{
"description": null,
"_filename": "examples/Questionnaire-HSR.json",
"package_name": "ca.on.health.sadie",
"subjectType": [ "Patient" ],
"date": null,
"meta": {
"source": "#bGVYbVewo4Lr6Ku2",
"versionId": "81",
"lastUpdated": "2021-06-25T18:40:56.418+00:00"
},
"publisher": null,
"name": "Health Status Report",
"item": [ {
"linkId": "0",
"repeats": false,
"item": [ {
"item": [ {
"text": "Profession",
"type": "string",
"linkId": "0.1.1",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 100
} ],
"text": "Health Care Professional Details",
"type": "group",
"linkId": "0.1",
"repeats": false,
"readOnly": false,
"required": false
}, {
"item": [ {
"text": "Important: Member ID and referral ID are provided to ODSP applicants by their caseworkers. The ID’s can be found at the top of your applicant’s paper Disability Determination Package Forms. If your patient does not have an applicant started with the ministry, you cannot complete this form.",
"type": "display",
"linkId": "0.2.1",
"repeats": false,
"readOnly": false,
"required": false
}, {
"text": "Member ID (9 digits)",
"type": "string",
"linkId": "member-id",
"repeats": false,
"readOnly": false,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "[0-9]*"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/minLength",
"valueInteger": 9
} ],
"maxLength": 9
}, {
"text": "Referral ID (16 digits)",
"type": "string",
"linkId": "referral-id",
"repeats": false,
"readOnly": false,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "[0-9]*"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/minLength",
"valueInteger": 16
} ],
"maxLength": 16
} ],
"text": "Applicant's Social Assistance Identification",
"type": "group",
"linkId": "0.2",
"repeats": false,
"readOnly": false,
"required": false
}, {
"item": [ {
"item": [ {
"text": "Very important: Please ensure that your patient has completed the form, as missing information may impact adjudication timelines.",
"type": "display",
"linkId": "0.3.1-help",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Help-Button",
"coding": [ {
"code": "help",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Help-Button"
} ]
}
} ]
} ],
"text": "With your patient’s consent, you may upload their Consent to the Release of Medical and Related Information form.",
"type": "boolean",
"linkId": "0.3.1",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 0
}, {
"text": "Attach your patient’s consent form.",
"type": "attachment",
"linkId": "0.3.2",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 0,
"enableWhen": [ {
"operator": "=",
"question": "0.3.1",
"answerBoolean": true
} ]
}, {
"text": "With your patient’s consent, you may upload their Self Report form.",
"type": "boolean",
"linkId": "0.3.3",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 0
}, {
"enableBehavior": "any",
"linkId": "0.3.4",
"repeats": false,
"type": "attachment",
"enableWhen": [ {
"operator": "=",
"question": "0.3.3",
"answerBoolean": true
} ],
"readOnly": false,
"maxLength": 0,
"required": false,
"text": "Attach your patient’s Self Report form."
} ],
"text": "Applicant Forms",
"type": "group",
"linkId": "0.3",
"repeats": false,
"readOnly": false,
"required": false
} ],
"type": "group",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Header",
"coding": [ {
"code": "header",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Header"
} ]
}
} ],
"readOnly": false,
"maxLength": 0,
"required": false,
"text": "General"
}, {
"linkId": "1",
"repeats": false,
"item": [ {
"item": [ {
"item": [ {
"text": "First Name",
"type": "string",
"linkId": "1.1.1.1",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 100
}, {
"text": "Middle Initial",
"type": "string",
"linkId": "1.1.1.2",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 2
}, {
"text": "Last Name",
"type": "string",
"linkId": "1.1.1.3",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 100
}, {
"text": "Date of Birth",
"type": "date",
"linkId": "1.1.1.4",
"repeats": false,
"readOnly": false,
"required": true
} ],
"text": "Specify the requested patient information:",
"type": "group",
"linkId": "1.1.1",
"repeats": false
} ],
"text": "Applicant's Information",
"type": "group",
"linkId": "1.1",
"repeats": false,
"readOnly": false,
"required": false
}, {
"item": [ {
"text": "Unit Number",
"type": "string",
"linkId": "1.2.1",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 10
}, {
"text": "Street Number",
"type": "integer",
"linkId": "1.2.2",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 10
}, {
"text": "Street Name",
"type": "string",
"linkId": "1.2.3",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 25
}, {
"text": "City/Town",
"type": "string",
"linkId": "1.2.4",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 25
}, {
"text": "Province",
"type": "string",
"linkId": "1.2.5",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 25
}, {
"text": "Postal Code",
"type": "string",
"linkId": "1.2.6",
"repeats": false,
"readOnly": false,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/minLength",
"valueInteger": 6
} ],
"maxLength": 7
} ],
"text": "Applicant's Current Address",
"type": "group",
"linkId": "1.2",
"repeats": false,
"readOnly": false,
"required": false
} ],
"type": "group",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Header",
"coding": [ {
"code": "header",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Header"
} ]
}
} ],
"readOnly": false,
"maxLength": 0,
"required": false,
"text": "Applicant"
}, {
"linkId": "2",
"repeats": false,
"item": [ {
"item": [ {
"linkId": "2.1.1",
"repeats": false,
"type": "choice",
"answerOption": [ {
"valueCoding": {
"code": "Medical Condition",
"display": "Refers to illness, disease, injury (e.g., physiological, mental health, psychological, developmental)."
