{
"description": "This is the interRAI™ Child and Youth Mental Health (ChYMH) Adolescent Supplement, version 9.3.0 – CIHI Canadian Standard. It captures additional assessment content specific to adolescents and is intended to supplement the CHYMH Community Based Form when required. The core content was developed by interRAI, adapted by the Canadian Institute for Health Information (CIHI), and modified by Ontario Health. When applicable, the Adolescent Supplement is completed and submitted together with the CHYMH Community Based Form as part of a single CHYMH Full assessment. The FHIR artifact is maintained and published by Ontario Health.",
"_filename": "examples/Questionnaire-iar-interrai-chymh-adolescent-supplement-v1.0.0-oh.json",
"package_name": "ca.on.oh.setp.iar.dev",
"subjectType": [ "Patient" ],
"date": null,
"publisher": "Ontario Health",
"approvalDate": "2025-03-02",
"name": null,
"item": [ {
"item": [ {
"item": [ {
"text": "Given Name",
"type": "string",
"linkId": "A1a",
"prefix": "a",
"required": true
}, {
"text": "Initial or Middle Name",
"type": "string",
"linkId": "A1b",
"prefix": "b"
}, {
"text": "Family Name",
"type": "string",
"linkId": "A1c",
"prefix": "c",
"required": true
}, {
"text": "Suffix",
"type": "string",
"linkId": "A1d",
"prefix": "d"
} ],
"text": "Name",
"type": "group",
"linkId": "A1",
"prefix": "1."
}, {
"item": [ {
"text": "SEX",
"type": "choice",
"linkId": "A2a",
"prefix": "a",
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/sex"
}, {
"text": "GENDER IDENTITY",
"type": "choice",
"linkId": "A2b",
"prefix": "b",
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/gender-identity"
}, {
"text": "YOUNG PERSON SELF IDENTIFIES GENDER AS - Enter up to 25 characters. Do not include any names (full or partial) oe the young person's Health Care Identification Number or date of birth.",
"type": "string",
"linkId": "A2c",
"prefix": "c",
"maxLength": 25
} ],
"text": "2. SEX/GENDER IDENTITY",
"type": "group",
"linkId": "A2"
}, {
"text": "BIRTHDATE",
"type": "date",
"linkId": "A3",
"prefix": "3.",
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/entryFormat",
"valueString": "yyyy/MM/dd"
} ]
}, {
"item": [ {
"text": "Health Care Identification Number",
"type": "string",
"linkId": "A4a",
"prefix": "a",
"required": true
}, {
"text": "Province or Territory Issuing Health Care Identifcation Number",
"type": "choice",
"linkId": "A4b",
"prefix": "b.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/province-type"
}, {
"text": "Case Record Number",
"type": "string",
"linkId": "A4c",
"prefix": "c.",
"required": true
} ],
"text": "4. NUMERIC IDENTIFIERS [EXAMPLE—CANADA]",
"type": "group",
"linkId": "A4"
}, {
"text": "AGENCY IDENTIFIER [EXAMPLE - CANADA]",
"type": "string",
"linkId": "A5",
"prefix": "5.",
"required": true,
"maxLength": 11
}, {
"text": "ASSESSMENT REFERENCE DATE",
"type": "date",
"linkId": "A6",
"prefix": "6.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/entryFormat",
"valueString": "yyyy/MM/dd"
} ]
} ],
"text": "SECTION A – Identification",
"type": "group",
"linkId": "A"
}, {
"item": [ {
"text": "ALCOHOL – Highest number of drinks in any “single sitting” in LAST 14 DAYS",
"type": "choice",
"linkId": "B1",
"prefix": "1.",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-of-alcohol-intake"
}, {
"text": "2. NUMBER OF DAYS IN LAST 30 DAYS CONSUMED ALCOHOL TO POINT OF INTOXICATION",
"type": "choice",
"linkId": "B2",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-of-alcohol-intoxication"
}, {
"item": [ {
"text": "Inhalants e.g., glue, gasoline, paint thinners, solvents ",
"type": "choice",
"linkId": "B3a",
"prefix": "a",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
}, {
"text": "Hallucinogens - e.g., “angel dust,” LSD, “ecstasy” ",
"type": "choice",
"linkId": "B3b",
"prefix": "b",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
}, {
"text": "Cocaine or crack",
"type": "choice",
"linkId": "B3c",
"prefix": "c",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
}, {
"text": "Stimulants e.g., amphetamines, “uppers,” “speed”",
"type": "choice",
"linkId": "B3d",
"prefix": "d",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
}, {
"text": "Opiates (Including Synthetics) e.g., heroin, methadone",
"type": "choice",
