{
"description": "A 'standard' form developed using FHIR-based Questionnaire tools intended to demonstrate the range of Questionnaire capabilities needed by form fillers",
"_filename": "examples/20250321Hematology.json",
"package_name": "ca.on.oh-eforms",
"subjectType": [ "Patient" ],
"date": "2025-03-21T21:47:22.960+00:00",
"publisher": "Ontario Health & eHealth Centre of Excellence",
"approvalDate": "2025-03-21",
"name": null,
"item": [ {
"item": [ {
"text": "Surname:",
"type": "string",
"linkId": "patient_surname",
"extension": [ {
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-definitionExtractValue",
"extension": [ {
"url": "definition",
"valueUri": "http://ehealthontario.ca/fhir/StructureDefinition/ca-on-eReferral-profile-Patient#Patient.name.use"
}, {
"url": "fixed-value",
"valueString": "official"
} ]
}, {
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-definitionExtract",
"extension": [ {
"url": "definition",
"valueCanonical": "http://ehealthontario.ca/fhir/StructureDefinition/ca-on-eReferral-profile-Patient"
} ]
} ],
"definition": "http://ehealthontario.ca/fhir/StructureDefinition/ca-on-eReferral-profile-Patient#Patient.name.family"
}, {
"text": "First Name",
"type": "string",
"linkId": "patient_firstname"
}, {
"text": "DOB:",
"type": "date",
"linkId": "patient_date_of_birth",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/entryFormat",
"valueString": "yyyy/MM/dd"
} ]
}, {
"text": "Gender:",
"type": "choice",
"linkId": "patient_gender",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/preferredTerminologyServer",
"valueUrl": "http://hl7.org/fhir/administrative-gender"
} ],
"answerOption": [ {
"valueCoding": {
"code": "male",
"system": "http://hl7.org/fhir/administrative-gender",
"display": "Male"
}
}, {
"valueCoding": {
"code": "female",
"system": "http://hl7.org/fhir/administrative-gender",
"display": "Female"
}
}, {
"valueCoding": {
"code": "other",
"system": "http://hl7.org/fhir/administrative-gender",
"display": "Other"
}
} ]
}, {
"item": [ {
"text": "HN:",
"type": "integer",
"linkId": "patient_hc_number",
"maxLength": 10
}, {
"text": "HN VC:",
"type": "string",
"linkId": "patient_hc_vc",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/minLength",
"valueInteger": 2
} ]
} ],
"text": "HN PC:",
"type": "string",
"linkId": "patient_hc_pc",
"maxLength": 2
}, {
"item": [ {
"text": "Address (Line 2):",
"type": "string",
"linkId": "patient_address_line2"
}, {
"text": "City:",
"type": "string",
"linkId": "patient_address_city"
}, {
"text": "Province:",
"type": "string",
"linkId": "patient_address_province",
"maxLength": 2
}, {
"text": "Postal Code:",
"type": "string",
"linkId": "patient_address_postalcode",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "/^[ABCEGHJ-NPRSTVXY]\\d[ABCEGHJ-NPRSTV-Z][ -]?\\d[ABCEGHJ-NPRSTV-Z]\\d$/i"
} ]
} ],
"text": "Address (Line 1):",
"type": "string",
"linkId": "patient_address_line1"
}, {
"text": "Mobile #:",
"type": "string",
"linkId": "patient_phone_mobile",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "^(\\+\\d{1,2}\\s?)?\\(?\\d{3}\\)?[\\s.-]?\\d{3}[\\s.-]?\\d{4}$"
} ]
}, {
"text": "Home #:",
"type": "string",
"linkId": "patient_phone_home",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "^(\\+\\d{1,2}\\s?)?\\(?\\d{3}\\)?[\\s.-]?\\d{3}[\\s.-]?\\d{4}$"
} ]
}, {
"text": "Business #:",
"type": "string",
"linkId": "patient_phone_business",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "^(\\+\\d{1,2}\\s?)?\\(?\\d{3}\\)?[\\s.-]?\\d{3}[\\s.-]?\\d{4}$"
} ]
}, {
"text": "Email:",
"type": "string",
"linkId": "patient_email",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "(?:[a-z0-9!#$%&'*+/=?^_`{|}~-]+(?:\\.[a-z0-9!#$%&'*+/=?^_`{|}~-]+)*|\"(?:[\\x01-\\x08\\x0b\\x0c\\x0e-\\x1f\\x21\\x23-\\x5b\\x5d-\\x7f]|\\\\[\\x01-\\x09\\x0b\\x0c\\x0e-\\x7f])*\")@(?:(?:[a-z0-9](?:[a-z0-9-]*[a-z0-9])?\\.)+[a-z0-9](?:[a-z0-9-]*[a-z0-9])?|\\[(?:(?:(2(5[0-5]|[0-4][0-9])|1[0-9][0-9]|[1-9]?[0-9]))\\.){3}(?:(2(5[0-5]|[0-4][0-9])|1[0-9][0-9]|[1-9]?[0-9])|[a-z0-9-]*[a-z0-9]:(?:[\\x01-\\x08\\x0b\\x0c\\x0e-\\x1f\\x21-\\x5a\\x53-\\x7f]|\\\\[\\x01-\\x09\\x0b\\x0c\\x0e-\\x7f])+)\\])"
} ]
} ],
"text": "Patient Information",
"type": "group",
"_text": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "Patient Information"
