FHIR IG Statistics: Questionnaire/questionnaire-example-dast

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Drug Abuse Screening Test-10 [DAST-10]

Center for Addiction and Mental Health Copyright 982 Center for Addiction and Mental Health. Used with permission. URL: http://www.camh.ca/en/hospital/Pages/home.aspx

Source

{
  "resourceType": "Questionnaire",
  "id": "questionnaire-example-dast",
  "meta": {
    "profile": [
      "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/argo-questionnaire"
    ]
  },
  "text": {
    "status": "additional",
    "div": "<!-- snip (see above) -->"
  },
  "extension": [
    {
      "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-timeLimit",
      "valueDuration": {
        "value": 2,
        "unit": "day",
        "system": "http://unitsofmeasure.org",
        "code": "d"
      }
    }
  ],
  "url": "http://fhir.org/guides/argonaut/questionnaire/Questionnaire/questionnaire-example-dast",
  "identifier": [
    {
      "system": "http://acme.org/q-identifiers",
      "value": "dast"
    }
  ],
  "version": "0.0.0",
  "title": "Drug Abuse Screening Test-10 [DAST-10]",
  "status": "draft",
  "date": "2018-07-26",
  "publisher": "Argonaut Project",
  "useContext": [
    {
      "code": {
        "system": "http://hl7.org/fhir/usage-context-type",
        "code": "task",
        "display": "Workflow Task"
      },
      "valueCodeableConcept": {
        "coding": [
          {
            "system": "http://acme.org",
            "code": "example",
            "display": "Example of Use"
          }
        ]
      }
    }
  ],
  "jurisdiction": [
    {
      "coding": [
        {
          "system": "urn:iso:std:iso:3166",
          "code": "US",
          "display": "United States of America"
        }
      ]
    }
  ],
  "contact": [
    {
      "telecom": [
        {
          "system": "url",
          "value": "http://argonautwiki.hl7.org"
        }
      ]
    }
  ],
  "copyright": "Center for Addiction and Mental Health\nCopyright 982 Center for Addiction and Mental Health. Used with permission.\nURL: http://www.camh.ca/en/hospital/Pages/home.aspx",
  "code": [
    {
      "system": "http://loinc.org",
      "code": "82666-9",
      "display": "Drug Abuse Screening Test-10 [DAST-10]"
    }
  ],
  "subjectType": [
    "Patient"
  ],
  "item": [
    {
      "extension": [
        {
          "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
          "valueBoolean": true
        },
        {
          "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
          "valueInteger": 0
        },
        {
          "url": "http://hl7.org/fhir/StructureDefinition/designNote",
          "valueMarkdown": "this is hidden text/should not be displayed to the user"
        }
      ],
      "linkId": "g1",
      "text": "Form",
      "type": "group",
      "required": true,
      "item": [
        {
          "extension": [
            {
              "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
              "valueInteger": 0
            }
          ],
          "linkId": "g1.d",
          "text": "The following questions concern information about your possible involvement with drugs not including alcoholic beverages during the past 12 months. \"Drug abuse\" refers to (1) the use of prescribed or over-the-counter drugs in excess of the directions, and (2) any nonmedical use of drugs.\n\n The various classes of drugs may include cannabis (marijuana, hashish), solvents (e.g., paint thinner), tranquilizers (e.g., Valium), barbiturates, cocaine, stimulants (e.g., speed), hallucinogens (e.g., LSD) or narcotics (e.g., heroin). Remember that the questions do not include alcoholic beverages. \n\nPlease answer every question. If you have difficulty with a statement, then choose the response that is mostly right.",
          "type": "display"
        },
        {
          "extension": [
            {
              "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
              "valueInteger": 1
            }
          ],
          "linkId": "g1.q1",
          "code": [
            {
              "system": "http://loinc.org",
              "code": "68525-5"
            }
          ],
          "prefix": "1.",
          "text": "Have you used drugs other than those required for medical reasons?",
          "type": "choice",
          "required": true,
          "repeats": false,
          "option": [
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue",
                  "valueDecimal": 0
                },
                {
                  "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
                  "valueInteger": 0
                }
              ],
              "valueCoding": {
                "system": "http://loinc.org",
                "code": "LA32-8",
                "display": "No"
              }
            },
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue",
                  "valueDecimal": 1
                },
                {
                  "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
                  "valueInteger": 1
                }
              ],
              "valueCoding": {
                "system": "http://loinc.org",
                "code": "LA33-6",
                "display": "Yes"
              }
            }
          ]
        },
        {
          "extension": [
            {
              "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
              "valueInteger": 2
            }
          ],
          "linkId": "g1.q2",
          "code": [
            {
              "system": "http://loinc.org",
              "code": "68526-3"
            }
          ],
          "prefix": "2.",
          "text": "Do you abuse more than one drug at a time?",
          "type": "choice",
          "required": true,
          "repeats": false,
          "option": [
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue",
                  "valueDecimal": 0
                },
                {
                  "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
                  "valueInteger": 0
                }
              ],
              "valueCoding": {
                "system": "http://loinc.org",
                "code": "LA32-8",
                "display": "No"
              }
            },
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue",
                  "valueDecimal": 1
                },
                {
                  "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
                  "valueInteger": 1
                }
              ],
              "valueCoding": {
                "system": "http://loinc.org",
                "code": "LA33-6",
