866,"cno":"","email":"declined@031925.com","ename":"","eno":"","pphy":"POLLARD, DOUGLAS C","ppno":2073513530,"pcpadd":"York Hospital Internal Medicine of York,12 Hospital Dr Ste B","pcpcity":"York","pcpstate":"ME","pcpzip":"03909","pcpcounty":"","pcpid":"","pcpname":"YORK HOSPITAL INTERNAL MEDICINE OF YORK","plan":"Martin's Point","program":"MEDICARE","lob":"GA - 2025","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"27 KIMBALL ST","madd2":"","madd3":"","mcity":"SANFORD","mstate":"ME","mzip":"04073","pcpfaxno":2073513574,"pcpnpi":1710969803,"currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"3RM7VY6ME71","medicaidid":"","pcpFlag":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["M47814","C8511","C83398","G9389","D496","G935","G936","R29898","F419","F1090","C83390","R531","R5381","R001","K140","M4802","M5021","M50323","M47812","Z01818","M5126","M51379","M47817","Z5111","Z006","R930","R4182","R569","D849","Z79899","K5730","R7401","D709","R918","M6281","R5383","R4701","D499","G939","R4702","C8380","C8331","H2513"],"date":["2025-09-21","2025-09-16","2025-09-16","2025-10-10","2025-09-16","2025-09-16","2025-09-17","2025-09-15","2025-10-29","2025-09-16","2025-11-10","2025-09-15","2025-09-15","2025-09-15","2025-08-05","2025-09-21","2025-09-21","2025-09-21","2025-09-21","2025-09-16","2025-09-21","2025-09-21","2025-09-21","2025-10-20","2025-11-10","2025-09-15","2025-09-15","2025-10-29","2025-10-19","2025-10-21","2025-09-15","2025-10-27","2025-10-14","2025-09-15","2025-09-15","2025-09-15","2025-09-15","2025-09-15","2025-09-15","2025-09-15","2025-10-10","2025-09-29","2025-09-29"],"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":[["","","LEUCOVORIN CALCIUM","","","Select","Select",""],["","","ELIQUIS","","","Select","Select",""],["","","ONDANSETRON HCL","","","Select","Select",""],["","","LACOSAMIDE","","","Select","Select",""],["","","ACETAZOLAMIDE","","","Select","Select",""],["","","FLUOXETINE HCL","","","Select","Select",""],["","","PROCHLORPERAZINE MALEATE","","","Select","Select",""],["","","LEVETIRACETAM","","","Select","Select",""],["","","ACYCLOVIR","","","Select","Select",""],["","","SULFAMETHOXAZOLE-TRIMETHOPRIM","","","Select","Select",""],["","","FAMOTIDINE","","","Select","Select",""],["","","CLOTRIMAZOLE","","","Select","Select",""],["","","DEXAMETHASONE","","","Select","Select",""],["","","LORAZEPAM","","","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":""}]}]}