{ "description": null, "_filename": "example/Questionnaire-SDOHCC-QuestionnairePRAPARE.json", "package_name": "hl7.fhir.us.sdoh-clinicalcare", "subjectType": [ "Patient" ], "date": "2021-04-01T04:01:34+00:00", "meta": { "profile": [ "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-extr-smap" ] }, "publisher": "HL7 International Patient Care WG", "jurisdiction": [ { "coding": [ { "code": "US", "system": "urn:iso:std:iso:3166", "display": "United States of America" } ] } ], "name": "SDOHCCQuestionnairePRAPARE", "item": [ { "code": [ { "code": "93025-5", "system": "http://loinc.org", "display": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]" } ], "item": [ { "code": [ { "code": "93043-8", "system": "http://loinc.org", "display": "Personal characteristics" } ], "item": [ { "code": [ { "code": "56051-6", "system": "http://loinc.org", "display": "Do you consider yourself Hispanic/Latino?" } ], "text": "Do you consider yourself Hispanic/Latino?", "type": "choice", "linkId": "/93043-8/56051-6", "required": false, "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" } ] } } ], "answerOption": [ { "valueCoding": { "code": "LA33-6", "system": "http://loinc.org", "display": "Yes" } }, { "valueCoding": { "code": "LA32-8", "system": "http://loinc.org", "display": "No" } }, { "valueCoding": { "code": "LA30122-8", "system": "http://loinc.org", "display": "I choose not to answer this question" } } ] }, { "code": [ { "code": "32624-9", "system": "http://loinc.org", "display": "Race" } ], "text": "Race", "type": "choice", "linkId": "/93043-8/32624-9", "repeats": true, "required": false, "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" } ] } } ], "answerOption": [ { "valueCoding": { "code": "LA6156-9", "system": "http://loinc.org", "display": "Asian" } }, { "valueCoding": { "code": "LA14045-1", "system": "http://loinc.org", "display": "Native Hawaiian" } }, { "valueCoding": { "code": "LA30187-1", "system": "http://loinc.org", "display": "Pacific Islander" } }, { "valueCoding": { "code": "LA14042-8", "system": "http://loinc.org", "display": "Black/African American" } }, { "valueCoding": { "code": "LA4457-3", "system": "http://loinc.org", "display": "White" } }, { "valueCoding": { "code": "LA4-4", "system": "http://loinc.org", "display": "American Indian/Alaskan Native" } }, { "valueCoding": { "code": "LA46-8", "system": "http://loinc.org", "display": "Other" } }, { "valueCoding": { "code": "LA30122-8", "system": "http://loinc.org", "display": "I choose not to answer this question" } } ] }, { "code": [ { "code": "93035-4", "system": "http://loinc.org", "display": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?" } ], "text": "At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income?", "type": "choice", "linkId": "/93043-8/93035-4", "required": false, "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" } ] } } ], "answerOption": [ { "valueCoding": { "code": "LA33-6", "system": "http://loinc.org", "display": "Yes" } }, { "valueCoding": { "code": "LA32-8", "system": "http://loinc.org", "display": "No" } }, { "valueCoding": { "code": "LA30122-8", "system": "http://loinc.org", "display": "I choose not to answer this question" } } ] }, { "code": [ { "code": "93034-7", "system": "http://loinc.org", "display": "Have you been discharged from the armed forces of the United States?" } ], "text": "Have you been discharged from the armed forces of the United States?", "type": "choice", "linkId": "/93043-8/93034-7", "required": false, "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" } ] } } ], "answerOption": [ { "valueCoding": { "code": "LA33-6", "system": "http://loinc.org", "display": "Yes" } }, { "valueCoding": { "code": "LA32-8", "system": "http://loinc.org", "display": "No" } }, { "valueCoding": { "code": "LA30122-8", "system": "http://loinc.org", "display": "I choose not to answer this question" } } ] }, { "code": [ { "code": "54899-0", "system": "http://loinc.org", "display": "Preferred language" } ], "text": "Preferred language", "type": "choice", "linkId": "/93043-8/54899-0", "required": false, "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" } ] } } ], "answerOption": [ { "valueCoding": { "code": "LA43-5", "system": "http://loinc.org", "display": "English" } }, { "valueCoding": { "code": "LA30188-9", "system": "http://loinc.org", "display": "Language other than English" } }, { "valueCoding": { "code": "LA30122-8", "system": "http://loinc.org", "display": "I choose not to answer this question" } } ] } ], "text": "Personal characteristics", "type": "group", "linkId": "/93043-8", "required": false }, { "code": [ { "code": "93042-0", "system": "http://loinc.org", "display": "Family