{
"description": null,
"_filename": "examples/Questionnaire-ADLI.json",
"package_name": "ca.on.health.sadie",
"subjectType": [ "Patient" ],
"date": null,
"meta": {
"source": "#ucdshNckDaJI500P",
"versionId": "27",
"lastUpdated": "2021-06-25T18:27:27.576+00:00"
},
"publisher": null,
"name": "Activities of Daily Living Index",
"item": [ {
"linkId": "0",
"repeats": false,
"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
}, {
"text": "Member ID (9 digits)",
"type": "string",
"linkId": "member-id",
"repeats": false,
"readOnly": false,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "[0-9]*"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/minLength",
"valueInteger": 9
} ],
"maxLength": 9
}, {
"text": "Referral ID (16 digits)",
"type": "string",
"linkId": "referral-id",
"repeats": false,
"readOnly": false,
"required": true,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "[0-9]*"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/minLength",
"valueInteger": 16
} ],
"maxLength": 16
} ],
"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,
"maxLength": 0
}, {
"text": "Attach your patient’s consent form.",
"type": "attachment",
"linkId": "0.3.2",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 0,
"enableWhen": [ {
"operator": "=",
"question": "0.3.1",
"answerBoolean": true
} ]
}, {
"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,
"maxLength": 0
}, {
"enableBehavior": "any",
"linkId": "0.3.4",
"repeats": false,
"type": "attachment",
"enableWhen": [ {
"operator": "=",
"question": "0.3.3",
"answerBoolean": true
} ],
"readOnly": false,
"maxLength": 0,
"required": false,
"text": "Attach your patient’s Self Report form."
} ],
"text": "Applicant Forms",
"type": "group",
"linkId": "0.3",
"repeats": false,
"readOnly": false,
"required": false
} ],
"type": "group",
"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"
} ]
}
} ],
"readOnly": false,
"maxLength": 0,
"required": false,
"text": "General"
}, {
"linkId": "1",
"repeats": false,
"item": [ {
"item": [ {
"item": [ {
"text": "First Name",
"type": "string",
"linkId": "1.1.1.1",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 100
}, {
"text": "Middle Initial",
"type": "string",
"linkId": "1.1.1.2",
"repeats": false,
"readOnly": false,
"required": false,
"maxLength": 2
}, {
"text": "Last Name",
"type": "string",
"linkId": "1.1.1.3",
"repeats": false,
"readOnly": false,
"required": true,
"maxLength": 100
}, {
"text": "Date of Birth",
"type": "date",
"linkId": "1.1.1.4",
"repeats": false,
"readOnly": false,
"required": true
} ],
"text": "Specify the requested patient information:",
"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,
"maxLength": 10
}, {
"text": "Street Number",
"type": "integer",
"linkId": "1.2.2",
"repeats": false,
"readOnly": false,
"required": true,
"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
} ],
"maxLength": 7
} ],
"text": "Applicant's Current Address",
"type": "group",
"linkId": "1.2",
"repeats": false,
"readOnly": false,
"required": false
} ],
"type": "group",
"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"
} ]
}
} ],
"readOnly": false,
"maxLength": 0,
"required": false,
"text": "Applicant"
}, {
"linkId": "2",
"repeats": false,
"item": [ {
"item": [ {
"item": [ {
"text": "Completing the rating scale information helps the ministry understand the direct impact of the impairments and restrictions within the Health Status Report 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"
} ]
}
} ],
"maxLength": 0
} ],
"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,
"maxLength": 0
}, {
"item": [ {
"linkId": "2.1.2.1",
"repeats": false,
"type": "choice",
"answerOption": [ {
"valueCoding": {
"code": "DK",
"display": "Don't Know"
}
}, {
"valueCoding": {
"code": "0",
"display": "Not present / Not at all"
}
}, {
"valueCoding": {
"code": "1",
"display": "Mild / Just a little"
}
}, {
"valueCoding": {
"code": "2",
"display": "Moderate / Quite a bit"
}
}, {
"valueCoding": {
"code": "3",
"display": "Severe / Very much"
}
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-displayCategory",
"valueCode": "display"
} ],
"readOnly": false,
"maxLength": 0,
"required": false,
"text": "Rating Scale"
}, {
"item": [ {
"linkId": "2.1.2.2.1",
"repeats": false,
"type": "choice",
"answerOption": [ {
"valueString": "DK"
}, {
"valueString": "0"
}, {
"valueString": "1"
}, {
"valueString": "2"
}, {
"valueString": "3"
