{
"description": null,
"_filename": "examples/Questionnaire-HSR.json",
"package_name": "ca.on.health.sadie",
"subjectType": [ "Patient" ],
"date": null,
"meta": {
"source": "#smE8jInbhtLHunCZ",
"profile": [ "http://health.gov.on.ca/sadie/fhir/StructureDefinition/FlexForm" ],
"versionId": "18",
"lastUpdated": "2021-10-15T15:36:24.703+00:00"
},
"publisher": "ODSP",
"name": "HealthStatusReport",
"item": [ {
"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 application started with the ministry, you cannot complete this form.",
"type": "display",
"linkId": "0.2.1",
"repeats": false,
"readOnly": false,
"required": false
}, {
"definition": "https://www.hl7.org/fhir/patient-definitions.html#Patient.identifier[1].value",
"linkId": "odsp-member-id",
"repeats": false,
"type": "string",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "[0-9]*"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/minLength",
"valueInteger": 9
} ],
"readOnly": false,
"maxLength": 9,
"required": true,
"text": "Member ID (9 digits)"
}, {
"definition": "https://www.hl7.org/fhir/servicerequest-definitions.html#ServiceRequest.identifier[1].value",
"linkId": "odsp-referral-id",
"repeats": false,
"type": "string",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "[0-9]*"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/minLength",
"valueInteger": 12
} ],
"readOnly": false,
"maxLength": 16,
"required": true,
"text": "Referral ID (12 to 16 digits)"
} ],
"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
}, {
"linkId": "0.3.2",
"repeats": false,
"item": [ {
"type": "string",
"linkId": "0.3.2-DocumentType",
"initial": [ {
"valueString": "DDP"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
}, {
"type": "string",
"linkId": "0.3.2-DocumentSubType",
"initial": [ {
"valueString": "Consent"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
} ],
"type": "attachment",
"enableWhen": [ {
"operator": "=",
"question": "0.3.1",
"answerBoolean": true
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/vnd.openxmlformats-officedocument.wordprocessingml.document"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/msword"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/rtf"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/tiff"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/pdf"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/gif"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 20
} ],
"readOnly": false,
"required": false,
"text": "Attach your patient's consent form."
}, {
"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
}, {
"enableBehavior": "any",
"linkId": "0.3.4",
"repeats": false,
"item": [ {
"type": "string",
"linkId": "0.3.4-DocumentType",
"initial": [ {
"valueString": "DDP"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
}, {
"type": "string",
"linkId": "0.3.4-DocumentSubType",
"initial": [ {
"valueString": "Self Report"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
} ],
"type": "attachment",
"enableWhen": [ {
"operator": "=",
"question": "0.3.3",
"answerBoolean": true
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/vnd.openxmlformats-officedocument.wordprocessingml.document"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/msword"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/rtf"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/tiff"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/pdf"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/gif"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 20
} ],
"readOnly": false,
"required": false,
"text": "Attach your patient's Self Report form."