and home" } ], "item": [ { "code": [ { "code": "63512-8", "system": "http://loinc.org", "display": "How many people are living or staying at this address?" } ], "text": "How many people are living or staying at this address?", "type": "integer", "linkId": "/93042-0/63512-8", "required": false, "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unit", "valueCoding": { "code": "{#}", "system": "http://unitsofmeasure.org", "display": "{#}" } } ] }, { "code": [ { "code": "71802-3", "system": "http://loinc.org", "display": "Housing status" } ], "item": [ { "text": "Describes patients living arrangement", "type": "display", "linkId": "/93042-0/71802-3-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": "Housing status", "type": "choice", "linkId": "/93042-0/71802-3", "required": false, "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" } ] } } ], "answerOption": [ { "valueCoding": { "code": "LA30189-7", "system": "http://loinc.org", "display": "I have housing" } }, { "valueCoding": { "code": "LA30190-5", "system": "http://loinc.org", "display": "I do not have housing (staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, or in a park)" } }, { "valueCoding": { "code": "LA30122-8", "system": "http://loinc.org", "display": "I choose not to answer this question" } } ] }, { "code": [ { "code": "93033-9", "system": "http://loinc.org", "display": "Are you worried about losing your housing?" } ], "text": "Are you worried about losing your housing?", "type": "choice", "linkId": "/93042-0/93033-9", "required": false, "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" } ] } } ], "answerOption": [ { "valueCoding": { "code": "LA33-6", "system": "http://loinc.org", "display": "Yes" } }, { "valueCoding": { "code": "LA32-8", "system": "http://loinc.org", "display": "No" } }, { "valueCoding": { "code": "LA30122-8", "system": "http://loinc.org", "display": "I choose not to answer this question" } } ] }, { "code": [ { "code": "56799-0", "system": "http://loinc.org", "display": "Address" } ], "text": "Address", "type": "string", "linkId": "/93042-0/56799-0", "required": false } ], "text": "Family and home", "type": "group", "linkId": "/93042-0", "required": false }, { "code": [ { "code": "93041-2", "system": "http://loinc.org", "display": "Money and resources" } ], "item": [ { "code": [ { "code": "82589-3", "system": "http://loinc.org", "display": "Highest level of educ" } ], "text": "Highest level of educ", "type": "choice", "linkId": "/93041-2/82589-3", "required": false, "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" } ] } } ], "answerOption": [ { "valueCoding": { "code": "LA30191-3", "system": "http://loinc.org", "display": "Less than high school degree" } }, { "valueCoding": { "code": "LA30192-1", "system": "http://loinc.org", "display": "High school diploma or GED" } }, { "valueCoding": { "code": "LA30193-9", "system": "http://loinc.org", "display": "More than high school" } }, { "valueCoding": { "code": "LA30122-8", "system": "http://loinc.org", "display": "I choose not to answer this question" } } ] }, { "code": [ { "code": "67875-5", "system": "http://loinc.org", "display": "Employment status current" } ], "text": "Employment status current", "type": "choice", "linkId": "/93041-2/67875-5", "required": false, "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" } ] } } ], "answerOption": [ { "valueCoding": { "code": "LA17956-6", "system": "http://loinc.org", "display": "Unemployed" } }, { "valueCoding": { "code": "LA30138-4", "system": "http://loinc.org", "display": "Part-time or temporary work" } }, { "valueCoding": { "code": "LA30136-8", "system": "http://loinc.org", "display": "Full-time work" } }, { "valueCoding": { "code": "LA30137-6", "system": "http://loinc.org", "display": "Otherwise unemployed but not seeking work (ex: student, retired, disabled, unpaid primary care giver)" } }, { "valueCoding": { "code": "LA30122-8", "system": "http://loinc.org", "display": "I choose not to answer this question" } } ] }, { "code": [ { "code": "76437-3", "system": "http://loinc.org", "display": "Primary insurance" } ], "text": "Primary insurance", "type": "choice", "linkId": "/93041-2/76437-3", "required": false, "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" } ] } } ], "answerOption": [ { "valueCoding": { "code": "LA30194-7", "system": "http://loinc.org", "display": "None/uninsured" } }, { "valueCoding": { "code": "LA17849-3", "system": "http://loinc.org", "display": "Medicaid" } }, { "valueCoding": { "code": "LA30195-4", "system": "http://loinc.org", "display": "CHIP Medicaid" } }, { "valueCoding": { "code": "LA15652-3", "system": "http://loinc.org", "display": "Medicare" } }, { "valueCoding": { "code": "LA30196-2", "system": "http://loinc.org", "display": "Other