} ]
},
"linkId": "patient_header",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "list",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "List"
} ]
}
} ]
}, {
"item": [ {
"text": "Sex assigned at birth:",
"type": "choice",
"linkId": "additionalinfo_sexassignedatbirth",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/preferredTerminologyServer",
"valueUrl": "http://example.org/mytxserver"
} ],
"answerOption": [ {
"valueCoding": {
"code": "LA3-6",
"system": "http://loinc.org",
"display": "Female"
}
}, {
"valueCoding": {
"code": "LA2-8",
"system": "http://loinc.org",
"display": "Male"
}
}, {
"valueCoding": {
"display": "Intersex"
}
}, {
"valueCoding": {
"code": "LA4489-6",
"system": "http://loinc.org",
"display": "Unknown"
}
} ]
}, {
"item": [ {
"text": "Other pronouns:",
"type": "string",
"linkId": "additionalinfo_pronouns_other",
"required": true,
"enableWhen": [ {
"operator": "=",
"question": "additionalinfo_pronouns",
"answerCoding": {
"display": "Other"
}
} ],
"enableBehavior": "all"
} ],
"text": "Pronouns:",
"type": "choice",
"linkId": "additionalinfo_pronouns",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/preferredTerminologyServer",
"valueUrl": "http://terminology.hl7.org/ValueSet/pronouns"
} ],
"answerOption": [ {
"valueCoding": {
"code": "LA29519-8",
"system": "http://loinc.org",
"display": "she/her/her/hers/herself"
}
}, {
"valueCoding": {
"code": "LA29518-0",
"system": "http://loinc.org",
"display": "he/him/his/his/himself"
}
}, {
"valueCoding": {
"code": "LA29520-6",
"system": "http://loinc.org",
"display": "they/them/their/theirs/themselves"
}
}, {
"valueCoding": {
"code": "LA46-8",
"system": "http://loinc.org",
"display": "Other"
}
} ]
}, {
"text": "Preferred name",
"type": "choice",
"_text": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": ""
} ]
},
"linkId": "additionalinfo_preferredname_select",
"repeats": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "check-box",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Check-box"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"display": "Preferred Name"
}
} ]
}, {
"text": "Prefered name String",
"type": "string",
"_text": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": ""
} ]
},
"linkId": "additionalinfo_preferredname",
"enableWhen": [ {
"operator": "=",
"question": "additionalinfo_preferredname_select",
"answerCoding": {
"display": "Preferred Name"
}
} ],
"enableBehavior": "all"
}, {
"item": [ {
"text": "Specify:",
"type": "string",
"linkId": "additionalinfo_preferredlanguage_specify",
"required": true,
"enableWhen": [ {
"operator": "=",
"question": "additionalinfo_preferredlanguage",
"answerCoding": {
"display": "Other"
}
} ],
"enableBehavior": "all"
}, {
"text": "Translator required",
"type": "choice",
"_text": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": ""
} ]
},
"linkId": "additionalinfo_preferredlanguage_translatorrequired",
"repeats": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "check-box",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Check-box"
} ]
}
} ],
"enableWhen": [ {
"operator": "=",
"question": "additionalinfo_preferredlanguage",
"answerCoding": {
"display": "Other"
}
} ],
"answerOption": [ {
"valueCoding": {
"code": "true",
"display": "Translator Required"
}
} ]
} ],
"text": "Preferred language:",
"type": "choice",
"linkId": "additionalinfo_preferredlanguage",
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/preferredTerminologyServer",
"valueUrl": "http://ehealthontario.ca/fhir/ValueSet/human-language"
} ],
"answerOption": [ {
"valueCoding": {
"code": "en",
"display": "English"
}
}, {
"valueCoding": {
"code": "fr",
"display": "French"
}
}, {
"valueCoding": {
"display": "Other"
}
} ]
}, {
"item": [ {
"enableBehavior": "any",
"linkId": "additionalinfo_bestmethodofcontact_voicemails",
"repeats": true,
"type": "choice",
"enableWhen": [ {
"operator": "=",
"question": "additionalinfo_bestmethodofcontact",
"answerCoding": {
"code": "mobile",
"system": "http://hl7.org/fhir/contact-point-use",
"display": "Mobile"
}
} ],
"answerOption": [ {
"valueCoding": {
"display": "Voicemails acceptable"
}
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "check-box",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Check-box"