} ],
"text": "Applicant Forms",
"type": "group",
"linkId": "0.3",
"repeats": false,
"readOnly": false,
"required": false
} ],
"text": "General",
"type": "group",
"linkId": "0",
"repeats": false,
"readOnly": false,
"required": false,
"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"
} ]
}
} ]
}, {
"item": [ {
"item": [ {
"item": [ {
"text": "Specify the requested patient information:",
"type": "display",
"linkId": "1.1.1.1",
"repeats": false,
"readOnly": false,
"required": false
}, {
"text": "First Name",
"type": "string",
"linkId": "patient-first-name",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 25,
"definition": "https://www.hl7.org/fhir/patient-definitions.html#Patient.name.given"
}, {
"text": "Middle Initial",
"type": "string",
"linkId": "1.1.1.2",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 2
}, {
"text": "Last Name",
"type": "string",
"linkId": "patient-last-name",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 25,
"definition": "https://www.hl7.org/fhir/patient-definitions.html#Patient.name.family"
}, {
"text": "Date of Birth",
"type": "date",
"linkId": "patient-date-of-birth",
"repeats": false,
"readOnly": false,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today()"
}
} ]
} ],
"definition": "https://www.hl7.org/fhir/patient-definitions.html#Patient.birthDate"
} ],
"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,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "[A-Za-z0-9]*"
} ],
"maxLength": 10
}, {
"text": "Street Number",
"type": "string",
"linkId": "1.2.2",
"repeats": false,
"readOnly": false,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "[0-9]*"
} ],
"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
}, {
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "[A-Za-z][0-9][A-Za-z][0-9][A-Za-z][0-9]"
} ],
"maxLength": 6
} ],
"text": "Applicant's Current Address",
"type": "group",
"linkId": "1.2",
"repeats": false,
"readOnly": false,
"required": false
} ],
"text": "Applicant",
"type": "group",
"linkId": "1",
"repeats": false,
"readOnly": false,
"required": false,
"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"
} ]
}
} ]
}, {
"item": [ {
"item": [ {
"type": "string",
"linkId": "details",
"initial": [ {
"valueString": "Health Status Report"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ],
"definition": "https://www.hl7.org/fhir/servicerequest-definitions.html#ServiceRequest.orderDetail[0].text"
}, {
"type": "string",
"linkId": "additional-details",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}, {
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression",
"valueExpression": {
"language": "text/fhirpath",
"expression": "%context.item.where(linkId='0').item.where(linkId='0.2').item.where(linkId='odsp-referral-id').answer.valueString",
"description": "ODSP Referral Id"
}
} ],
"definition": "https://www.hl7.org/fhir/servicerequest-definitions.html#ServiceRequest.orderDetail[1].text"
}, {
"text": "Please provide information below.",
"type": "choice",
"linkId": "2.1.1",
"repeats": false,
"readOnly": false,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-displayCategory",
"valueCode": "display"
} ],
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassLegend"
}, {
"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
}, {
"text": "Prognosis",
"type": "choice",
"linkId": "2.1.2.4",
"repeats": false,
"readOnly": false,
"required": true,
"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"
} ],
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-PrognosisTypes"
}, {
"text": "Duration of impairment",
"type": "choice",
"linkId": "2.1.2.5",
"repeats": false,
"readOnly": false,
"required": true,
"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"
} ],
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-Durations"
}, {
"text": "Frequency of impairment(s) - are the impairments:",
"type": "choice",
"linkId": "2.1.2.6",
"repeats": false,
"readOnly": false,
"required": true,
"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"
} ],
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-RecurrentTypes"
} ],
"text": "Provide information about medical conditions and associated impairments, durations and restrictions.",
"type": "group",
"linkId": "2.1.2",
"repeats": true,
"readOnly": false,
"required": false
} ],
"text": "1. Medical Conditions that Contribute to the Applicant's Current Status",
"type": "group",
"linkId": "2.1",
"repeats": false,
"readOnly": false,
"required": false
}, {
"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
}, {
"text": "Mental health condition",
"type": "boolean",
"linkId": "2.2.1",
"repeats": false,
"readOnly": false,
"required": true
}, {
"text": "Substance-related or addictive disorder",
"type": "boolean",
"linkId": "2.2.2",
"repeats": false,
"readOnly": false,
"required": true
}, {
"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
}, {
"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
}, {
"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,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-AttachmentCategories"
}, {
"type": "string",
"linkId": "2.2.6-DocumentType",
"initial": [ {
"valueString": "AMI"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
}, {
"type": "string",
"linkId": "2.2.6-DocumentSubType",
"initial": [ {
"valueString": "Regular or IR AMI"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
} ],
"text": "Attach related documents",
"type": "attachment",
"linkId": "2.2.6",
"repeats": true,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/vnd.openxmlformats-officedocument.wordprocessingml.document"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/msword"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/rtf"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/tiff"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/pdf"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/gif"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 20
