{
"description": "COVID-19 assessment questionnaire",
"_filename": "examples/cov-app-en.questionnaire.json",
"package_name": "d4l-data4life.covid-19.r4",
"subjectType": [ "Patient" ],
"date": "2020-04-24T22:00:00.000Z",
"publisher": "D4L data4life gGmbH",
"name": "Covid19_assesment_questionnaire",
"item": [ {
"item": [ {
"code": [ {
"code": "46251-5",
"system": "http://loinc.org",
"display": "Age group"
} ],
"text": "How old are you?",
"type": "choice",
"linkId": "P0",
"required": true,
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/age-group"
}, {
"code": [ {
"code": "21612-7",
"system": "http://loinc.org",
"display": "Age - Reported"
} ],
"text": "Are you 65 years old or older?",
"type": "choice",
"linkId": "P1",
"required": true,
"enableWhen": [ {
"operator": "=",
"question": "P0",
"answerCoding": {
"code": "61-70",
"system": "http://fhir.data4life.care/covid-19/r4/CodeSystem/age-group"
}
} ],
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesno"
}, {
"code": [ {
"code": "71802-3",
"system": "http://loinc.org",
"display": "Housing status"
} ],
"text": "What is your current living situation?",
"type": "choice",
"linkId": "P2",
"required": true,
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/housing-situation"
}, {
"item": [ {
"text": "Care services or support that you provide in connection with your professional activity isn't meant.",
"type": "display",
"linkId": "P3-Explanation"
} ],
"text": "At least once a week, do you privately care for people with age-related conditions, chronic illnesses, or frailty?",
"type": "choice",
"linkId": "P3",
"required": true,
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesno"
}, {
"code": [ {
"code": "85658-3",
"system": "http://loinc.org",
"display": "Occupation [Type]"
} ],
"text": "Do you work in one of the following areas?",
"type": "choice",
"linkId": "P4",
"required": true,
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/occupation-class"
}, {
"code": [ {
"code": "72166-2",
"system": "http://loinc.org",
"display": "Tobacco smoking status"
} ],
"text": "Do you smoke?",
"type": "choice",
"linkId": "P5",
"required": true,
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesno"
}, {
"code": [ {
"code": "82810-3",
"system": "http://loinc.org",
"display": "Pregnancy status"
} ],
"text": "Are you pregnant?",
"type": "choice",
"linkId": "P6",
"required": true,
"answerValueSet": "http://loinc.org/vs/LL4129-4"
} ],
"text": "Personal information",
"type": "group",
"linkId": "P",
"required": true
}, {
"item": [ {
"code": [ {
"code": "840546002",
"system": "http://snomed.info/sct",
"display": "Exposure to SARS-CoV-2"
} ],
"item": [ {
"text": "Close contact with a confirmed case means:\n\n* Face-to-face contact for longer than 15 minutes\n* Direct, physical contact (touching, shaking hands, kissing)\n* Being within 1.5 meters of the person for more than 15 minutes\n* Contact with or exchange of body fluids\n* Living in the same apartment\n\n\nChoose \"no\" if you have worn adequate protective measures (mask, smock) on contact.",
"type": "display",
"linkId": "C0-Explanation"
} ],
"text": "Have you had close contact with a confirmed case?",
"type": "choice",
"linkId": "C0",
"required": true,
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesno"
}, {
"code": [ {
"code": "94652-5",
"system": "http://loinc.org",
"display": "Known exposure date"
} ],
"item": [ {
"text": "Make sure to enter a full date in the DD MM YYYY format that isn’t in the future.",
"type": "display",
"linkId": "CZ-Explanation"
} ],
"text": "What day was the last contact?",
"type": "date",
"linkId": "CZ",
"required": true,
"enableWhen": [ {
"operator": "=",
"question": "C0",
"answerCoding": {
"code": "LA33-6",
"system": "http://loinc.org"
}
} ]
} ],
"text": "Contact with COVID-19 cases",
"type": "group",
"linkId": "C",
"required": true
}, {
"item": [ {
"code": [ {
"code": "386661006",
"system": "http://snomed.info/sct",
"display": "Fever (finding)"
} ],