"linkId": "B3e",
"prefix": "e",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
}, {
"text": "Cannabis",
"type": "choice",
"linkId": "B3f",
"prefix": "f",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
} ],
"text": "3. TIME SINCE USE OF THE FOLLOWING SUBSTANCES",
"type": "group",
"linkId": "B3"
}, {
"text": "4. INTENTIONAL MISUSE OF PRESCRIPTION OR OVER-THE-COUNTER MEDICATION IN LAST 90 DAYS e.g., used medication such as methylphenidate, oxycodone, cold remedies, or laxatives for purpose other than intended",
"type": "choice",
"linkId": "B4",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}, {
"text": "5. WITHDRAWAL SYMPTOMS Severity of signs and symptoms possibly indicative of withdrawal from alcohol, drugs, or medication. Code for most severe level in LAST 3 DAYS.",
"type": "choice",
"linkId": "B5",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-withdrawal-symptoms"
}, {
"text": "6. Excessive Gambling",
"type": "choice",
"linkId": "B6",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}, {
"item": [ {
"text": "Any instances of binge eating, purging, or bulimia",
"type": "choice",
"linkId": "B7a",
"prefix": "a",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}, {
"text": "Unrealistic fear of weight gain; statements that suggest a distorted body image",
"type": "choice",
"linkId": "B7b",
"prefix": "b",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}, {
"text": "Fasting or major restriction of diet — EXCLUDE RELIGIOUS PRACTICES",
"type": "choice",
"linkId": "B7c",
"prefix": "c",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
} ],
"text": "7. POTENTIAL SIGNS OF EATING DISORDER IN LAST 30 DAYS",
"type": "group",
"linkId": "B7"
}, {
"item": [ {
"text": "Promiscuity — e.g., casual and indiscriminate sexual behaviour",
"type": "choice",
"linkId": "B8a",
"prefix": "a",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}, {
"text": "Performed sexual acts for money, desired objects or favours (includes participation in sex trade)",
"type": "choice",
"linkId": "B8b",
"prefix": "b",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
} ],
"text": "8. SEXUAL ACTIVITY IN LAST 90 DAYS",
"type": "group",
"linkId": "B8"
}, {
"text": "9. HISTORY OF SEXUAL VIOLENCE OR ASSAULT AS PERPETRATOR",
"type": "choice",
"linkId": "B9",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}, {
"item": [ {
"text": "Making or Selling Drugs",
"type": "choice",
"linkId": "B10a",
"prefix": "a",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/iar-chymh-as-antisocial-behaviour"
}, {
"text": "Driving under the influence of alcohol or drugs",
"type": "choice",
"linkId": "B10b",
"prefix": "b",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/iar-chymh-as-antisocial-behaviour"
}, {
"text": "Illegally entering a premises — e.g., breaking into school after hours",
"type": "choice",
"linkId": "B10c",
"prefix": "c",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/iar-chymh-as-antisocial-behaviour"
}, {
"text": "Engaging in antisocial online behaviour — e.g., hacking, online harassment",
"type": "choice",
"linkId": "B10d",
"prefix": "d",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/iar-chymh-as-antisocial-behaviour"
} ],
"text": "10. ANTISOCIAL BEHAVIOUR - ADDITIONAL SUPPLEMENTARY ITEMS",
"type": "group",
"linkId": "B10"
} ],
"text": "SECTION B – SUBSTANCE USE OR EXCESSIVE BEHAVIOUR",
"type": "group",
"linkId": "B"
}, {
"item": [ {
"text": "1. PREGNANCY, STILL BIRTH, OR BIRTH OF A CHILD Code for any pregnancy, or fathering of a child, including stillbirth, miscarriage, or abortion.",
"type": "choice",
"linkId": "C1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}, {
"text": "2. YOUTH HAS DEPENDANT(S)",
"type": "choice",
"linkId": "C2",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}, {
"text": "3. INVOLVEMENT OF CHILD PROTECTIVE SERVICES Current involvement for youth’s dependants",
"type": "choice",
"linkId": "C3",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-not-applicable"
}, {
"text": "4. FAMILY, CAREGIVER, FRIEND OR STAFF EXPRESSES CONCERN THAT YOUTH DOES NOT HAVE ADEQUATE SUPPORTS IN CAREGIVER ROLE e.g., youth requires parenting class, respite, help from informal supports",
"type": "choice",
"linkId": "C4",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