} ]
}
} ],
"_text": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": ""
} ]
},
"text": "Voicemails acceptable"
} ],
"text": "Best method of contact:",
"type": "choice",
"linkId": "additionalinfo_bestmethodofcontact",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/preferredTerminologyServer",
"valueUrl": "http://hl7.org/fhir/ValueSet/contact-point-system"
} ],
"answerOption": [ {
"valueCoding": {
"code": "mobile",
"system": "http://hl7.org/fhir/contact-point-use",
"display": "Mobile"
}
}, {
"valueCoding": {
"code": "home",
"system": "http://hl7.org/fhir/contact-point-use",
"display": "Home"
}
}, {
"valueCoding": {
"code": "work",
"system": "http://hl7.org/fhir/contact-point-use",
"display": "Work"
}
}, {
"valueCoding": {
"code": "email",
"system": "http://hl7.org/fhir/contact-point-system",
"display": "Email"
}
} ]
}, {
"text": "Alternate contact",
"type": "choice",
"_text": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": ""
} ]
},
"linkId": "additionalinfo_alternatecontact_select",
"repeats": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "check-box",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Check-box"
} ]
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/preferredTerminologyServer",
"valueUrl": "https://fhir.infoway-inforoute.ca/ValueSet/sharedyesnounknown"
} ],
"answerOption": [ {
"valueCoding": {
"code": "Y",
"system": "http://terminology.hl7.org/CodeSystem/v2-0532",
"display": "Alternate contact"
}
} ]
}, {
"text": "Name:",
"type": "string",
"linkId": "additionalinfo_alternatecontact_name",
"required": true,
"enableWhen": [ {
"operator": "=",
"question": "additionalinfo_alternatecontact_select",
"answerCoding": {
"code": "Y",
"system": "http://terminology.hl7.org/CodeSystem/v2-0532",
"display": "Alternate contact"
}
} ],
"enableBehavior": "all"
}, {
"text": "Alternate contact phone #:",
"type": "string",
"linkId": "additionalinfo_alternatecontact_phone",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "^(\\+\\d{1,2}\\s?)?\\(?\\d{3}\\)?[\\s.-]?\\d{3}[\\s.-]?\\d{4}$"
} ],
"enableWhen": [ {
"operator": "=",
"question": "additionalinfo_alternatecontact_select",
"answerCoding": {
"code": "Y",
"system": "http://terminology.hl7.org/CodeSystem/v2-0532",
"display": "Alternate contact"
}
} ],
"enableBehavior": "all"
}, {
"text": "Relationship:",
"type": "string",
"linkId": "additionalinfo_alternatecontact_relationship",
"enableWhen": [ {
"operator": "=",
"question": "additionalinfo_alternatecontact_select",
"answerCoding": {
"code": "Y",
"system": "http://terminology.hl7.org/CodeSystem/v2-0532",
"display": "Alternate contact"
}
} ],
"enableBehavior": "all"
}, {
"text": "Is Alternate contact the appointment booking contact?:",
"type": "choice",
"linkId": "additionalinfo_alternatecontact_bookingcontact",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"enableWhen": [ {
"operator": "=",
"question": "additionalinfo_alternatecontact_select",
"answerCoding": {
"display": "Alternate contact"
}
} ],
"answerOption": [ {
"valueCoding": {
"display": "Yes"
}
}, {
"valueCoding": {
"display": "No"
}
} ],
"enableBehavior": "all"
}, {
"text": "Unsafe contact persons (do not speak with)",
"type": "choice",
"_text": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": ""
} ]
},
"linkId": "additionalinfo_unsafecontacts_select",
"repeats": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "check-box",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Check-box"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"display": "Unsafe contact persons (do not speak with)"
}
} ]
}, {
"enableBehavior": "all",
"linkId": "additionalinfo_unsafecontacts_speakwithpatientdirectly",
"repeats": true,
"type": "choice",
"enableWhen": [ {
"operator": "=",
"question": "additionalinfo_unsafecontacts_select",
"answerCoding": {
"display": "Unsafe contact persons (do not speak with)"
}
} ],
"answerOption": [ {
"valueCoding": {
"display": "Only speak with patient directly"
}
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "check-box",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Check-box"
} ]
}
} ],
"_text": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": ""
} ]
},
"text": "Only speak with patient directly"
}, {