}
}, {
"valueCoding": {
"code": "Impairment",
"display": "Refers to any loss or deviation in psychological, physiological or anatomical structure or function."
}
}, {
"valueCoding": {
"code": "Duration",
"display": "Refers to how long the impairment, either continuous or recurrent, is expected to last from the date the disability determination form is completed."
}
}, {
"valueCoding": {
"code": "Restriction",
"display": "Refers to a limitation in activities of daily living caused directly by the impairment."
}
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-displayCategory",
"valueCode": "display"
} ],
"readOnly": false,
"maxLength": 0,
"required": true,
"text": "Please provide information below."
}, {
"item": [ {
"text": "To add additional conditions or associated impairments, click on the '+' button",
"type": "display",
"linkId": "2.1.2-help",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Help-Button",
"coding": [ {
"code": "help",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Help-Button"
} ]
}
} ]
}, {
"text": "Medical Condition",
"type": "text",
"linkId": "2.1.2.1",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 100
}, {
"item": [ {
"text": "Refers to any loss or deviation in psychological, physiological or anatomical structure or function.",
"type": "display",
"linkId": "2.1.2.2-help",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Help-Button",
"coding": [ {
"code": "help",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Help-Button"
} ]
}
} ]
} ],
"text": "Describe associated impairment(s)",
"type": "text",
"linkId": "2.1.2.2",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 500
}, {
"item": [ {
"text": "Refers to a limitation in activities of daily living caused directly by the impairment.",
"type": "display",
"linkId": "2.1.2.1.3-help",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Help-Button",
"coding": [ {
"code": "help",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Help-Button"
} ]
}
} ]
} ],
"text": "Describe associated restriction(s)",
"type": "text",
"linkId": "2.1.2.3",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 500
}, {
"linkId": "2.1.2.4",
"repeats": false,
"type": "choice",
"answerOption": [ {
"valueString": "Deteriorate"
}, {
"valueString": "Improve"
}, {
"valueString": "Remain the Same"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Radio Button",
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "vertical"
} ],
"readOnly": false,
"maxLength": 0,
"required": true,
"text": "Prognosis"
}, {
"linkId": "2.1.2.5",
"repeats": false,
"type": "choice",
"answerOption": [ {
"valueString": "1 year or more"
}, {
"valueString": "Less than 1 year"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Radio Button",
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "vertical"
} ],
"readOnly": false,
"maxLength": 0,
"required": true,
"text": "Duration of impairment"
}, {
"linkId": "2.1.2.6",
"repeats": false,
"type": "choice",
"answerOption": [ {
"valueString": "Recurrent/episodic"
}, {
"valueString": "Continuous"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Radio Button",
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "vertical"
} ],
"readOnly": false,
"maxLength": 0,
"required": true,
"text": "Frequency"
} ],
"text": "Provide information about medical conditions and associated impairments, durations and restrictions.",
"type": "group",
"linkId": "2.1.2",
"repeats": true,
"readOnly": false,
"required": false,
"maxLength": 0
} ],
"text": "1. Medical Conditions that Contribute to the Applicant's Current Status",
"type": "group",
"linkId": "2.1",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 0
}, {
"item": [ {
"text": "Indicate whether any of the medical conditions reported in section 1 include conditions described below.",
"type": "display",
"linkId": "2.2.0",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 0
}, {
"text": "Mental health condition",
"type": "boolean",
"linkId": "2.2.1",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 0
}, {
"text": "Substance-related or addictive disorder",
"type": "boolean",
"linkId": "2.2.2",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 0
}, {
"text": "Neurodevelopmental disorder (e.g., intellectual disability, autism spectrum disorder, developmental delay, specific learning disability, attention-deficit/hyperactivity disorder, Fetal Alcohol Spectrum Disorder",
"type": "boolean",
"linkId": "2.2.3",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 0
}, {
"text": "Other medical condition presenting with a mental or cognitive impairment (e.g., traumatic brain injury, stroke, seizure disorder)",
"type": "boolean",
"linkId": "2.2.4",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 0
}, {
"item": [ {
"text": "Relevant additional information may include: History, interventions, access to treatment, services, housing, homelessness, etc. that might be useful to understand the presenting impairments and their impact.",
"type": "display",
"linkId": "2.2.5-help",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Help-Button",
"coding": [ {
"code": "help",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Help-Button"
} ]
}
} ]
} ],