} ]
} ],
"text": "2. Additional Information",
"type": "group",
"linkId": "2.2",
"repeats": false
}, {
"item": [ {
"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"
} ]
}
} ]
} ],
"text": "Intellectual and Emotional Wellness Scale (IEWS)",
"type": "display",
"linkId": "2.3.1b",
"repeats": false,
"readOnly": false,
"required": true
}, {
"item": [ {
"text": "Rating Scale",
"type": "choice",
"linkId": "2.3.2.1",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-displayCategory",
"valueCode": "display"
} ],
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClass"
}, {
"item": [ {
"text": "Ammotivation",
"type": "choice",
"linkId": "2.3.2.2.1",
"repeats": false,
"readOnly": false,
"required": true,
"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"
} ]
}
}, {
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}
} ]
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"required": true,
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"text": "Radio Button",
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"code": "radio-button",
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} ]
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"valueCode": "horizontal"
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"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
} ],
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"linkId": "2.3.2.20",
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} ]
}, {
"item": [ {
"text": "Judgement deficit",
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"readOnly": false,
"required": true,
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}
}, {
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"valueCode": "horizontal"
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"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
} ],
"type": "group",
"linkId": "2.3.2.21",
"repeats": false,
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"text": "Group gtable",
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}
} ]
}, {
"item": [ {
"text": "Learning deficits",
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"readOnly": false,
"required": true,
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"valueCodeableConcept": {
"text": "Radio Button",
"coding": [ {
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"display": "Radio Button"
} ]
}
}, {
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"valueCode": "horizontal"
} ],
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
}, {
"text": "Describe the learning deficits:",
"type": "text",
"linkId": "2.3.2.22.2",
"repeats": false,
"readOnly": false,
"required": false,
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"valueExpression": {
"language": "text/fhirpath",
"expression": "%context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.22').item.where(linkId='2.3.2.22.1').answer.valueCoding.code='1' or %context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.22').item.where(linkId='2.3.2.22.1').answer.valueCoding.code='2' or %context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.22').item.where(linkId='2.3.2.22.1').answer.valueCoding.code='3'"
}
} ],
"maxLength": 200
} ],
"type": "group",
"linkId": "2.3.2.22",
"repeats": false,
"extension": [ {
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"text": "Group gtable",
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} ]
}, {
"item": [ {
"text": "Memory deficit",
"type": "choice",
"linkId": "2.3.2.23.1",
"repeats": false,
"readOnly": false,
"required": true,
"extension": [ {
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"valueCodeableConcept": {
"text": "Radio Button",
"coding": [ {
"code": "radio-button",
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} ]
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}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
} ],
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
}, {
"text": "Memory Deficit - select all that apply: ",
"type": "choice",
"linkId": "2.3.2.23.2",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Check box",
"coding": [ {
"code": "check-box",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Check box"
} ]
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"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
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"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='2.3.2.23').item.where(linkId='2.3.2.23.1').answer.valueCoding.code='1' or %context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.23').item.where(linkId='2.3.2.23.1').answer.valueCoding.code='2' or %context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.23').item.where(linkId='2.3.2.23.1').answer.valueCoding.code='3'"
}
} ],
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-MemoryImpairments"
} ],
"type": "group",
"linkId": "2.3.2.23",
"repeats": false,
"extension": [ {
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"valueCodeableConcept": {
"text": "Group gtable",
"coding": [ {
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"display": "Group gtable"
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} ]
}, {
"item": [ {
"text": "Psychomotor retardation",
"type": "choice",
"linkId": "2.3.2.24.1",
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"required": true,
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"valueCode": "horizontal"
} ],
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
}, {
"text": "Agitation or retardation?",
"type": "choice",
"linkId": "2.3.2.24.2",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
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"text": "Radio Button",
"coding": [ {