"text": "Do not speak with:",
"type": "string",
"linkId": "additionalinfo_unsafecontacts_donotspeakwith",
"enableWhen": [ {
"operator": "=",
"question": "additionalinfo_unsafecontacts_select",
"answerCoding": {
"display": "Unsafe contact persons (do not speak with)"
}
} ],
"enableBehavior": "all"
}, {
"text": "Accessibility concerns or disability",
"type": "choice",
"_text": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": ""
} ]
},
"linkId": "additionalinfo_accessibilityconcernsordisability_select",
"repeats": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "check-box",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Check-box"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"display": "Accessibility concerns or disability"
}
} ]
}, {
"text": "Accessibility concerns Options",
"type": "choice",
"_text": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "
"
} ]
},
"linkId": "additionalinfo_accessibilityconcernsordisability",
"repeats": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "check-box",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Check-box"
} ]
}
} ],
"enableWhen": [ {
"operator": "=",
"question": "additionalinfo_accessibilityconcernsordisability_select",
"answerCoding": {
"display": "Accessibility concerns or disability"
}
} ],
"answerOption": [ {
"valueCoding": {
"display": "Falls risk"
}
}, {
"valueCoding": {
"display": "Patient requires lift"
}
}, {
"valueCoding": {
"display": "Wheelchair"
}
}, {
"valueCoding": {
"display": "Hearing impaired"
}
} ]
}, {
"text": "Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)",
"type": "choice",
"_text": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": ""
} ]
},
"linkId": "additionalinfo_specialconsiderations_select",
"repeats": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "check-box",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Check-box"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"display": "Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)"
}
} ]
}, {
"text": "Details of special considerations:",
"type": "text",
"linkId": "additionalinfo_specialconsiderations",
"enableWhen": [ {
"operator": "=",
"question": "additionalinfo_specialconsiderations_select",
"answerCoding": {
"display": "Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)"
}
} ]
}, {
"text": "Send copies of reports to additional providers",
"type": "choice",
"_text": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": ""
} ]
},
"linkId": "additionalinfo_sendcopiestoadditionalproviders",
"repeats": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "check-box",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Check-box"
} ]
}
} ],
"answerOption": [ {
"valueCoding": {
"display": "Send copies of reports to additional providers"
}
} ]
}, {
"item": [ {
"text": "Contact information:",
"type": "string",
"linkId": "additionalinfo_sendcopiestoadditionalproviders_contactinfo",
"required": true,
"enableWhen": [ {
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Suggested investigations to include with referral:
Suggested investigations to include with referral:
Suggested investigations to include with referral:
Referral Guidance:
Suggested investigations to include with referral:
Suggested investigations to include with referral:
Suggested investigations to include with referral:
Suggested investigations to include with referral:
Suggested investigations to include with referral:
Suggested investigations to include with referral:
Suggested investigations to include with referral:
Suggested investigations to include with referral:
Suggested investigations to include with referral:
Suggested investigations to include with referral:
Suggested investigations to include with referral:
Suggested investigations to include with referral:
Suggested investigations to include with referral:
Suggested investigations to include with referral:
Suggested investigations to include with referral:
Suggested investigations to include with referral:
Suggested investigations to include with referral:
Suggested investigations to include with referral:
Suggested investigations to include with referral:
Suggested investigations to include with referral:
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