"text": "If there is additional information that might be useful in understanding the applicant’s mental or cognitive impairments please describe or attach copies of available reports (e.g., psychology, psychiatry, educational assessment, individual education plan, neuropsychological assessment, other mental health consult).",
"type": "text",
"linkId": "2.2.5",
"repeats": true,
"readOnly": false,
"required": false,
"maxLength": 8000
}, {
"item": [ {
"text": "Attachment Categories",
"type": "choice",
"linkId": "2.2.6-categories",
"repeats": false,
"readOnly": false,
"required": false,
"answerOption": [ {
"valueString": "Lab result/report"
}, {
"valueString": "Clinical consult/progress note"
}, {
"valueString": "Discussion/Description"
}, {
"valueString": "Medication record"
}, {
"valueString": "Procedure result/report"
}, {
"valueString": "Other"
} ]
} ],
"text": "Attach related documents",
"type": "attachment",
"linkId": "2.2.6",
"repeats": true,
"readOnly": false,
"required": false
} ],
"text": "2. Additional Information",
"type": "group",
"linkId": "2.2",
"repeats": false
}, {
"item": [ {
"text": "Does your patient have features or symptoms that might be seen in mental health, substance use, neurocognitive and related conditions?",
"type": "boolean",
"linkId": "2.3.1",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 0
}, {
"linkId": "2.3.1b",
"repeats": false,
"item": [ {
"text": "The list below consists of some features or symptoms that might be seen in mental health, substance use, neurocognitive and related conditions that can impact daily functioning. Rate the symptoms in the context of the applicant’s presenting conditions and impairments. For episodic symptoms, please describe how fluctuations in the severity level affect the patient.",
"type": "display",
"linkId": "2.3.1b-help",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Help-Button",
"coding": [ {
"code": "help",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Help-Button"
} ]
}
} ]
} ],
"type": "display",
"enableWhen": [ {
"operator": "=",
"question": "2.3.1",
"answerBoolean": true
} ],
"readOnly": false,
"maxLength": 0,
"required": true,
"text": "Intellectual and Emotional Wellness Scale (IEWS)"
}, {
"item": [ {
"linkId": "2.3.2.1",
"repeats": false,
"type": "choice",
"answerOption": [ {
"valueCoding": {
"code": "DK",
"display": "Don't Know"
}
}, {
"valueCoding": {
"code": "0",
"display": "Not present / Not at all"
}
}, {
"valueCoding": {
"code": "1",
"display": "Mild / Just a little"
}
}, {
"valueCoding": {
"code": "2",
"display": "Moderate / Quite a bit"
}
}, {
"valueCoding": {
"code": "3",
"display": "Severe / Very much"
}
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-displayCategory",
"valueCode": "display"
} ],
"readOnly": false,
"maxLength": 0,
"required": false,
"text": "Rating Scale"
}, {
"item": [ {
"linkId": "2.3.2.2.1",
"repeats": false,
"type": "choice",
"answerOption": [ {
"valueString": "DK"
}, {
"valueString": "0"
}, {
"valueString": "1"
}, {
"valueString": "2"
}, {
"valueString": "3"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Radio Button",
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
} ],
"readOnly": false,
"maxLength": 0,
"required": true,
"text": "Ammotivation"
} ],
"type": "group",
"linkId": "2.3.2.2",
"repeats": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Group gtable",
"coding": [ {
"code": "gtable",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Group gtable"
} ]
}
} ]
}, {
"item": [ {
"linkId": "2.3.2.3.1",
"repeats": false,
"type": "choice",
"answerOption": [ {
"valueString": "DK"
}, {
"valueString": "0"
}, {
"valueString": "1"
}, {
"valueString": "2"
}, {
"valueString": "3"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Radio Button",
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
} ],
"readOnly": false,
"maxLength": 0,
"required": true,
"text": "Anxiety"
} ],
"type": "group",
"linkId": "2.3.2.3",
"repeats": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Group gtable",
"coding": [ {
"code": "gtable",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Group gtable"
} ]
}
} ]
}, {
"item": [ {
"linkId": "2.3.2.4.1",
"repeats": false,
"type": "choice",
"answerOption": [ {
"valueString": "DK"
}, {
"valueString": "0"
}, {
"valueString": "1"
}, {
"valueString": "2"
}, {
"valueString": "3"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Radio Button",
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
} ],
"readOnly": false,
"maxLength": 0,
"required": true,
"text": "Appetite Change"
}, {
"linkId": "2.3.2.4.2",
"repeats": false,
"type": "choice",
"answerOption": [ {
"valueString": "Increase"
}, {
"valueString": "Decrease"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Radio Button",
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}, {
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-enableWhenExpression",
"valueExpression": {
"language": "text/fhirpath",
"expression": "%context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.4').item.where(linkId='2.3.2.4.1').answer.valueString='1' or %context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.4').item.where(linkId='2.3.2.4.1').answer.valueString='2' or %context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.4').item.where(linkId='2.3.2.4.1').answer.valueString='3'"
}
} ],
"readOnly": false,
"maxLength": 0,
"required": false,
"text": "How has the appetite changed?"