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"valueCode": "horizontal"
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"valueExpression": {
"language": "text/fhirpath",
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}
} ],
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-Psychomotor"
} ],
"type": "group",
"linkId": "2.3.2.24",
"repeats": false,
"extension": [ {
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"valueCodeableConcept": {
"text": "Group gtable",
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}
} ]
}, {
"item": [ {
"text": "Sleep dysfunction",
"type": "choice",
"linkId": "2.3.2.25.1",
"repeats": false,
"readOnly": false,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
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"text": "Radio Button",
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}, {
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"valueCode": "horizontal"
} ],
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
}, {
"text": "Difficulty sleeping or excessive sleeping?",
"type": "choice",
"linkId": "2.3.2.25.2",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
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"coding": [ {
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} ]
}
}, {
"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='2.3.2.25').item.where(linkId='2.3.2.25.1').answer.valueCoding.code='1' or %context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.25').item.where(linkId='2.3.2.25.1').answer.valueCoding.code='2' or %context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.25').item.where(linkId='2.3.2.25.1').answer.valueCoding.code='3'"
}
} ],
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-Sleep"
} ],
"type": "group",
"linkId": "2.3.2.25",
"repeats": false,
"extension": [ {
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"text": "Group gtable",
"coding": [ {
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"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Group gtable"
} ]
}
} ]
}, {
"item": [ {
"text": "Speech deficit (not due to language barrier)",
"type": "choice",
"linkId": "2.3.2.26.1",
"repeats": false,
"readOnly": false,
"required": true,
"extension": [ {
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"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"
} ],
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
}, {
"text": "Specify:",
"type": "text",
"linkId": "2.3.2.26.2",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"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='2.3.2.26').item.where(linkId='2.3.2.26.1').answer.valueCoding.code='1' or %context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.26').item.where(linkId='2.3.2.26.1').answer.valueCoding.code='2' or %context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.26').item.where(linkId='2.3.2.26.1').answer.valueCoding.code='3'"
}
} ],
"maxLength": 200
} ],
"type": "group",
"linkId": "2.3.2.26",
"repeats": false,
"extension": [ {
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"valueCodeableConcept": {
"text": "Group gtable",
"coding": [ {
"code": "gtable",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Group gtable"
} ]
}
} ]
}, {
"item": [ {
"text": "Suicidality",
"type": "choice",
"linkId": "2.3.2.27.1",
"repeats": false,
"readOnly": false,
"required": true,
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} ]
}
}, {
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"valueCode": "horizontal"
} ],
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
}, {
"text": "Suicidal behaviours - select all that apply:",
"type": "choice",
"linkId": "2.3.2.27.2",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Check box",
"coding": [ {
"code": "check-box",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Check box"
} ]
}
}, {
"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='2.3.2.27').item.where(linkId='2.3.2.27.1').answer.valueCoding.code='1' or %context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.27').item.where(linkId='2.3.2.27.1').answer.valueCoding.code='2' or %context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.27').item.where(linkId='2.3.2.27.1').answer.valueCoding.code='3'"
}
} ],
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-Suicidal"
} ],
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"linkId": "2.3.2.27",
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"extension": [ {
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}
} ]
}, {
"item": [ {
"text": "Thought disorganization",
"type": "choice",
"linkId": "2.3.2.28.1",
"repeats": false,
"readOnly": false,
"required": true,
"extension": [ {
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"coding": [ {
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}, {
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"valueCode": "horizontal"
} ],
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
} ],
"type": "group",
"linkId": "2.3.2.28",
"repeats": false,
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} ]
}, {
"item": [ {
"text": "Withdrawn",
"type": "choice",
"linkId": "2.3.2.29.1",
"repeats": false,
"readOnly": false,
"required": true,
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"coding": [ {
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} ]
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
} ],
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
} ],
"type": "group",
"linkId": "2.3.2.29",
"repeats": false,
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} ]
} ],
"type": "group",
"linkId": "2.3.2",
"repeats": false,
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"display": "Group table"
} ]
}
} ]
}, {
"text": "For episodic symptoms, describe how fluctuations in severity level affect the patient",
"type": "text",