                "display": "Yes"
              }
            }
          ]
        },
        {
          "extension": [
            {
              "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
              "valueInteger": 3
            }
          ],
          "linkId": "g1.q3",
          "code": [
            {
              "system": "http://loinc.org",
              "code": "68527-1"
            }
          ],
          "prefix": "3.",
          "text": "Are you unable to stop abusing drugs when you want to?",
          "type": "choice",
          "required": true,
          "repeats": false,
          "option": [
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue",
                  "valueDecimal": 1
                },
                {
                  "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
                  "valueInteger": 0
                }
              ],
              "valueCoding": {
                "system": "http://loinc.org",
                "code": "LA32-8",
                "display": "No"
              }
            },
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue",
                  "valueDecimal": 0
                },
                {
                  "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
                  "valueInteger": 1
                }
              ],
              "valueCoding": {
                "system": "http://loinc.org",
                "code": "LA33-6",
                "display": "Yes"
              }
            }
          ]
        },
        {
          "extension": [
            {
              "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
              "valueInteger": 4
            }
          ],
          "linkId": "g1.q4",
          "code": [
            {
              "system": "http://loinc.org",
              "code": "68528-9"
            }
          ],
          "prefix": "4.",
          "text": "Have you ever had blackouts or flashbacks as a result of drug use?",
          "type": "choice",
          "required": true,
          "repeats": false,
          "option": [
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue",
                  "valueDecimal": 0
                },
                {
                  "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
                  "valueInteger": 0
                }
              ],
              "valueCoding": {
                "system": "http://loinc.org",
                "code": "LA32-8",
                "display": "No"
              }
            },
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue",
                  "valueDecimal": 1
                },
                {
                  "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
                  "valueInteger": 1
                }
              ],
              "valueCoding": {
                "system": "http://loinc.org",
                "code": "LA33-6",
                "display": "Yes"
              }
            }
          ]
        },
        {
          "extension": [
            {
              "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
              "valueInteger": 5
            }
          ],
          "linkId": "g1.q5",
          "code": [
            {
              "system": "http://loinc.org",
              "code": "68529-7"
            }
          ],
          "prefix": "5.",
          "text": "Do you ever feel bad or guilty about your drug use?",
          "type": "choice",
          "required": true,
          "repeats": false,
          "option": [
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue",
                  "valueDecimal": 0
                },
                {
                  "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
                  "valueInteger": 0
                }
              ],
              "valueCoding": {
                "system": "http://loinc.org",
                "code": "LA32-8",
                "display": "No"
              }
            },
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue",
                  "valueDecimal": 1
                },
                {
                  "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
                  "valueInteger": 1
                }
              ],
              "valueCoding": {
                "system": "http://loinc.org",
                "code": "LA33-6",
                "display": "Yes"
              }
            }
          ]
        },
        {
          "extension": [
            {
              "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
              "valueInteger": 6
            }
          ],
          "linkId": "g1.q6",
          "code": [
            {
              "system": "http://loinc.org",
              "code": "68530-5"
            }
          ],
          "prefix": "6.",
          "text": "Does your spouse (or parents) ever complain about your involvement with drugs?",
          "type": "choice",
          "required": true,
          "repeats": false,
          "option": [
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue",
                  "valueDecimal": 0
                },
                {
                  "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
                  "valueInteger": 0
                }
              ],
              "valueCoding": {
                "system": "http://loinc.org",
                "code": "LA32-8",
                "display": "No"
              }
            },
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue",
                  "valueDecimal": 1
                },
                {
                  "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
                  "valueInteger": 1
                }
              ],
              "valueCoding": {
                "system": "http://loinc.org",
                "code": "LA33-6",
                "display": "Yes"
              }
            }
          ]
        },
        {
          "extension": [
            {
              "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
              "valueInteger": 7
            }
          ],
          "linkId": "g1.q7",
          "code": [
            {
              "system": "http://loinc.org",
              "code": "68531-3"
            }
          ],
          "prefix": "7.",
          "text": "Have you neglected your family because of your use of drugs?",
          "type": "choice",
          "required": true,
          "repeats": false,
          "option": [
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue",
                  "valueDecimal": 0
                },
                {
                  "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