public insurance (not CHIP)" } }, { "valueCoding": { "code": "LA30197-0", "system": "http://loinc.org", "display": "Other public insurance (CHIP)" } }, { "valueCoding": { "code": "LA6350-8", "system": "http://loinc.org", "display": "Private insurance" } } ] }, { "code": [ { "code": "63586-2", "system": "http://loinc.org", "display": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?" } ], "text": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?", "type": "decimal", "linkId": "/93041-2/63586-2", "required": false, "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unit", "valueCoding": { "code": "/a", "system": "http://unitsofmeasure.org", "display": "/a" } } ] }, { "code": [ { "code": "93031-3", "system": "http://loinc.org", "display": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?" } ], "text": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?", "type": "choice", "linkId": "/93041-2/93031-3", "repeats": true, "required": false, "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" } ] } } ], "answerOption": [ { "valueCoding": { "code": "LA30125-1", "system": "http://loinc.org", "display": "Food" } }, { "valueCoding": { "code": "LA30126-9", "system": "http://loinc.org", "display": "Clothing" } }, { "valueCoding": { "code": "LA30124-4", "system": "http://loinc.org", "display": "Utilities" } }, { "valueCoding": { "code": "LA30127-7", "system": "http://loinc.org", "display": "Child care" } }, { "valueCoding": { "code": "LA30128-5", "system": "http://loinc.org", "display": "Medicine or Any Health Care (Medical, Dental, Mental Health, Vision)" } }, { "valueCoding": { "code": "LA30129-3", "system": "http://loinc.org", "display": "Phone" } }, { "valueCoding": { "code": "LA46-8", "system": "http://loinc.org", "display": "Other" } }, { "valueCoding": { "code": "LA30122-8", "system": "http://loinc.org", "display": "I choose not to answer this question" } } ] }, { "code": [ { "code": "93030-5", "system": "http://loinc.org", "display": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?" } ], "text": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?", "type": "choice", "linkId": "/93041-2/93030-5", "repeats": true, "required": false, "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" } ] } } ], "answerOption": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-optionPrefix", "valueString": "A" } ], "valueCoding": { "code": "LA30133-5", "system": "http://loinc.org", "display": "Yes, it has kept me from medical appointments or from getting my medications" } }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-optionPrefix", "valueString": "B" } ], "valueCoding": { "code": "LA30134-3", "system": "http://loinc.org", "display": "Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need" } }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-optionPrefix", "valueString": "C" } ], "valueCoding": { "code": "LA32-8", "system": "http://loinc.org", "display": "No" } }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-optionPrefix", "valueString": "X" } ], "valueCoding": { "code": "LA30257-2", "system": "http://loinc.org", "display": "Patient unable to respond" } } ] } ], "text": "Money and resources", "type": "group", "linkId": "/93041-2", "required": false }, { "code": [ { "code": "93040-4", "system": "http://loinc.org", "display": "Social and emotional health" } ], "item": [ { "code": [ { "code": "93029-7", "system": "http://loinc.org", "display": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?" } ], "text": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?", "type": "choice", "linkId": "/93040-4/93029-7", "required": false, "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" } ] } } ], "answerOption": [ { "valueCoding": { "code": "LA27722-0", "system": "http://loinc.org", "display": "Less than once a week" } }, { "valueCoding": { "code": "LA30130-1", "system": "http://loinc.org", "display": "1 or 2 times a week" } }, { "valueCoding": { "code": "LA30131-9", "system": "http://loinc.org", "display": "3 to 5 times a week" } }, { "valueCoding": { "code": "LA30132-7", "system": "http://loinc.org", "display": "5 or more times a week" } }, { "valueCoding": { "code": "LA30122-8", "system": "http://loinc.org", "display": "I choose not to answer this question" } } ] }, { "code": [ { "code": "93038-8", "system": "http://loinc.org", "display": "Stress is when someone feels tense, nervous, anxious or can't sleep at night because their mind is troubled. How stressed are you?" } ], "text": "Stress is when someone feels tense, nervous, anxious or can't sleep at night because their mind is