"text": "Have you had a fever (over 38°C) in the past 24 hours?",
"type": "choice",
"linkId": "S0",
"required": true,
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesno"
}, {
"code": [ {
"code": "386661006",
"system": "http://snomed.info/sct",
"display": "Fever (finding)"
} ],
"text": "Have you had a fever (over 38°C) in the past 4 days?",
"type": "choice",
"linkId": "S1",
"required": true,
"enableWhen": [ {
"operator": "=",
"question": "S0",
"answerCoding": {
"code": "LA32-8",
"system": "http://loinc.org"
}
} ],
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesno"
}, {
"code": [ {
"code": "8315-4",
"system": "http://loinc.org",
"display": "Body temperature 24 hour maximum"
} ],
"text": "What was the highest temperature, approx.?",
"type": "choice",
"linkId": "S2",
"required": true,
"enableWhen": [ {
"operator": "=",
"question": "S0",
"answerCoding": {
"code": "LA33-6",
"system": "http://loinc.org"
}
}, {
"operator": "=",
"question": "S1",
"answerCoding": {
"code": "LA33-6",
"system": "http://loinc.org"
}
} ],
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/fever-class",
"enableBehavior": "any"
}, {
"code": [ {
"code": "43724002",
"system": "http://snomed.info/sct",
"display": "Chill (finding)"
} ],
"text": "Have you had chills in the past 24 hours?",
"type": "choice",
"linkId": "S3",
"required": true,
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesno"
}, {
"code": [ {
"code": "84229001",
"system": "http://snomed.info/sct",
"display": "Fatigue (finding)"
} ],
"item": [ {
"text": "The question relates to acute or exacerbated symptoms and excludes chronic complaints or seasonal or allergic complaints. If you have a chronic illness, compare your current symptoms with your previous problems to answer the question.",
"type": "display",
"linkId": "S4-Explanation"
} ],
"text": "In the past 24 hours, have you felt tired or worn out?",
"type": "choice",
"linkId": "S4",
"required": true,
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesno"
}, {
"code": [ {
"code": "68962001",
"system": "http://snomed.info/sct",
"display": "Muscle pain (finding)"
} ],
"item": [ {
"text": "The question relates to acute or exacerbated symptoms and excludes chronic complaints or seasonal or allergic complaints. If you have a chronic illness, compare your current symptoms with your previous problems to answer the question.",
"type": "display",
"linkId": "S5-Explanation"
} ],
"text": "In the past 24 hours, have you had body aches?",
"type": "choice",
"linkId": "S5",
"required": true,
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesno"
}, {
"code": [ {
"code": "49727002",
"system": "http://snomed.info/sct",
"display": "Cough (finding)"
} ],
"item": [ {
"text": "The question relates to cold symptoms and excludes chronic cough, seasonal or allergy-related cough. If you have a chronic cough, compare your current coughing to your regular problems.",
"type": "display",
"linkId": "S6-Explanation"
} ],
"text": "In the past 24 hours, have you had a persistent cough?",
"type": "choice",
"linkId": "S6",
"required": true,
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesno"
}, {
"code": [ {
"code": "82272006",
"system": "http://snomed.info/sct",
"display": "Common cold (disorder)"
} ],
"item": [ {
"text": "The question relates to cold symptoms and excludes chronic runny nose, seasonal or allergy-related runny nose. If you have chronic sniffling, compare your current conditions with your existing problems.",
"type": "display",
"linkId": "S7-Explanation"
} ],
"text": "In the past 24 hours, have you had a runny nose?",
"type": "choice",
"linkId": "S7",
"required": true,
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesno"
}, {
"code": [ {
"code": "62315008",
"system": "http://snomed.info/sct",
"display": "Diarrhea (finding)"
} ],
"item": [ {
"text": "The question relates to acute or exacerbated symptoms and excludes chronic complaints or seasonal or allergic complaints. If you have a chronic illness, compare your current symptoms with your previous problems to answer the question.",