"linkId": "2.3.3",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 4000
} ],
"text": "2.2 Intellectual and Emotional Wellness ",
"type": "group",
"linkId": "2.3",
"repeats": false,
"readOnly": false,
"required": false
}, {
"item": [ {
"text": "Note: You do not have to repeat the information already provided in previous sections.",
"type": "display",
"linkId": "2.4.1",
"repeats": false,
"readOnly": false,
"required": false
}, {
"text": "How long have you known the applicant?",
"type": "string",
"linkId": "2.4.2",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 100
}, {
"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": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unit",
"valueCoding": {
"code": "cm"
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"valueInteger": 0
} ],
"maxLength": 255
}, {
"text": "If relevant, state the applicant's weight in kilograms",
"type": "decimal",
"linkId": "2.4.5",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unit",
"valueCoding": {
"code": "kg"
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"valueInteger": 0
} ],
"maxLength": 255
}, {
"text": "Body Mass Index (BMI)",
"type": "decimal",
"linkId": "2.4.6",
"repeats": false,
"readOnly": true,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression",
"valueExpression": {
"language": "text/fhirpath",
"expression": "iif(%context.item.where(linkId='2').item.where(linkId='2.4').item.where(linkId='2.4.4').answer.valueDecimal.exists() and %context.item.where(linkId='2').item.where(linkId='2.4').item.where(linkId='2.4.5').answer.valueDecimal.exists(), (%context.item.where(linkId='2').item.where(linkId='2.4').item.where(linkId='2.4.5').answer.valueDecimal / ((%context.item.where(linkId='2').item.where(linkId='2.4').item.where(linkId='2.4.4').answer.valueDecimal / 100.0) * (%context.item.where(linkId='2').item.where(linkId='2.4').item.where(linkId='2.4.4').answer.valueDecimal / 100.0))).round(1))",
"description": "BMI Calculation"
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/maxDecimalPlaces",
"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",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 4000,
"enableWhen": [ {
"operator": "=",
"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
}, {
"text": "Comment (e.g., pending or waiting list, not available)",
"type": "text",
"linkId": "2.4.12N",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 1000,
"enableWhen": [ {
"operator": "=",
"question": "2.4.11",
"answerBoolean": 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"
}, {
"linkId": "2.4.12-attachment",
"repeats": true,
"item": [ {
"text": "Attachment Categories",
"type": "choice",
"linkId": "2.4.12-categories",
"repeats": false,
"readOnly": false,
"required": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-AttachmentCategories"
}, {
"type": "string",
"linkId": "2.4.12-DocumentType",
"initial": [ {
"valueString": "AMI"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
}, {
"type": "string",
"linkId": "2.4.12-DocumentSubType",
"initial": [ {
"valueString": "Regular or IR AMI"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
} ],
"type": "attachment",
"enableWhen": [ {
"operator": "=",
"question": "2.4.11",
"answerBoolean": true
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/vnd.openxmlformats-officedocument.wordprocessingml.document"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/msword"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/rtf"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/tiff"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/pdf"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/gif"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 20
} ],
"readOnly": false,
"required": false,
"text": "Attach relevant diagnostic tests or investigations"
}, {
"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"
}, {
"linkId": "2.4.13-attachment",
"repeats": true,
"item": [ {
"text": "Attachment Categories",
"type": "choice",
"linkId": "2.4.13-categories",
"repeats": false,
"readOnly": false,
"required": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-AttachmentCategories"
}, {
"type": "string",
"linkId": "2.4.13-DocumentType",
"initial": [ {
"valueString": "AMI"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
}, {
"type": "string",
"linkId": "2.4.13-DocumentSubType",
"initial": [ {
"valueString": "Regular or IR AMI"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
} ],
"type": "attachment",
"enableWhen": [ {
"operator": "=",
"question": "2.4.11",
"answerBoolean": true
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/vnd.openxmlformats-officedocument.wordprocessingml.document"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/msword"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/rtf"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/tiff"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/pdf"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/gif"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 20
} ],
"readOnly": false,
"required": false,
"text": "Attach relevant specialist consults"
}, {
"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"
}, {
"linkId": "2.4.14-attachment",
"repeats": true,
"item": [ {
"text": "Attachment Categories",
"type": "choice",
"linkId": "2.4.14-categories",
"repeats": false,
"readOnly": false,
"required": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-AttachmentCategories"
}, {
"type": "string",
"linkId": "2.4.14-DocumentType",
"initial": [ {
"valueString": "AMI"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
}, {
"type": "string",
"linkId": "2.4.14-DocumentSubType",
"initial": [ {
"valueString": "Regular or IR AMI"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
} ],
"type": "attachment",
"enableWhen": [ {
"operator": "=",
"question": "2.4.11",
"answerBoolean": true