troubled. How stressed are you?", "type": "choice", "linkId": "/93040-4/93038-8", "required": false, "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" } ] } } ], "answerOption": [ { "valueCoding": { "code": "LA6568-5", "system": "http://loinc.org", "display": "Not at all" } }, { "valueCoding": { "code": "LA13863-8", "system": "http://loinc.org", "display": "A little bit" } }, { "valueCoding": { "code": "LA13909-9", "system": "http://loinc.org", "display": "Somewhat" } }, { "valueCoding": { "code": "LA13902-4", "system": "http://loinc.org", "display": "Quite a bit" } }, { "valueCoding": { "code": "LA13914-9", "system": "http://loinc.org", "display": "Very much" } }, { "valueCoding": { "code": "LA30122-8", "system": "http://loinc.org", "display": "I choose not to answer this question" } } ] } ], "text": "Social and emotional health", "type": "group", "linkId": "/93040-4", "required": false }, { "code": [ { "code": "93039-6", "system": "http://loinc.org", "display": "Optional additional questions" } ], "item": [ { "code": [ { "code": "93028-9", "system": "http://loinc.org", "display": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?" } ], "text": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?", "type": "choice", "linkId": "/93039-6/93028-9", "required": false, "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" } ] } } ], "answerOption": [ { "valueCoding": { "code": "LA33-6", "system": "http://loinc.org", "display": "Yes" } }, { "valueCoding": { "code": "LA32-8", "system": "http://loinc.org", "display": "No" } }, { "valueCoding": { "code": "LA30122-8", "system": "http://loinc.org", "display": "I choose not to answer this question" } } ] }, { "code": [ { "code": "93027-1", "system": "http://loinc.org", "display": "Are you a refugee?" } ], "text": "Are you a refugee?", "type": "choice", "linkId": "/93039-6/93027-1", "required": false, "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" } ] } } ], "answerOption": [ { "valueCoding": { "code": "LA33-6", "system": "http://loinc.org", "display": "Yes" } }, { "valueCoding": { "code": "LA32-8", "system": "http://loinc.org", "display": "No" } }, { "valueCoding": { "code": "LA30122-8", "system": "http://loinc.org", "display": "I choose not to answer this question" } } ] }, { "code": [ { "code": "93026-3", "system": "http://loinc.org", "display": "Do you feel physically and emotionally safe where you currently live?" } ], "text": "Do you feel physically and emotionally safe where you currently live?", "type": "choice", "linkId": "/93039-6/93026-3", "required": false, "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" } ] } } ], "answerOption": [ { "valueCoding": { "code": "LA33-6", "system": "http://loinc.org", "display": "Yes" } }, { "valueCoding": { "code": "LA32-8", "system": "http://loinc.org", "display": "No" } }, { "valueCoding": { "code": "LA14072-5", "system": "http://loinc.org", "display": "Unsure" } }, { "valueCoding": { "code": "LA30122-8", "system": "http://loinc.org", "display": "I choose not to answer this question" } } ] }, { "code": [ { "code": "76501-6", "system": "http://loinc.org", "display": "Within the last year, have you been afraid of your partner or ex-partner?" } ], "text": "Within the last year, have you been afraid of your partner or ex-partner?", "type": "choice", "linkId": "/93039-6/76501-6", "required": false, "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" } ] } } ], "answerOption": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-optionPrefix", "valueString": "1" }, { "url": "http://hl7.org/fhir/StructureDefinition/ordinalValue", "valueDecimal": 1 } ], "valueCoding": { "code": "LA33-6", "system": "http://loinc.org", "display": "Yes" } }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-optionPrefix", "valueString": "0" }, { "url": "http://hl7.org/fhir/StructureDefinition/ordinalValue", "valueDecimal": 0 } ], "valueCoding": { "code": "LA32-8", "system": "http://loinc.org", "display": "No" } } ] } ], "text": "Optional additional questions", "type": "group", "linkId": "/93039-6", "required": false } ], "text": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]", "type": "group", "linkId": "/93025-5", "required": false } ], "type": null, "experimental": null, "resourceType": "Questionnaire", "title": "SDOHCC Questionnaire PRAPARE", "package_version": "2.1.0", "extension": [ { "url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-targetStructureMap", "valueCanonical": "http://hl7.org/fhir/us/sdoh-clinicalcare/StructureMap/SDOHCC-StructureMapPRAPARE" } ], "status": "draft", "id": "7a575330-4d18-4272-b4eb-5f0e65a647a7", "kind": null, "url": 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