} ],
"text": "SECTION C. PARENTAL STATUS (YOUTH AS PARENT)",
"type": "group",
"linkId": "C"
}, {
"item": [ {
"item": [ {
"item": [ {
"text": "Performance",
"type": "choice",
"linkId": "D1aP",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence"
}, {
"text": "Capacity",
"type": "choice",
"linkId": "D1aC",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence1"
} ],
"text": "Managing money — How money or allowance is spent",
"type": "group",
"linkId": "D1a",
"prefix": "a"
}, {
"item": [ {
"text": "Performance",
"type": "choice",
"linkId": "D1bP",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence"
}, {
"text": "Capacity",
"type": "choice",
"linkId": "D1bC",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence1"
} ],
"text": "Shopping — How shopping is performed for food and household items (e.g., selecting items, paying money) — EXCLUDE TRANSPORTATION",
"type": "group",
"linkId": "D1b",
"prefix": "b"
}, {
"item": [ {
"text": "Performance",
"type": "choice",
"linkId": "D1cP",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence"
}, {
"text": "Capacity",
"type": "choice",
"linkId": "D1cC",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence1"
} ],
"text": "Transportation — Travels by public transportation (including family’s) or driving self (including getting out of house, into and out of vehicles)",
"type": "group",
"linkId": "D1c",
"prefix": "c"
}, {
"item": [ {
"text": "Performance",
"type": "choice",
"linkId": "D1dP",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence"
}, {
"text": "Capacity",
"type": "choice",
"linkId": "D1dC",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence1"
} ],
"text": "Meal preparation — How meals and snacks are prepared, assembles ingredients and necessary utensils, makes a sandwich, cooks noodles, heats food",
"type": "group",
"linkId": "D1d",
"prefix": "d"
}, {
"item": [ {
"text": "Performance",
"type": "choice",
"linkId": "D1eP",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence"
}, {
"text": "Capacity",
"type": "choice",
"linkId": "D1eC",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence1"
} ],
"text": "Housework — How light housework and cleaning tasks are performed, remembering to take medicines, opening containers, or organizing objects",
"type": "group",
"linkId": "D1e",
"prefix": "e"
}, {
"item": [ {
"text": "Performance",
"type": "choice",
"linkId": "D1fP",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence"
}, {
"text": "Capacity",
"type": "choice",
"linkId": "D1fC",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-independence1"
} ],
"text": "Laundry — How sorts, washes, folds, puts away personal laundry (e.g., clothing, underwear, bedding, towels)",
"type": "group",
"linkId": "D1f",
"prefix": "f"
} ],
"text": "1. IADL SELF-PERFORMANCE AND CAPACITY Code for PERFORMANCE in routine activities around the home or in the community during the LAST 7 DAYS Code for CAPACITY based on presumed ability to carry out activity as independently as possible. This will require “speculation” by the assessor.",
"type": "group",
"linkId": "D1"
}, {
"text": "2. DIFFICULTY WITH ABSTRACT THINKING — Youth thinks in a highly concrete manner (e.g., considers only the literal meaning of words, has difficulty understanding idioms and abstract concepts)",
"type": "choice",
"linkId": "D2",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
} ],
"text": "SECTION D. INDEPENDENCE IN DAILY ACTIVITIES",
"type": "group",
"linkId": "D"
}, {
"item": [ {
"text": "1. YOUTH IS ENGAGED IN TREATMENT - e.g., attends and actively participates in programs, counselling or support groups",
"type": "choice",
"linkId": "E1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-youth-engaged-in-treatment"
}, {
"item": [ {
"text": "Detoxification or Post-Detox Stabilization",
"type": "choice",
"linkId": "E2a",
"prefix": "a",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period-of-intervention"
}, {
"text": "Alcohol / Drug Treatment",
"type": "choice",
"linkId": "E2b",
"prefix": "b",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period-of-intervention"
} ],
"text": "2. FOCUS OF INTERVENTIONS Code for types of issues that were a major focus of interventions in LAST 30 DAYS (or since admission if LESS THAN 30 DAYS)",