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/vnd.openxmlformats-officedocument.wordprocessingml.document"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/msword"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/rtf"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/tiff"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/pdf"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/gif"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 20
} ],
"readOnly": false,
"required": false,
"text": "Attach relevant other assessments or reports"
}, {
"text": "Describe relevant findings",
"type": "text",
"linkId": "2.4.15",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 4000,
"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,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today()"
}
} ]
} ],
"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,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today()"
}
} ]
} ],
"enableWhen": [ {
"operator": "=",
"question": "2.5.1",
"answerBoolean": true
} ]
}, {
"text": "Snellen Visual Acuity Chart Details",
"type": "display",
"linkId": "2.5.5-display",
"repeats": false,
"readOnly": false,
"required": false,
"enableWhen": [ {
"operator": "=",
"question": "2.5.1",
"answerBoolean": true
} ]
}, {
"item": [ {
"item": [ {
"text": "Left eye",
"type": "display",
"linkId": "2.5.5-left-display",
"repeats": false,
"readOnly": false,
"required": false
}, {
"text": "Uncorrected - Near",
"type": "string",
"linkId": "2.5.5.2-left",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 100
}, {
"text": "Uncorrected - Distance",
"type": "string",
"linkId": "2.5.5.3-left",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 100
}, {
"text": "Corrected - Near",
"type": "string",
"linkId": "2.5.5.4-left",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 100
}, {
"text": "Corrected - Distance",
"type": "string",
"linkId": "2.5.5.5-left",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 100
} ],
"type": "group",
"linkId": "2.5.5-left-group-table",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Group table",
"coding": [ {
"code": "table",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Group table"
} ]
}
} ]
}, {
"item": [ {
"text": "Right eye",
"type": "display",
"linkId": "2.5.5-right-display",
"repeats": false,
"readOnly": false,
"required": false
}, {
"text": "Uncorrected - Near",
"type": "string",
"linkId": "2.5.5.2-right",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 100
}, {
"text": "Uncorrected - Distance",
"type": "string",
"linkId": "2.5.5.3-right",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 100
}, {
"text": "Corrected - Near",
"type": "string",
"linkId": "2.5.5.4-right",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 100
}, {
"text": "Corrected - Distance",
"type": "string",
"linkId": "2.5.5.5-right",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 100
} ],
"type": "group",
"linkId": "2.5.5-right-group-table",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Group table",
"coding": [ {
"code": "table",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Group table"
} ]
}
} ]
}, {
"item": [ {
"text": "Both eyes",
"type": "display",
"linkId": "2.5.5-both-display",
"repeats": false,
"readOnly": false,
"required": false
}, {
"text": "Uncorrected - Near",
"type": "string",
"linkId": "2.5.5.2-both",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 100
}, {
"text": "Uncorrected - Distance",
"type": "string",
"linkId": "2.5.5.3-both",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 100
}, {
"text": "Corrected - Near",
"type": "string",
"linkId": "2.5.5.4-both",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 100
}, {
"text": "Corrected - Distance",
"type": "string",
"linkId": "2.5.5.5-both",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 100
} ],
"type": "group",
"linkId": "2.5.5-both-group-table",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Group table",
"coding": [ {
"code": "table",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Group table"
} ]
}
} ]
} ],
"type": "group",
"linkId": "2.5.5-gtable",
"repeats": false,
"readOnly": false,
"required": 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"
} ]
}
} ],
"enableWhen": [ {
"operator": "=",
"question": "2.5.1",
"answerBoolean": true
} ]
}, {
"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
}, {
"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
}, {
"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
} ]
}, {
"linkId": "2.5.10",
"repeats": true,
"item": [ {
"text": "Attachment Categories",
"type": "choice",
"linkId": "2.5.10-categories",
"repeats": false,
"readOnly": false,
"required": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-AttachmentCategories"
}, {
"type": "string",
"linkId": "2.5.10-DocumentType",
"initial": [ {
"valueString": "AMI"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
}, {
"type": "string",
"linkId": "2.5.10-DocumentSubType",
"initial": [ {
"valueString": "Regular or IR AMI"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
} ],
"type": "attachment",
"enableWhen": [ {
"operator": "=",
"question": "2.5.1",
"answerBoolean": true
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/vnd.openxmlformats-officedocument.wordprocessingml.document"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/msword"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/rtf"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/tiff"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/pdf"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/gif"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 20
} ],
"readOnly": false,
"required": false,
"text": "Attach copies of Visual report(s) pertaining to the patient's diagnosis/condition. You may also wish to attach consult notes."