"type": "display",
"linkId": "S8-Explanation"
} ],
"text": "In the past 24 hours, have you had diarrhea?",
"type": "choice",
"linkId": "S8",
"required": true,
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesno"
}, {
"code": [ {
"code": "162397003",
"system": "http://snomed.info/sct",
"display": "Pain in throat (finding)"
} ],
"text": "In the past 24 hours, have you had a sore throat?",
"type": "choice",
"linkId": "S9",
"required": true,
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesno"
}, {
"code": [ {
"code": "25064002",
"system": "http://snomed.info/sct",
"display": "Headache (finding)"
} ],
"item": [ {
"text": "The question relates to acute or exacerbated symptoms and excludes chronic complaints or seasonal or allergic complaints. If you have a chronic illness, compare your current symptoms with your previous problems to answer the question.",
"type": "display",
"linkId": "SA-Explanation"
} ],
"text": "In the past 24 hours, have you had a headache?",
"type": "choice",
"linkId": "SA",
"required": true,
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesno"
}, {
"code": [ {
"code": "267036007",
"system": "http://snomed.info/sct",
"display": "Dyspnea (finding)"
} ],
"item": [ {
"text": "Choose \"Yes\" if you:\n* Become breathless faster than usual or have difficulty breathing with light loads, such as a walk or climbing a short flight of stairs\n* Experience difficulty breathing or shortness of breath when sitting or lying down\n* Have a feeling of breathlessness/shortness of breath when getting up from bed or a chair\n\n\nIf you have chronic lung disease, compare your current breathing problems with your existing breathing problems.",
"type": "display",
"linkId": "SB-Explanation"
} ],
"text": "In the past 24 hours, did you feel that you were more quickly out of breath than usual?",
"type": "choice",
"linkId": "SB",
"required": true,
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesno"
}, {
"code": [ {
"code": "44169009",
"system": "http://snomed.info/sct",
"display": "Loss of sense of smell (finding)"
} ],
"item": [ {
"text": "The question relates to acute or exacerbated symptoms and excludes chronic complaints or seasonal or allergic complaints. If you have a chronic illness, compare your current symptoms with your previous problems to answer the question.",
"type": "display",
"linkId": "SC-Explanation"
} ],
"text": "Have you had any taste and/or smell loss in the last 24 hours?",
"type": "choice",
"linkId": "SC",
"required": true,
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesno"
}, {
"code": [ {
"code": "85585-8",
"system": "http://loinc.org",
"display": "Date of condition onset"
} ],
"item": [ {
"text": "Make sure to enter a full date in the DD MM YYYY format that isn’t in the future.",
"type": "display",
"linkId": "SZ-Explanation"
} ],
"text": "With regard to all questions about symptoms: since when have you had the symptoms you specified?",
"type": "date",
"linkId": "SZ",
"required": true,
"enableWhen": [ {
"operator": "=",
"question": "S0",
"answerCoding": {
"code": "LA33-6",
"system": "http://loinc.org"
}
}, {
"operator": "=",
"question": "S1",
"answerCoding": {
"code": "LA33-6",
"system": "http://loinc.org"
}
}, {
"operator": "=",
"question": "S3",
"answerCoding": {
"code": "LA33-6",
"system": "http://loinc.org"
}
}, {
"operator": "=",
"question": "S4",
"answerCoding": {
"code": "LA33-6",
"system": "http://loinc.org"
}
}, {
"operator": "=",
"question": "S5",
"answerCoding": {
"code": "LA33-6",
"system": "http://loinc.org"
}
}, {
"operator": "=",
"question": "S6",
"answerCoding": {
"code": "LA33-6",
"system": "http://loinc.org"
}
}, {
"operator": "=",
"question": "S7",
"answerCoding": {
"code": "LA33-6",
"system": "http://loinc.org"
}
}, {
"operator": "=",
"question": "S8",
"answerCoding": {
"code": "LA33-6",
"system": "http://loinc.org"
}
}, {
"operator": "=",
"question": "S9",