} ],
"type": "group",
"linkId": "2.3.2.4",
"repeats": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Group gtable",
"coding": [ {
"code": "gtable",
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"text": "Psychomotor retardation"
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"valueString": "Agitation"
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"valueString": "Retardation"
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"readOnly": false,
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"text": "Agitation or retardation?"
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"item": [ {
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"readOnly": false,
"maxLength": 0,
"required": true,
"text": "Sleep dysfunction"
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"linkId": "2.3.2.24.2",
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"type": "choice",
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"valueString": "Difficulty sleeping"
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"valueString": "Excessive sleeping"
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"readOnly": false,
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"item": [ {
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"readOnly": false,
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"maxLength": 0,
"required": true,
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"valueString": "Attempts"
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"readOnly": false,
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"required": false,
"text": "Suicidal behaviours – select all that apply:"
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"readOnly": false,
"maxLength": 0,
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"required": true,
"text": "Withdrawn"
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} ],
"enableWhen": [ {
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}, {
"text": "For episodic symptoms, describe how fluctuations in severity level affect the patient",
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} ],
"text": "2.2 Intellectual and Emotional Wellness ",
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"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 0
}, {
"item": [ {
"text": "Note: You do not have to repeat the information already provided in previous sections.",
"type": "display",
"linkId": "2.4.1",
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"readOnly": false,
"required": false
}, {
"text": "How long have you known the applicant?",
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"linkId": "2.4.2",
"repeats": false,
"readOnly": false,
"required": false
}, {
"text": "How often do you see the applicant for the conditions and/or impairments listed in Section 1?",
"type": "string",
"linkId": "2.4.3",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 100
}, {
"text": "If relevant, state the applicant’s height in centimetres",
"type": "decimal",
"linkId": "2.4.4",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
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"valueCoding": {
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}
} ],
"maxLength": 255
}, {
"text": "If relevant, state the applicant’s weight in kilograms",
"type": "decimal",
"linkId": "2.4.5",
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"readOnly": false,
"required": false,
"extension": [ {
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"valueCoding": {
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}
} ],
"maxLength": 255
}, {
"text": "Body Mass Index (BMI)",
"type": "decimal",
"linkId": "2.4.6",
"repeats": false,
"readOnly": true,
"required": false,
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}
}, {
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"valueInteger": 1
} ],
"maxLength": 10
}, {
"text": "Other relevant Patient details (i.e. Blood Pressure)",
"type": "string",
"linkId": "2.4.7",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 100
}, {
"text": "Are there examination findings that you wish to include?",
"type": "boolean",
"linkId": "2.4.8",
"repeats": false,
"readOnly": false,
"required": true
}, {
"text": "Enter examination findings:",
"type": "text",
"linkId": "2.4.9",
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"required": false,
"maxLength": 4000,
"enableWhen": [ {
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"question": "2.4.8",
"answerBoolean": true
} ]
}, {
"text": "For recurrent or episodic impairments listed, describe how fluctuations in severity level affect the patient.",
"type": "text",
"linkId": "2.4.10",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 4000,
"enableWhen": [ {
"operator": "=",
"question": "2.4.8",
"answerBoolean": true
} ]
}, {
"text": "Have any consultations or assessments been completed by another health care professional?",
"type": "boolean",
"linkId": "2.4.11",
"repeats": false,
"readOnly": false,
"required": false
}, {
"linkId": "2.4.12",
"repeats": false,
"item": [ {