} ],
"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,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today()"
}
} ]
} ],
"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,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today()"
}
} ]
} ],
"enableWhen": [ {
"operator": "=",
"question": "2.6.1",
"answerBoolean": true
} ]
}, {
"linkId": "2.6.4",
"repeats": false,
"type": "choice",
"enableWhen": [ {
"operator": "=",
"question": "2.6.1",
"answerBoolean": true
} ],
"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,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-Hearing",
"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,
"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
} ]
}, {
"linkId": "2.6.19",
"repeats": true,
"item": [ {
"text": "Attachment Categories",
"type": "choice",
"linkId": "2.6.19-categories",
"repeats": false,
"readOnly": false,
"required": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-AttachmentCategories"
}, {
"type": "string",
"linkId": "2.6.19-DocumentType",
"initial": [ {
"valueString": "AMI"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
}, {
"type": "string",
"linkId": "2.6.19-DocumentSubType",
"initial": [ {
"valueString": "Regular or IR AMI"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
} ],
"type": "attachment",
"enableWhen": [ {
"operator": "=",
"question": "2.6.1",
"answerBoolean": true
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/vnd.openxmlformats-officedocument.wordprocessingml.document"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/msword"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/rtf"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/tiff"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/pdf"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/gif"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 20
} ],
"readOnly": false,
"required": false,
"text": "Attach copies of Auditory report(s) pertaining to the patient's diagnosis/condition. You may also wish to attach consult notes. "
} ],
"text": "5. Auditory",
"type": "group",
"linkId": "2.6",
"repeats": false,
"readOnly": false,
"required": false
}, {
"item": [ {
"text": "6.1 Is the applicant receiving any interventions and treatment for conditions and impairments listed in section 1 (e.g. Admission, Emergency Room Visit, Surgery, Pharmacotherapy, Interventions and Services.)",
"type": "boolean",
"linkId": "2.7.1",
"repeats": false,
"readOnly": false,
"required": true
}, {
"text": "Does the applicant have any relevant admissions, emergency room visits or surgeries?",
"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 or, 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,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today()"
}
} ]
} ]
}, {
"text": "Duration",
"type": "text",
"linkId": "2.7.3.3",
"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,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-AttachmentCategories"
}, {
"type": "string",
"linkId": "2.7.3.5-DocumentType",
"initial": [ {
"valueString": "AMI"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
}, {
"type": "string",
"linkId": "2.7.3.5-DocumentSubType",
"initial": [ {
"valueString": "Regular or IR AMI"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
} ],
"text": "Discharge Report",
"type": "attachment",
"linkId": "2.7.3.5",
"repeats": true,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "vertical"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 20
} ]
} ],
"text": "Describe admissions, emergency room visits or surgeries, 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 pharmacological interventions?",
"type": "boolean",
"linkId": "2.7.6",
"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": "2.7.7-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": "Enter name of pharmacotherapy treatment.",
"type": "display",
"linkId": "2.7.7.1-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": "Pharmacotherapy treatment",
"type": "string",
"linkId": "2.7.7.1",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 255
}, {
"text": "Start Date (if known)",
"type": "date",
"linkId": "2.7.7.2",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today()"
}
} ]
} ]
}, {
"text": "Dosage",
"type": "string",
"linkId": "2.7.7.3",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 100
}, {
"text": "Frequency",
"type": "text",
"linkId": "2.7.7.4",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 500
}, {