} ],
"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"
} ],
"readOnly": false,
"maxLength": 0,
"required": true,
"text": "Bladder control"
}, {
"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.valueString='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.valueString='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.valueString='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": [ {
"linkId": "2.1.2.3.1",
"repeats": false,
"type": "choice",
"answerOption": [ {
"valueString": "DK"
}, {
"valueString": "0"
}, {
"valueString": "1"
}, {
"valueString": "2"
}, {
"valueString": "3"
} ],
"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"
} ],
"readOnly": false,
"maxLength": 0,
"required": true,
"text": "Bowel control"
}, {
"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.valueString='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.valueString='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.valueString='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": [ {
"linkId": "2.1.2.4.1",
"repeats": false,
"type": "choice",
"answerOption": [ {
"valueString": "DK"
}, {
"valueString": "0"
}, {
"valueString": "1"
}, {
"valueString": "2"
}, {
"valueString": "3"
} ],
"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"
} ],
"readOnly": false,
"maxLength": 0,
"required": true,
"text": "Bathing and self-cleaning"
}, {
"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.valueString='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.valueString='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.valueString='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": [ {
"linkId": "2.1.2.5.1",
"repeats": false,
"type": "choice",
"answerOption": [ {
"valueString": "DK"
}, {
"valueString": "0"
}, {
"valueString": "1"
}, {
"valueString": "2"
}, {
"valueString": "3"
} ],
"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"
} ],
"readOnly": false,
"maxLength": 0,
"required": true,
"text": "Grooming (hair, face, teeth, hands and nails)"
}, {
"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.valueString='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.valueString='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.valueString='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": [ {
"linkId": "2.1.2.6.1",
"repeats": false,
"type": "choice",
"answerOption": [ {
"valueString": "DK"
}, {
"valueString": "0"
}, {
"valueString": "1"
}, {
"valueString": "2"
}, {
"valueString": "3"
} ],
"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"
} ],
"readOnly": false,
"maxLength": 0,
"required": true,
"text": "Dressing (including buttons, clasps, zips, shoe laces)"
}, {
"text": "Describe limitation, if needed",
"type": "text",
"linkId": "2.1.2.6.2",
"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='2.1.2.6').item.where(linkId='2.1.2.6.1').answer.valueString='1' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.6').item.where(linkId='2.1.2.6.1').answer.valueString='2' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.6').item.where(linkId='2.1.2.6.1').answer.valueString='3'"
}
} ],
"maxLength": 500
} ],
"type": "group",
"linkId": "2.1.2.6",
"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": [ {
"linkId": "2.1.2.7.1",
"repeats": false,
"type": "choice",
"answerOption": [ {
"valueString": "DK"
}, {
"valueString": "0"
}, {
"valueString": "1"
}, {
"valueString": "2"
}, {
"valueString": "3"
} ],
"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"
} ],
"readOnly": false,
"maxLength": 0,
"required": true,
"text": "Select clothes for weather and situation"
}, {
"text": "Describe limitation, if needed",
"type": "text",
"linkId": "2.1.2.7.2",
"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='2.1.2.7').item.where(linkId='2.1.2.7.1').answer.valueString='1' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.7').item.where(linkId='2.1.2.7.1').answer.valueString='2' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.7').item.where(linkId='2.1.2.7.1').answer.valueString='3'"
}
} ],
"maxLength": 500
} ],
"type": "group",
"linkId": "2.1.2.7",
"repeats": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"text": "Group gtable",
"coding": [ {
"code": "gtable",
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"item": [ {
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"readOnly": false,
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