"text": "For example, laboratory, biopsy, sleep study, ultrasound, imaging, stress test",
"type": "display",
"linkId": "2.4.12-help",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Help-Button",
"coding": [ {
"code": "help",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Help-Button"
} ]
}
} ]
} ],
"type": "text",
"enableWhen": [ {
"operator": "=",
"question": "2.4.11",
"answerBoolean": true
} ],
"readOnly": false,
"maxLength": 4000,
"required": false,
"text": "Describe diagnostic tests or investigations"
}, {
"item": [ {
"text": "Attachment Categories",
"type": "choice",
"linkId": "2.4.12-categories",
"repeats": false,
"readOnly": false,
"required": false,
"answerOption": [ {
"valueString": "Lab result/report"
}, {
"valueString": "Clinical consult/progress note"
}, {
"valueString": "Discussion/Description"
}, {
"valueString": "Medication record"
}, {
"valueString": "Procedure result/report"
}, {
"valueString": "Other"
} ]
} ],
"text": "Attach relevant diagnostic tests or investigations",
"type": "attachment",
"linkId": "2.4.12-attachment",
"repeats": true,
"readOnly": false,
"required": false,
"enableWhen": [ {
"operator": "=",
"question": "2.4.11",
"answerBoolean": true
} ]
}, {
"linkId": "2.4.13",
"repeats": false,
"item": [ {
"text": "For example, cardiology, neurology, oncology, psychiatry, psychology, rheumatology",
"type": "display",
"linkId": "2.4.13-help",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Help-Button",
"coding": [ {
"code": "help",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Help-Button"
} ]
}
} ]
} ],
"type": "text",
"enableWhen": [ {
"operator": "=",
"question": "2.4.11",
"answerBoolean": true
} ],
"readOnly": false,
"maxLength": 4000,
"required": false,
"text": "Describe specialist consults"
}, {
"item": [ {
"text": "Attachment Categories",
"type": "choice",
"linkId": "2.4.13-categories",
"repeats": false,
"readOnly": false,
"required": false,
"answerOption": [ {
"valueString": "Lab result/report"
}, {
"valueString": "Clinical consult/progress note"
}, {
"valueString": "Discussion/Description"
}, {
"valueString": "Medication record"
}, {
"valueString": "Procedure result/report"
}, {
"valueString": "Other"
} ]
} ],
"text": "Attach relevant specialist consults",
"type": "attachment",
"linkId": "2.4.13-attachment",
"repeats": true,
"readOnly": false,
"required": false,
"enableWhen": [ {
"operator": "=",
"question": "2.4.11",
"answerBoolean": true
} ]
}, {
"linkId": "2.4.14",
"repeats": false,
"item": [ {
"text": "For example, vocational assessment, occupational therapy report",
"type": "display",
"linkId": "2.4.14-help",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Help-Button",
"coding": [ {
"code": "help",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Help-Button"
} ]
}
} ]
} ],
"type": "text",
"enableWhen": [ {
"operator": "=",
"question": "2.4.11",
"answerBoolean": true
} ],
"readOnly": false,
"maxLength": 4000,
"required": false,
"text": "Describe other assessments or reports"
}, {
"item": [ {
"text": "Attachment Categories",
"type": "choice",
"linkId": "2.4.14-categories",
"repeats": false,
"readOnly": false,
"required": false,
"answerOption": [ {
"valueString": "Lab result/report"
}, {
"valueString": "Clinical consult/progress note"
}, {
"valueString": "Discussion/Description"
}, {
"valueString": "Medication record"
}, {
"valueString": "Procedure result/report"
}, {
"valueString": "Other"
} ]
} ],
"text": "Attach relevant other assessments or reports",
"type": "attachment",
"linkId": "2.4.14-attachment",
"repeats": true,
"readOnly": false,
"required": false,
"enableWhen": [ {
"operator": "=",
"question": "2.4.11",
"answerBoolean": true
} ]
} ],
"text": "3. Available Medical and Other Information Related to Section 1",
"type": "group",
"linkId": "2.4",
"repeats": false,
"readOnly": false,
"required": false
}, {
"item": [ {
"text": "Does the patient have a visual impairment as described in Section 1 of this request?",
"type": "boolean",
"linkId": "2.5.1",
"repeats": false,
"readOnly": false,
"required": true
}, {
"text": "Date of Diagnosis (if known) ",
"type": "date",
"linkId": "2.5.2",
"repeats": false,
"readOnly": false,
"required": false,
"enableWhen": [ {
"operator": "=",
"question": "2.5.1",
"answerBoolean": true
} ]
}, {
"text": "Most Recent Assessment Date",
"type": "date",
"linkId": "2.5.3",
"repeats": false,
"readOnly": false,
"required": false,
"enableWhen": [ {
"operator": "=",
"question": "2.5.1",
"answerBoolean": true
} ]
}, {
"linkId": "2.5.5",
"repeats": true,
"item": [ {
"linkId": "2.5.5.1",
"repeats": false,
"item": [ {
"text": "Select the eye being reported on (i.e. right eye)",
"type": "display",
"linkId": "2.5.5.1-help",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Help-Button",
"coding": [ {
"code": "help",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Help-Button"
} ]
}
} ]
} ],
"type": "choice",
"answerOption": [ {
"valueString": "Both eyes"
}, {
"valueString": "Left eye"
}, {
"valueString": "Right eye"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Drop down",