"text": "List Conditions or Impairments being treated",
"type": "text",
"linkId": "2.7.7.5",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 4000
}, {
"item": [ {
"text": "Attachment Categories",
"type": "choice",
"linkId": "2.7.7.6-categories",
"repeats": false,
"readOnly": false,
"required": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-AttachmentCategories"
}, {
"type": "string",
"linkId": "2.7.7.6-DocumentType",
"initial": [ {
"valueString": "AMI"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
}, {
"type": "string",
"linkId": "2.7.7.6-DocumentSubType",
"initial": [ {
"valueString": "Regular or IR AMI"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
} ],
"text": "Attach Report",
"type": "attachment",
"linkId": "2.7.7.6",
"repeats": true,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "vertical"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 20
} ]
} ],
"text": "Describe pharmacological interventions, completing relevant sections below.",
"type": "group",
"linkId": "2.7.7",
"repeats": true,
"readOnly": false,
"required": true,
"enableWhen": [ {
"operator": "=",
"question": "2.7.6",
"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
} ]
}, {
"text": "If no, provide additional information: (e.g., pending, side effects, no definitive diagnosis, not available, poor insight)",
"type": "text",
"linkId": "2.7.10",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 1000,
"enableWhen": [ {
"operator": "=",
"question": "2.7.4",
"answerBoolean": false
} ]
}, {
"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": [ {
"text": "Select an intervention or Service from the list or if not listed type in ",
"type": "display",
"linkId": "2.7.5.1-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": "open-choice",
"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,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-Intervention",
"maxLength": 500,
"required": true,
"text": "Interventions and Services"
}, {
"type": "text",
"linkId": "2.7.5.1a",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-enableWhenExpression",
"valueExpression": {
"language": "text/fhirpath",
"expression": "%context.item.where(linkId='2').item.where(linkId='2.7').item.where(linkId='2.7.5').item.where(linkId='2.7.5.1').answer.valueCoding.code='Intervention-9' or %context.item.where(linkId='2').item.where(linkId='2.7').item.where(linkId='2.7.5').item.where(linkId='2.7.5.1').answer.valueCoding.code='Intervention-10'",
"description": "Show if one of the 'other' options are selected"
}
} ],
"maxLength": 500
}, {
"text": "Start Date (Approximate start date)",
"type": "date",
"linkId": "2.7.5.2",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today() + 1 day"
}
} ]
} ]
}, {
"text": "End Date (Approximate end date)",
"type": "date",
"linkId": "2.7.5.3",
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today() + 1 day"
}
} ]
} ]
}, {
"text": "Describe Response to Treatment",
"type": "text",
"linkId": "2.7.5.4",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 4000
}, {
"item": [ {
"text": "Attachment Categories",
"type": "choice",
"linkId": "2.7.5.5-categories",
"repeats": false,
"readOnly": false,
"required": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-AttachmentCategories"
}, {
"type": "string",
"linkId": "2.7.5.5-DocumentType",
"initial": [ {
"valueString": "AMI"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
}, {
"type": "string",
"linkId": "2.7.5.5-DocumentSubType",
"initial": [ {
"valueString": "Regular or IR AMI"
} ],
"repeats": false,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
} ]
} ],
"text": "Attach Report",
"type": "attachment",
"linkId": "2.7.5.5",
"repeats": true,
"readOnly": false,
"required": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "vertical"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 20
} ]
} ],
"text": "Describe interventions and services, completing relevant sections below and comment on progress.",
"type": "group",
"linkId": "2.7.5",
"repeats": true,
"readOnly": false,
"required": true,
"enableWhen": [ {
"operator": "=",
"question": "2.7.4",
"answerBoolean": true
} ]
}, {
"text": "6.2 Describe any relevant past treatment and reason for discontinuation (e.g., remission, failed treatment, change in treatment, side effects)",
"type": "text",
"linkId": "2.7.8",
"repeats": false,
"readOnly": false,
"required": false,
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"effectivePeriod": {
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}
}