{
"description": null,
"_filename": "examples/Questionnaire-ADLI.json",
"package_name": "ca.on.health.sadie",
"subjectType": [ "Patient" ],
"date": null,
"meta": {
"source": "#thSVcqfzMi8kQ32b",
"profile": [ "http://health.gov.on.ca/sadie/fhir/StructureDefinition/FlexForm" ],
"versionId": "9",
"lastUpdated": "2021-10-15T14:57:57.495+00:00"
},
"publisher": "ODSP",
"name": "ActivitiesofDailyLivingIndex",
"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 applicant 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)"
}, {
"type": "string",
"linkId": "details",
"initial": [ {
"valueString": "Activities of Daily Living Index"
} ],
"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": "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": [ {
"item": [ {
"text": "This information helps the ministry understand the direct impact of the impairments and restrictions listed in Section 1 on the applicant’s current ability to perform and carry out each activity.",
"type": "display",
"linkId": "2.1.1-help",
"repeats": false,
"readOnly": false,
"required": false,
"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": "This section consists of a list of activities that seeks to understand the impact of the presenting impairments on the applicant's restrictions.",
"type": "display",
"linkId": "2.1.1",
"repeats": false,
"readOnly": false,
"required": false
}, {
"item": [ {
"text": "Please rate the limitation for each activity",
"type": "choice",
"linkId": "2.1.2.1",
"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/ODSP-SymptomClassHelp"
}, {
"item": [ {
"text": "1. Bladder control",
"type": "choice",
"linkId": "2.1.2.2.1",
"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"
} ]
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
} ],
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
}, {
"text": "Describe limitation, if needed",
"type": "text",
"linkId": "2.1.2.2.2",
"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='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.2').item.where(linkId='2.1.2.2.1').answer.valueCoding.code='1' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.2').item.where(linkId='2.1.2.2.1').answer.valueCoding.code='2' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.2').item.where(linkId='2.1.2.2.1').answer.valueCoding.code='3'"
}
} ],
"maxLength": 500
} ],
"type": "group",
"linkId": "2.1.2.2",
"repeats": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Group gtable",
"coding": [ {
"code": "gtable",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Group gtable"
} ]
}
} ]
}, {
"item": [ {
"text": "2. Bowel control",
"type": "choice",
"linkId": "2.1.2.3.1",
"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"
} ]
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
} ],
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
}, {
"text": "Describe limitation, if needed",
"type": "text",
"linkId": "2.1.2.3.2",
"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='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.3').item.where(linkId='2.1.2.3.1').answer.valueCoding.code='1' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.3').item.where(linkId='2.1.2.3.1').answer.valueCoding.code='2' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.3').item.where(linkId='2.1.2.3.1').answer.valueCoding.code='3'"
}
} ],
"maxLength": 500
} ],
"type": "group",
"linkId": "2.1.2.3",
"repeats": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Group gtable",
"coding": [ {
"code": "gtable",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Group gtable"
} ]
}
} ]
}, {
"item": [ {
"text": "3. Bathing and self-cleaning",
"type": "choice",
"linkId": "2.1.2.4.1",
"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"
} ]
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
} ],
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
}, {
"text": "Describe limitation, if needed",
"type": "text",
"linkId": "2.1.2.4.2",
"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='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.4').item.where(linkId='2.1.2.4.1').answer.valueCoding.code='1' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.4').item.where(linkId='2.1.2.4.1').answer.valueCoding.code='2' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.4').item.where(linkId='2.1.2.4.1').answer.valueCoding.code='3'"
}
} ],
"maxLength": 500
} ],
"type": "group",
"linkId": "2.1.2.4",
"repeats": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Group gtable",
"coding": [ {
"code": "gtable",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Group gtable"
} ]
}
} ]
}, {
"item": [ {
"text": "4. Grooming (hair, face, teeth, hands and nails)",
"type": "choice",
"linkId": "2.1.2.5.1",
"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"
} ]
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
} ],
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
}, {
"text": "Describe limitation, if needed",
"type": "text",
"linkId": "2.1.2.5.2",
"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='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.5').item.where(linkId='2.1.2.5.1').answer.valueCoding.code='1' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.5').item.where(linkId='2.1.2.5.1').answer.valueCoding.code='2' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.5').item.where(linkId='2.1.2.5.1').answer.valueCoding.code='3'"
}
} ],
"maxLength": 500
} ],
"type": "group",
"linkId": "2.1.2.5",
"repeats": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Group gtable",
"coding": [ {
"code": "gtable",
"system": "http://hl7.org/fhir/questionnaire-item-control",
"display": "Group gtable"
} ]
}
} ]
}, {
"item": [ {
"text": "5. Dressing (including buttons, clasps, zips, shoe laces)",
"type": "choice",
"linkId": "2.1.2.6.1",
"repeats": false,
"readOnly": false,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
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