"coding": [ {
"code": "drop down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"readOnly": false,
"required": false,
"text": "Eye"
}, {
"text": "Uncorrected - Near",
"type": "text",
"linkId": "2.5.5.2",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 100
}, {
"text": "Uncorrected - Distance",
"type": "text",
"linkId": "2.5.5.3",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 100
}, {
"text": "Corrected - Near",
"type": "text",
"linkId": "2.5.5.4",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 100
}, {
"text": "Corrected - Distance",
"type": "text",
"linkId": "2.5.5.5",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 100
} ],
"type": "group",
"enableWhen": [ {
"operator": "=",
"question": "2.5.1",
"answerBoolean": true
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-minOccurs",
"valueInteger": 3
} ],
"readOnly": false,
"required": true,
"text": "Snellen Visual Acuity Chart Details"
}, {
"text": "Is there a visual field defect component in the visual impairment?",
"type": "boolean",
"linkId": "2.5.6",
"repeats": false,
"readOnly": false,
"required": true,
"enableWhen": [ {
"operator": "=",
"question": "2.5.1",
"answerBoolean": true
} ]
}, {
"item": [ {
"item": [ {
"text": "Please describe the visual field defect component and/or attach reports.",
"type": "display",
"linkId": "2.5.7.1-help",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Help-Button",
"coding": [ {
"code": "help",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Help-Button"
} ]
}
} ]
} ],
"text": "Describe the visual field defect of the patient",
"type": "display",
"linkId": "2.5.7.1",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 0
}, {
"text": "Visual Field Defect",
"type": "text",
"linkId": "2.5.7.1b",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 1000
} ],
"type": "group",
"linkId": "2.5.7",
"repeats": false,
"readOnly": false,
"required": true,
"enableWhen": [ {
"operator": "=",
"question": "2.5.6",
"answerBoolean": true
} ]
}, {
"text": "Is there a change in ocular mobility (e.g., diplopia, strabismus) or deformities of the orbit that alter function?",
"type": "boolean",
"linkId": "2.5.8",
"repeats": false,
"readOnly": false,
"required": true,
"enableWhen": [ {
"operator": "=",
"question": "2.5.1",
"answerBoolean": true
} ]
}, {
"item": [ {
"item": [ {
"text": "Please describe the change in ocular mobility or deformities and/or attach reports.",
"type": "display",
"linkId": "2.5.9.1-help",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Help-Button",
"coding": [ {
"code": "help",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Help-Button"
} ]
}
} ]
} ],
"text": "Describe the ocular mobility defect of the patient",
"type": "display",
"linkId": "2.5.9.1",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 0
}, {
"text": "Ocular Mobility Defect",
"type": "text",
"linkId": "2.5.9.1b",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 1000
} ],
"type": "group",
"linkId": "2.5.9",
"repeats": false,
"readOnly": false,
"required": false,
"enableWhen": [ {
"operator": "=",
"question": "2.5.8",
"answerBoolean": true
} ]
}, {
"item": [ {
"text": "Attachment Categories",
"type": "choice",
"linkId": "2.5.10-categories",
"repeats": false,
"readOnly": false,
"required": false,
"answerOption": [ {
"valueString": "Lab result/report"
}, {
"valueString": "Clinical consult/progress note"
}, {
"valueString": "Discussion/Description"
}, {
"valueString": "Medication record"
}, {
"valueString": "Procedure result/report"
}, {
"valueString": "Other"
} ]
} ],
"text": "Attach copies of Visual report(s) pertaining to the patient's diagnosis/condition. You may also wish to attach consult notes.",
"type": "attachment",
"linkId": "2.5.10",
"repeats": true,
"readOnly": false,
"required": false,
"enableWhen": [ {
"operator": "=",
"question": "2.5.1",
"answerBoolean": true
} ]
} ],
"text": "4. Visual",
"type": "group",
"linkId": "2.5",
"repeats": false,
"readOnly": false,
"required": false
}, {
"item": [ {
"text": "Does the patient have an auditory impairment as described in Section 1 of this request?",
"type": "boolean",
"linkId": "2.6.1",
"repeats": false,
"readOnly": false,
"required": true
}, {
"text": "Date of Diagnosis (if known)",
"type": "date",
"linkId": "2.6.2",
"repeats": false,
"readOnly": false,
"required": false,
"enableWhen": [ {
"operator": "=",
"question": "2.6.1",
"answerBoolean": true
} ]
}, {
"text": "Most Recent Assessment Date",
"type": "date",
"linkId": "2.6.3",
"repeats": false,
"readOnly": false,
"required": false,
"enableWhen": [ {
"operator": "=",
"question": "2.6.1",
"answerBoolean": true
} ]
}, {
"linkId": "2.6.4",
"repeats": false,
"type": "choice",
"enableWhen": [ {
"operator": "=",
"question": "2.6.1",
"answerBoolean": true
} ],
"answerOption": [ {
"valueString": "Bilateral"
}, {
"valueString": "Unilateral"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Drop down",
"coding": [ {
"code": "drop down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"readOnly": false,
"required": true,
"text": "What type is the hearing loss?"