                  "valueInteger": 0
                }
              ],
              "valueCoding": {
                "system": "http://loinc.org",
                "code": "LA32-8",
                "display": "No"
              }
            },
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue",
                  "valueDecimal": 1
                },
                {
                  "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
                  "valueInteger": 1
                }
              ],
              "valueCoding": {
                "system": "http://loinc.org",
                "code": "LA33-6",
                "display": "Yes"
              }
            }
          ]
        },
        {
          "extension": [
            {
              "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
              "valueInteger": 8
            }
          ],
          "linkId": "g1.q8",
          "code": [
            {
              "system": "http://loinc.org",
              "code": "68532-1"
            }
          ],
          "prefix": "8.",
          "text": "Have you engaged in illegal activities in order to obtain drugs?",
          "type": "choice",
          "required": true,
          "repeats": false,
          "option": [
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue",
                  "valueDecimal": 0
                },
                {
                  "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
                  "valueInteger": 0
                }
              ],
              "valueCoding": {
                "system": "http://loinc.org",
                "code": "LA32-8",
                "display": "No"
              }
            },
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue",
                  "valueDecimal": 1
                },
                {
                  "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
                  "valueInteger": 1
                }
              ],
              "valueCoding": {
                "system": "http://loinc.org",
                "code": "LA33-6",
                "display": "Yes"
              }
            }
          ]
        },
        {
          "extension": [
            {
              "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
              "valueInteger": 9
            }
          ],
          "linkId": "g1.q9",
          "code": [
            {
              "system": "http://loinc.org",
              "code": "68533-9"
            }
          ],
          "prefix": "9.",
          "text": "Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?",
          "type": "choice",
          "required": true,
          "repeats": false,
          "option": [
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue",
                  "valueDecimal": 0
                },
                {
                  "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
                  "valueInteger": 0
                }
              ],
              "valueCoding": {
                "system": "http://loinc.org",
                "code": "LA32-8",
                "display": "No"
              }
            },
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue",
                  "valueDecimal": 1
                },
                {
                  "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
                  "valueInteger": 1
                }
              ],
              "valueCoding": {
                "system": "http://loinc.org",
                "code": "LA33-6",
                "display": "Yes"
              }
            }
          ]
        },
        {
          "extension": [
            {
              "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
              "valueInteger": 10
            }
          ],
          "linkId": "g1.q10",
          "code": [
            {
              "system": "http://loinc.org",
              "code": "68534-7"
            }
          ],
          "prefix": "10.",
          "text": "Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)?",
          "type": "choice",
          "repeats": false,
          "option": [
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue",
                  "valueDecimal": 0
                },
                {
                  "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
                  "valueInteger": 0
                }
              ],
              "valueCoding": {
                "system": "http://loinc.org",
                "code": "LA32-8",
                "display": "No"
              }
            },
            {
              "extension": [
                {
                  "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue",
                  "valueDecimal": 1
                },
                {
                  "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
                  "valueInteger": 1
                }
              ],
              "valueCoding": {
                "system": "http://loinc.org",
                "code": "LA33-6",
                "display": "Yes"
              }
            }
          ]
        }
      ]
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
          "valueBoolean": true
        },
        {
          "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
          "valueInteger": 1
        },
        {
          "url": "http://hl7.org/fhir/StructureDefinition/designNote",
          "valueMarkdown": "this is hidden text/should not be displayed to the user"
        }
      ],
      "linkId": "g2",
      "text": "Scoring Instructions",
      "type": "group",
      "required": true,
      "item": [
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
              "valueBoolean": true
            },
            {
              "url": "http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder",
              "valueInteger": 0
            },
            {
              "url": "http://hl7.org/fhir/StructureDefinition/designNote",
              "valueMarkdown": "this is hidden text/should not be displayed to the user"
            }
          ],
          "linkId": "g2.d",
          "text": "Scoring: Score 1 point for each question answered “Yes,” except for question 3 for which\na “No” receives 1 point.\n\nInterpretation of Score:\nScore Degree of Problems Related to Drug Abuse Suggested Action\n0 No problems reported None at this time\n1‐2 Low level Monitor, re‐assess at a later date\n3‐5 Moderate level Further investigation\n6‐8 Substantial level Intensive assessment\n9‐10 Severe level Intensive assessment",
          "type": "display"
        }
      ]
    }
  ]
}