{"version":"0.4","data":[{"t":"Demographics","q":[{"name":"Austrid S Todd","gend":1,"currentgend":"","add":"54 GOVERNORS WAY APT 724","city":"TOPSHAM","state":"ME","zip":"04086","dob":"1926-12-13","age":"","mstatus":"","insh":"10000090117","cliId":"","pno":"2077295703","cno":"2075226720","email":"krickards1@live.com","ename":"","eno":"","pphy":"BOUCHER, NAN M","ppno":"2077778810","pcpadd":"PO BOX 95000 LBX 7650,","pcpcity":"PHILADELPHIA","pcpstate":"PA","pcpzip":"19195000","pcpcounty":"","pcpid":"","pcpname":"NORTHERN LIGHT MERCY INTERNAL MEDICINE","plan":"Martin's Point","program":"Medicare","lob":"GA - Wave 2","region":"","aligned":"","ano":"","add2":"","add3":"","madd1":"15 QUARRY RD","madd2":"","madd3":"","mcity":"BRUNSWICK","mstate":"ME","mzip":"04011","pcpfaxno":"","pcpnpi":"1033157227","currentgendcomment":"","pphycomment":"","uniqueid":"","medicareid":"4WE0F07AH08","medicaidid":"","pcpFlag":""},{"a":{"indx":["","","","","","","","1"],"comment":["","","","","","","",""],"sub":{"indx":[["No Ethnicity"]],"comment":[[""]],"sub":[]}}},{"a":[]},{"a":[]},{"a":[]},{"a":[]}]},{"t":"Previously Documented Conditions","q":[{"a":{"diag":["H179","H1820","H40052","H353124","M7120","H3530","M25561","M1711","B351","M79674","M79675","M1990","R0989","N1830","Z0189","N1831","D631","G35","G8929","Z7189","R195","K5790","R140","Z79899","J069","S82842D","S82842A","J90","R918","R0602","R059","M25572","Z993","S82832A","S8252XA","R051","J189","M80062D","I2782","Z01818","J449","S82402A","R600","M5450","M7121","H353213","A000","N390","M542","G629","B353","W19XXXA","R197","S40022A","L2489","L853","M79622","Z043","R079","M792","K5900","M79602","M25512","M25522","M546","N189","S7291XA","S299XXA","K449","S199XXA","M47812","R531","Z7409"],"date":["2025-08-01","2023-04-12","2025-08-01","2025-08-01","2023-05-09","2023-05-09","2024-10-02","2024-10-07","2025-12-19","2025-12-19","2025-12-19","2023-07-04","2023-07-04","2025-03-21","2023-11-01","2023-11-07","2025-01-31","2023-09-26","2024-01-09","2024-07-03","2023-12-21","2023-12-21","2024-01-23","2024-01-09","2024-01-23","2025-06-02","2025-03-21","2024-07-17","2024-07-17","2024-07-17","2024-07-17","2025-03-21","2025-06-23","2025-03-21","2025-03-21","2024-07-17","2024-07-23","2025-07-20","2025-01-31","2025-03-18","2025-03-18","2025-03-18","2025-03-18","2025-12-27","2024-06-11","2025-08-01","2025-06-20","2024-08-02","2025-12-28","2023-03-28","2025-11-26","2025-06-23","2025-09-09","2025-03-03","2026-01-07","2026-01-07","2025-03-03","2025-03-03","2025-12-28","2025-10-13","2025-08-04","2025-02-28","2025-02-28","2025-03-03","2025-12-27","2025-12-27","2025-06-23","2025-12-27","2025-12-27","2025-12-27","2025-12-27","2025-12-28","2025-12-28"],"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":[["","","FLUTICASONE PROP","50 MCG","","Select","Select",""],["","","Timolol Mal (Twice Daily) 0.5 % Ophth Sol","","","Select","Select",""],["","","FLUAD","","","Select","Select",""],["","","ALBUTEROL HFA","90 MCG","","Select","Select",""],["","","PREGABALIN","25 MG","","Select","Select",""],["","","SPIKEVAX","","","Select","Select",""],["","","Fluorometholone 0.1 % Ophth Susp Pacific","","","Select","Select",""],["","","Erythromycin 0.5 % Ophth Oint B&L","","","Select","Select",""],["","","AZITHROMYCIN","250 MG","","Select","Select",""],["","","Fluad Quad 2023-2024","","","Select","Select",""],["","","XARELTO","","","Select","Select",""],["","","AMOXICILLIN","500 MG","","Select","Select",""],["","","Spikevax 2023-2024","","","Select","Select",""],["","","Fluorometholone 0.1 % Ophth Susp Amneal","","","Select","Select",""],["","","Diclofenac Sod 1 % Gel Amneal","","","Select","Select",""],["","","TIMOLOL MAL (TWICE DAILY)","0.005","","Select","Select",""],["","","FLUAD QUAD","","","Select","Select",""],["","","ERYTHROMYCIN","0.005","","Select","Select",""],["","","FLUOROMETHOLONE","0.001","","Select","Select",""],["","","DICLOFENAC SOD","0.01","","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":""}]}]}