}, {
"text": "Has there been any change in hearing loss over the last 5 years?",
"type": "boolean",
"linkId": "2.6.5",
"repeats": false,
"readOnly": false,
"required": true,
"enableWhen": [ {
"operator": "=",
"question": "2.6.1",
"answerBoolean": true
} ]
}, {
"text": "Describe the auditory impairment the patient experienced",
"type": "text",
"linkId": "2.6.6",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 4000,
"enableWhen": [ {
"operator": "=",
"question": "2.6.5",
"answerBoolean": true
} ]
}, {
"text": "Does the applicant have difficulty understanding speech in a quiet environment?",
"type": "boolean",
"linkId": "2.6.7",
"repeats": false,
"readOnly": false,
"required": true,
"enableWhen": [ {
"operator": "=",
"question": "2.6.1",
"answerBoolean": true
} ]
}, {
"text": "Describe the patient's difficulty understanding speech in a quiet environment.",
"type": "text",
"linkId": "2.6.8",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 4000,
"enableWhen": [ {
"operator": "=",
"question": "2.6.7",
"answerBoolean": true
} ]
}, {
"text": "Does the applicant have difficulty understanding conversational speech in the presence of background noise? ",
"type": "boolean",
"linkId": "2.6.9",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 0,
"enableWhen": [ {
"operator": "=",
"question": "2.6.1",
"answerBoolean": true
} ]
}, {
"text": "Describe the applicant's difficulty understanding conversational speech in the presence of background noise.",
"type": "text",
"linkId": "2.6.10",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 4000,
"enableWhen": [ {
"operator": "=",
"question": "2.6.9",
"answerBoolean": true
} ]
}, {
"text": "Are there safety concerns related to hearing (e.g., unable to localize sound of approaching vehicles)?",
"type": "boolean",
"linkId": "2.6.11",
"repeats": false,
"readOnly": false,
"required": true,
"enableWhen": [ {
"operator": "=",
"question": "2.6.1",
"answerBoolean": true
} ]
}, {
"text": "Describe the safety concerns related to hearing.",
"type": "text",
"linkId": "2.6.12",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 4000,
"enableWhen": [ {
"operator": "=",
"question": "2.6.11",
"answerBoolean": true
} ]
}, {
"text": "Does the applicant have a constant/annoying ringing (tinnitus) in ears?",
"type": "boolean",
"linkId": "2.6.13",
"repeats": false,
"readOnly": false,
"required": true,
"enableWhen": [ {
"operator": "=",
"question": "2.6.1",
"answerBoolean": true
} ]
}, {
"text": "Describe the applicant's tinnitus.",
"type": "text",
"linkId": "2.6.14",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 4000,
"enableWhen": [ {
"operator": "=",
"question": "2.6.13",
"answerBoolean": true
} ]
}, {
"text": "Does the applicant wear hearing aids?",
"type": "boolean",
"linkId": "2.6.15",
"repeats": false,
"readOnly": false,
"required": true,
"enableWhen": [ {
"operator": "=",
"question": "2.6.1",
"answerBoolean": true
} ]
}, {
"text": "Describe the applicant's hearing aids.",
"type": "text",
"linkId": "2.6.16",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 4000,
"enableWhen": [ {
"operator": "=",
"question": "2.6.15",
"answerBoolean": true
} ]
}, {
"text": "With the hearing aid(s), could or can the applicant function within normal limits?",
"type": "boolean",
"linkId": "2.6.17",
"repeats": false,
"readOnly": false,
"required": true,
"enableWhen": [ {
"operator": "=",
"question": "2.6.15",
"answerBoolean": true
} ]
}, {
"text": "If no, describe",
"type": "text",
"linkId": "2.6.18",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 4000,
"enableWhen": [ {
"operator": "=",
"question": "2.6.17",
"answerBoolean": false
} ]
}, {
"item": [ {
"text": "Attachment Categories",
"type": "choice",
"linkId": "2.6.19-categories",
"repeats": false,
"readOnly": false,
"required": false,
"answerOption": [ {
"valueString": "Lab result/report"
}, {
"valueString": "Clinical consult/progress note"
}, {
"valueString": "Discussion/Description"
}, {
"valueString": "Medication record"
}, {