"type": "group",
"linkId": "E2"
} ],
"text": "SECTION E. PREVENTION, SERVICE UTILIZATION, TREATMENTS",
"type": "group",
"linkId": "E"
}, {
"item": [ {
"text": "1. EMPLOYMENT ARRANGEMENTS — EXCLUDE VOLUNTEERING",
"type": "choice",
"linkId": "F1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-employment-arrangements"
}, {
"text": "2. YOUTH REPORTS STRONG SENSE OF INVOLVEMENT IN COMMUNITY",
"type": "choice",
"linkId": "F2",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-could-not-respond"
} ],
"text": "SECTION F. STRENGTHS",
"type": "group",
"linkId": "F"
}, {
"item": [ {
"text": "1. DEGREE OF INSIGHT INTO MENTAL HEALTH PROBLEM",
"type": "choice",
"linkId": "G1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-degree-of-insight"
}, {
"item": [ {
"text": "Little interest or pleasure in things you normally enjoy?",
"type": "choice",
"linkId": "G2a",
"prefix": "a",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1"
}, {
"text": "Anxious, restless, or uneasy?",
"type": "choice",
"linkId": "G2b",
"prefix": "b",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1"
}, {
"text": "Sad, depressed, or hopeless?",
"type": "choice",
"linkId": "G2c",
"prefix": "c",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period1"
} ],
"text": "2. SELF-REPORTED MOOD",
"type": "group",
"linkId": "G2"
}, {
"text": "3. SELF-REPORTED HEALTH Ask: “In general, how would you rate your health?”",
"type": "choice",
"linkId": "G3",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-rating-with-missing-value"
}, {
"text": "4. SELF-REPORTED SLEEP Ask: “In general, how would you rate your sleep quality?”",
"type": "choice",
"linkId": "G4",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-rating-with-missing-value"
}, {
"text": "5. SELF-REPORTED WEIGHT CONCERNS Ask: “Do you consider yourself…?”",
"type": "choice",
"linkId": "G5",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-self-reported-weight-concerns"
}, {
"text": "6. YOUTH REPORTS PERSISTENT FEELINGS OF NOT BELONGING — e.g., feeling different from others",
"type": "choice",
"linkId": "G6",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "drop-down",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Drop down"
} ]
}
} ],
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-could-not-respond"
} ],
"text": "SECTION G. MENTAL HEALTH AND WELLBEING",
"type": "group",
"linkId": "G"
}, {
"item": [ {
"text": "1. SIGNATURE OF PERSON COORDINATING/COMPLETING THE ASSESSMENT Signature (sign on above line)",
"type": "string",
"linkId": "H1"
}, {
"text": "2. Date Assessment Signed as Complete",
"type": "date",
"linkId": "H2",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/entryFormat",
"valueString": "yyyy/MM/dd"
} ]
} ],
"text": "SECTION H. ASSESSMENT INFORMATION",
"type": "group",
"linkId": "H"
}, {
"item": [ {
"item": [ {
"text": "CYMH Criminality Prevention CAP",
"type": "choice",
"linkId": "CB-CAP2",
"prefix": "1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-0-1"
}, {
"text": "CYMH Harm to Others CAP",
"type": "choice",
"linkId": "CB-CAP3",
"prefix": "2",
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-3"
}, {
"text": "CYMH Hazardous Fire Involvement CAP",
"type": "choice",
"linkId": "CB-CAP4",
"prefix": "3",
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-4"
}, {
"text": "CYMH Sexual Behaviour CAP",
"type": "choice",
"linkId": "CB-CAP5",
"prefix": "4",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-0-1"
}, {
"text": "CYMH Suicidality and Purposeful Self-Harm CAP",
"type": "choice",
"linkId": "CB-CAP6",
"prefix": "5",
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-6"
}, {
"text": "CYMH Traumatic Life Events CAP",
"type": "choice",
"linkId": "CB-CAP7",
"prefix": "6",
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-7"
} ],
"text": "SAFETY",
"type": "group",
"linkId": "CAP_Safety"
}, {
"item": [ {
"text": "CYMH Attachment CAP",
"type": "choice",
"linkId": "CB-CAP8",
"prefix": "7",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-0-1"
}, {
"text": "CYMH Caregiver Distress CAP",
"type": "choice",
"linkId": "CB-CAP9",
"prefix": "8",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-0-1"
}, {
"text": "CYMH Interpersonal Conflict CAP",
"type": "choice",
