{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Priscilla F Goulet","gend":1,"currentgend":"","add":"23 WESTFIELD ST","city":"Biddeford","state":"ME","zip":"04005","dob":"1954-11-03","age":"","mstatus":"","insh":"10000075891","cliId":"","pno":"2072812063","cno":"","email":"PRISGOULET@GMAIL.COM","ename":"","eno":"","pphy":"BURLA, MARISA L","ppno":"2072838800","pcpadd":"SMHC Family Medicine,13 Industrial Park Rd Ste 2","pcpcity":"Saco","pcpstate":"ME","pcpzip":"04072","pcpcounty":"","pcpid":"","pcpname":"MAINEHEALTH PRIMARY CARE FAMILY MEDICINE","plan":"Martin's Point","program":"Medicare","lob":"GA - Wave 2","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"23 WESTFIELD ST","madd2":"","madd3":"","mcity":"Biddeford","mstate":"ME","mzip":"04005","pcpfaxno":"2072943561","pcpnpi":"1154701084","currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"6VA5PE1YW56","medicaidid":"","pcpFlag":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["H019","R599","H04032","H04003","Z0000","E782","H04023","Z98890","M8589","Z5181","Z853","Z79811","H903","U071","Z1231","R300"],"date":["2023-05-02","2023-07-20","2023-05-24","2023-07-20","2023-07-20","2023-08-30","2023-08-29","2023-08-29","2023-11-02","2023-11-02","2023-11-02","2023-11-02","2023-12-13","2024-02-01","2024-03-08","2024-04-29"],"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":[["","","Oxycodone Hcl","5 MG","","Select","Select",""],["","","Doxycycline Hyclate","100 MG","","Select","Select",""],["","","Prednisolone Ace 1 % Ophth Susp Lupin","","","Select","Select",""],["","","Atorvastatin","20 MG","","Select","Select",""],["","","Acyclovir","400 MG","","Select","Select",""],["","","Alendronate","70 MG","","Select","Select",""],["","","Paxlovid","300\/100 MG","","Select","Select",""],["","","Loteprednol 0.5 % Ophth Susp Sun Pharma","","","Select","Select",""],["","","Dexamethasone","4 MG","","Select","Select",""],["","","Allopurinol","300 MG","","Select","Select",""],["","","Ondansetron","8 MG","","Select","Select",""],["","","Clindamycin","300 MG","","Select","Select",""],["","","Hydroxyzine Hcl","25 MG","","Select","Select",""],["","","Azithromycin","250 MG","","Select","Select",""],["","","Shingrix","","","Select","Select",""],["","","Sulfamethoxazole\/Trimethoprim","400\/80 MG","","Select","Select",""],["","","Boostrix","","","Select","Select",""],["","","Albuterol Hfa","90 MCG","","Select","Select",""],["","","Citalopram","20 MG","","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":""}]}]}