"valueString": "Procedure result/report"
}, {
"valueString": "Other"
} ]
} ],
"text": "Attach copies of Auditory report(s) pertaining to the patient's diagnosis/condition. You may also wish to attach consult notes. ",
"type": "attachment",
"linkId": "2.6.19",
"repeats": true,
"readOnly": false,
"required": false,
"enableWhen": [ {
"operator": "=",
"question": "2.6.1",
"answerBoolean": true
} ]
} ],
"text": "5. Auditory",
"type": "group",
"linkId": "2.6",
"repeats": false,
"readOnly": false,
"required": false
}, {
"item": [ {
"text": "Is the applicant receiving any intervention and treatment for conditions and impairments listed in section 1?",
"type": "boolean",
"linkId": "2.7.1",
"repeats": false,
"readOnly": false,
"required": true
}, {
"text": "Does the applicant have any relevant hospitalizations?",
"type": "boolean",
"linkId": "2.7.2",
"repeats": false,
"readOnly": false,
"required": true,
"enableWhen": [ {
"operator": "=",
"question": "2.7.1",
"answerBoolean": true
} ]
}, {
"item": [ {
"text": "To add additional treatments/interventions, click on the '+' button",
"type": "display",
"linkId": "2.7.3-help",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Help-Button",
"coding": [ {
"code": "help",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Help-Button"
} ]
}
} ]
}, {
"item": [ {
"text": "Describe the nature of the visit (admission, emergency room visit, surgery)",
"type": "display",
"linkId": "GEN-DH-DRUG-TXT-help",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Help-Button",
"coding": [ {
"code": "help",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Help-Button"
} ]
}
} ]
} ],
"text": "Admission, Emergency Room Visit, Surgery",
"type": "string",
"linkId": "2.7.3.1",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 4000
}, {
"text": "Date of Visit",
"type": "date",
"linkId": "2.7.3.2",
"repeats": false,
"readOnly": false,
"required": false
}, {
"text": "Duration",
"type": "text",
"linkId": "22.7.3.3",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 500
}, {
"text": "Describe Purpose or Attach Admission/ Discharge Report",
"type": "text",
"linkId": "2.7.3.4",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 4000
}, {
"item": [ {
"text": "Attachment Categories",
"type": "choice",
"linkId": "2.7.3.5-categories",
"repeats": false,
"readOnly": false,
"required": false,
"answerOption": [ {
"valueString": "Lab result/report"
}, {
"valueString": "Clinical consult/progress note"
}, {
"valueString": "Discussion/Description"
}, {
"valueString": "Medication record"
}, {
"valueString": "Procedure result/report"
}, {
"valueString": "Other"
} ]
} ],
"text": "Discharge Report",
"type": "attachment",
"linkId": "2.7.3.5",
"repeats": true,
"readOnly": false,
"required": false
} ],
"text": "Describe hospitalizations, completing relevant sections below and comment on progress.",
"type": "group",
"linkId": "2.7.3",
"repeats": true,
"readOnly": false,
"required": true,
"enableWhen": [ {
"operator": "=",
"question": "2.7.2",
"answerBoolean": true
} ]
}, {
"text": "Does the applicant have any relevant interventions or services?",
"type": "boolean",
"linkId": "2.7.4",
"repeats": false,
"readOnly": false,
"required": true,
"enableWhen": [ {
"operator": "=",
"question": "2.7.1",
"answerBoolean": true
} ]
}, {
"item": [ {
"text": "To add additional medications, click on the '+' button",
"type": "display",
"linkId": "2.7.5-help",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Help-Button",
"coding": [ {
"code": "help",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Help-Button"
} ]
}
} ]
}, {
"linkId": "2.7.5.1",
"repeats": false,
"item": [ {
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} ],
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} ],
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}
} ],
"readOnly": false,
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"contact": [ {
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} ]
} ],
"effectivePeriod": {
"start": "2021-06-14T05:00:00.000Z"
}
}