{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Eric R Jensen","gend":0,"currentgend":"","add":"9 CRAGMOOR","city":"CAPE ELIZABETH","state":"ME","zip":"04107","dob":"1941-12-31","age":"","mstatus":"","insh":"10000044732","cliId":"","pno":"2077990748","cno":"","email":"jensenswims@gmail.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 - Wave 2","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"9 CRAGMOOR","madd2":"","madd3":"","mcity":"CAPE ELIZABETH","mstate":"ME","mzip":"04107","pcpfaxno":"2075238597","pcpnpi":"1720421217","currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"6VQ9MT0MH27","medicaidid":"","pcpFlag":""},{"a":{"indx":["1","","","","","","",""],"comment":["","","","","","","",""],"sub":[]}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["Z7901","H532","H02883","H02886","H35371","I4821","G20","R7303","Z87898","Z8639","K5909","H109","L814","L821","D1801","Z85828","L570","H579","H02846","J310","J189","G20A1","I4891","J209","G20A2","R059","Z0001","B351"],"date":["2024-06-19","2023-04-21","2023-04-21","2023-04-21","2023-04-21","2024-06-19","2023-06-22","2024-06-19","2023-06-01","2023-06-01","2023-06-01","2023-07-09","2023-07-13","2023-07-13","2023-07-13","2023-07-13","2023-07-13","2023-08-09","2023-08-09","2023-08-09","2023-10-23","2024-03-07","2023-10-28","2023-10-28","2023-11-03","2023-11-01","2024-02-12","2024-02-12"],"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":[["","","Warfarin","5 MG","","Select","Select",""],["","","Jantoven","","","Select","Select",""],["","","Prednisone","20 MG","","Select","Select",""],["","","Carbidopa\/Levodopa","25\/100 MG","","Select","Select",""],["","","Spikevax 2023-2024","","","Select","Select",""],["","","Azithromycin","250 MG","","Select","Select",""],["","","Comirnaty","","","Select","Select",""],["","","Pfizer-Biontech Gray","","","Select","Select",""],["","","Arexvy","","","Select","Select",""],["","","Levofloxacin","","","Select","Select",""],["","","Ipratropium 0.03 % Nas Spray Amneal","","","Select","Select",""],["","","Comirnaty 2023-2024","","","Select","Select",""],["","","Chlorhexidine 0.12 % Oral Rinse Xttrium","","","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":""}]}]}