"linkId": "CB-CAP10",
"prefix": "9",
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-10"
}, {
"text": "CYMH Parenting CAP",
"type": "choice",
"linkId": "CB-CAP11",
"prefix": "10",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-0-1"
}, {
"text": "CYMH Social and Peer Relationships CAP",
"type": "choice",
"linkId": "CB-CAP12",
"prefix": "11",
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-12"
} ],
"text": "FAMILY LIFE AND SOCIAL INTEGRATION",
"type": "group",
"linkId": "CAP_family"
}, {
"item": [ {
"text": "CYMH Communication CAP",
"type": "choice",
"linkId": "CB-CAP13",
"prefix": "12",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-0-1"
}, {
"text": "CYMH Life Skills CAP",
"type": "choice",
"linkId": "CB-CAP14",
"prefix": "13",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-14"
} ],
"text": "Functional Status",
"type": "group",
"linkId": "CAP_functional"
}, {
"item": [ {
"text": "CYMH Caffeine Use CAP",
"type": "choice",
"linkId": "CB-CAP15",
"prefix": "14",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-0-1"
}, {
"text": "CYMH Gambling CAP",
"type": "choice",
"linkId": "CB-CAP16",
"prefix": "15",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-0-1"
}, {
"text": "CYMH Medication Adherence CAP",
"type": "choice",
"linkId": "CB-CAP17",
"prefix": "16",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-0-1"
}, {
"text": "CYMH Medication Review CAP",
"type": "choice",
"linkId": "CB-CAP18",
"prefix": "17",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-0-1"
}, {
"text": "CYMH Physical Activity CAP",
"type": "choice",
"linkId": "CB-CAP19",
"prefix": "18",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-0-1"
}, {
"text": "CYMH Sleep Disturbance CAP",
"type": "choice",
"linkId": "CB-CAP20",
"prefix": "19",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-0-1"
}, {
"text": "CYMH Strengths CAP",
"type": "choice",
"linkId": "CB-CAP21",
"prefix": "20",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-0-1"
}, {
"text": "CYMH Substance Use CAP",
"type": "choice",
"linkId": "CB-CAP22",
"prefix": "21",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-0-1"
}, {
"text": "CYMH Tobacco and Nicotine Use CAP",
"type": "choice",
"linkId": "CB-CAP23",
"prefix": "22",
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-23"
}, {
"text": "CYMH Video Gaming CAP",
"type": "choice",
"linkId": "CB-CAP24",
"prefix": "23",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-0-1"
}, {
"text": "CYMH Weight Management CAP",
"type": "choice",
"linkId": "CB-CAP25",
"prefix": "24",
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-25"
} ],
"text": "HEALTH PROMOTIONS",
"type": "group",
"linkId": "CAP_Health"
}, {
"item": [ {
"text": "CYMH Education CAP",
"type": "choice",
"linkId": "CB-CAP26",
"prefix": "25",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-26"
}, {
"text": "CYMH Informal Support CAP",
"type": "choice",
"linkId": "CB-CAP27",
"prefix": "26",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-0-1"
}, {
"text": "CYMH Readmission CAP",
"type": "choice",
"linkId": "CB-CAP28",
"prefix": "27",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-0-1"
}, {
"text": "CYMH Transitions CAP",
"type": "choice",
"linkId": "CB-CAP30",
"prefix": "29",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
"code": "radio-button",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Radio Button"
} ]
}
} ],
"answerValueSet": "http://ccim.on.ca/fhir/iar/ValueSet/chymh-cb-calculated-cap-0-1"
} ],
"text": "SERVICE AND SUPPORTS",
"type": "group",
"linkId": "CAP_Service"
} ],
"text": "SECTION V. Collaborative Action Plans (CAPs)",
"type": "group",
"linkId": "CAP"
}, {
"item": [ {
"text": "Age at Assessment",
"type": "integer",
"linkId": "CB-OM_Age",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"valueInteger": 0
}, {
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"valueInteger": 130
} ]
}, {
"text": "Adolescent Supplement Flag",
"type": "choice",
"linkId": "CB-OM_Flag",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/chymh-adolescent-supplement-flag"
}, {
"text": "Externalzing Scale",
"type": "choice",
"linkId": "CB-OM1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [ {
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