"answerCoding": {
"code": "LA33-6",
"system": "http://loinc.org"
}
}, {
"operator": "=",
"question": "SA",
"answerCoding": {
"code": "LA33-6",
"system": "http://loinc.org"
}
}, {
"operator": "=",
"question": "SB",
"answerCoding": {
"code": "LA33-6",
"system": "http://loinc.org"
}
}, {
"operator": "=",
"question": "SC",
"answerCoding": {
"code": "LA33-6",
"system": "http://loinc.org"
}
} ],
"enableBehavior": "any"
} ],
"text": "Symptoms",
"type": "group",
"linkId": "S",
"required": true
}, {
"item": [ {
"code": [ {
"code": "413839001",
"system": "http://snomed.info/sct",
"display": "Chronic lung disease (disorder)"
} ],
"text": "Have you been diagnosed with chronic lung disease by a doctor?",
"type": "choice",
"linkId": "D0",
"required": true,
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesnodontknow"
}, {
"code": [ {
"code": "73211009",
"system": "http://snomed.info/sct",
"display": "Diabetes mellitus (disorder)"
} ],
"text": "Have you been diagnosed with diabetes by a doctor?",
"type": "choice",
"linkId": "D1",
"required": true,
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesnodontknow"
}, {
"code": [ {
"code": "56265001",
"system": "http://snomed.info/sct",
"display": "Heart disease (disorder)"
} ],
"text": "Have you been diagnosed with heart disease by a doctor?",
"type": "choice",
"linkId": "D2",
"required": true,
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesnodontknow"
}, {
"code": [ {
"code": "414916001",
"system": "http://snomed.info/sct",
"display": "Obesity (disorder)"
} ],
"text": "Have you been diagnosed with obesity by a doctor?",
"type": "choice",
"linkId": "D3",
"required": true,
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesnodontknow"
} ],
"text": "Chronic illnesses",
"type": "group",
"linkId": "D",
"required": true
}, {
"item": [ {
"code": [ {
"code": "steroid-intake",
"system": "http://fhir.data4life.care/covid-19/r4/CodeSystem/medication-questions",
"display": "Taking steroids"
} ],
"text": "Are you currently taking steroids?",
"type": "choice",
"linkId": "M0",
"required": true,
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesnodontknow"
}, {
"code": [ {
"code": "immunosuppressant-intake",
"system": "http://fhir.data4life.care/covid-19/r4/CodeSystem/medication-questions",
"display": "Taking immunosuppressants"
} ],
"item": [ {
"text": "You take or get immunosuppresives after an organ transplant, in the therapy of an autoimmune disease, or during chemotherapy.",
"type": "display",
"linkId": "M1-Explanation"
} ],
"text": "Are you currently taking immunosuppressants?",
"type": "choice",
"linkId": "M1",
"required": true,
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesnodontknow"
}, {
"code": [ {
"code": "recent-influenza-vaccine",
"system": "http://fhir.data4life.care/covid-19/r4/CodeSystem/medication-questions",
"display": "Influenza vaccine for the current influenza season"
} ],
"text": "Have you been vaccinated against flu between October 2019 and today?",
"type": "choice",
"linkId": "M2",
"required": true,
"answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesno"
} ],
"text": "Medication",
"type": "group",
"linkId": "M",
"required": true
} ],
"copyright": "D4L data4life gGmbH, Charité – Universitätsmedizin Berlin, BIH - Berliner Institut für Gesundheitsforschung, hih - health innovation hub des Bundesministeriums für Gesundheit, and MOLIT Institut gGmbH",
"type": null,
"experimental": null,
"resourceType": "Questionnaire",
"title": null,
"package_version": "0.7.0",
"status": "draft",
"language": "en",
"id": "5f8f0806-813c-481b-888e-5d0a8e0528a9",
"kind": null,
"url": "http://fhir.data4life.care/covid-19/r4/Questionnaire/covid19-recommendation",
"code": [ {
"code": "84170-0",
"system": "http://loinc.org",
"display": "Infectious disease Risk assessment and screening note"
} ],
"version": "3.0.0",
"contact": [ {
"name": "D4L data4life gGmbH",
"telecom": [ {
"value": "https://www.data4life.care",
"system": "url"
} ]
} ]
}