| Package | cinc.fhir.ig |
| Type | Questionnaire |
| Id | Id |
| FHIR Version | R4 |
| Source | https://build.fhir.org/ig/tewhatuora/cinc-fhir-ig/https://build.fhir.org/ig/tewhatuora/cinc-fhir-ig/Questionnaire-COVIDVaccinationSurveyQuestionnaire.html |
| Url | https://build.fhir.org/ig/tewhatuora/cinc-fhir-ig/Questionnaire/COVIDVaccinationSurveyQuestionnaire |
| Version | 0.4.0 |
| Status | draft |
| Date | 2023-07-19 |
| Name | COVIDVaccinationSurveyQuestionnaire |
| Title | COVID19 Vaccination Side Effects Questionnaire |
| Experimental | False |
| Realm | nz |
| Authority | national |
| Description | Te Whatu Ora post COVID-19 vaccination survey. |
| Purpose | Survey of side effects experienced after COVID-19 vaccination |
No resources found
No resources found
Note: links and images are rebased to the (stated) source
Generated Narrative: Questionnaire COVIDVaccinationSurveyQuestionnaire
Structure| LinkID | Text | Cardinality | Type | Description & Constraints |
|---|---|---|---|---|
  COVIDVaccinationSurveyQuestionnaire | Te Whatu Ora post COVID-19 vaccination survey. | Questionnaire | https://build.fhir.org/ig/tewhatuora/cinc-fhir-ig/Questionnaire/COVIDVaccinationSurveyQuestionnaire#0.4.0 | |
  p01 | page 1. Thanks for taking part in our survey to understand the side effects you experienced after your Pfizer COVID-19 vaccination. Please note this is a survey only and your answers will not result in a medical response to your situation. If you have concerns about your health since your vaccination, particularly if you have had chest pain, racing heartbeat, or trouble breathing, please seek medical attention. You may ring the Healthline at 0800 358 5453 or speak to your healthcare professional. This survey is optional and will take approximately 5 minutes to complete. Your responses will help us to monitor the safety of the Pfizer COVID-19 vaccine in Aotearoa New Zealand. For more information about this survey, visit http://medsafe.govt.nz/covid-safety-reporting/. | 0..1 | display | |
 p02 | page 2. Side Effects | 0..1 | group | |
  p02-q01-SideEffects | page 2 question 1. Select all the side effects you experienced after your recent COVID-19 vaccination | 0..* | choice | Options: 11 options |
 p02-q02-SideEffects.Rash | page 2 question 2. Rash not near injection site | 1..1 | boolean | |
| p02-q02-1-SideEffects.Rash.WhenStarted | page 2 question 2.1. When did the rash appear? | 1..1 | choice | Enable When: p02-q02-SideEffects.Rash = Options: 3 options |
| p02-q02-2-SideEffects.Rash.HowLong | page 2 question 2.2. How long did the rash last? | 1..1 | choice | Enable When: p02-q02-SideEffects.Rash = Options: 3 options |
| p02-q03-SideEffects.Other | page 2 question 3. Other or not listed side effect? | 1..1 | boolean | |
  p02-q03-1-SideEffects.Other.Description | page 2 question 3.1. What other side effects did you experience? | 0..1 | text | Enable When: p02-q03-SideEffects.Other = |
| p03 | page 3. Symptom Relief | 0..1 | group | |
| p03-q01-SymptomRelief.Medicines | page 3 question 1. Did you take any medicines to ease your symptoms for example paracetamol or ibuprofen? | 1..1 | boolean | |
| p03-q01-1-Medicines.ReducedSymptoms | page 3 question 1.1. Did the medicines help ease your symptoms? | 1..1 | boolean | Enable When: p03-q01-SymptomRelief.Medicines = |
| p03-q02-Medicines.SawDoctor | page 3 question 2. Did you see a healthcare provider for your symptoms? | 1..1 | boolean | |
| p03-q03-MissedActivities | page 3 question 3. Did your symptoms cause you to miss any normal daily or normal daily activities? For example, work, school, exercise or other activities. | 1..1 | boolean | |
| p03-q03-1-MissedActivities.Period | page 3 question 3.1. How many days did you miss? | 1..1 | choice | Enable When: p03-q03-MissedActivities = Options: 4 options |
| p04 | page 4. Health Conditions | 0..1 | group | |
| p04-q01-Pregnant | page 4 question 1. Are you pregnant or have you given birth in the last 6 weeks? | 1..1 | boolean | |
| p04-q02-LongTermConditions | page 4 question 2. Do you have any of the following conditions? | 0..* | choice | Options: 11 options |
| p04-q02-1-LongTermConditions.Other | page 4 question 2.1. Other or not listed long term condition? | 1..1 | boolean | |
| p04-q02-2-LongTermConditions.Other.Description | page 4 question 2.2. Please list any other long term condition(s) you have | 0..1 | text | Enable When: p04-q02-1-LongTermConditions.Other = |
| p05 | page 5. Thank you for taking part in this survey. The information you provide is confidential and is protected by the Privacy Act 2020 and by the safeguards we have put in place. Remember this is a survey only and your answers will not result in a medical response to your situation. If you have concerns about your health since your vaccination, particularly if you have had chest pain, racing heartbeat, or trouble breathing, please seek medical attention. You may ring the Healthline at 0800 358 5453 or speak to your healthcare professional. Results from the survey will be published on the Medsafe website at http://medsafe.govt.nz/covid-safety-reporting/as the survey progresses. | 0..1 | display | |
| Documentation for this format | ||||
Options Sets
Answer options for p02-q01-SideEffects
Answer options for p02-q02-1-SideEffects.Rash.WhenStarted
Answer options for p02-q02-2-SideEffects.Rash.HowLong
Answer options for p03-q03-1-MissedActivities.Period
Answer options for p04-q02-LongTermConditions
FHIR{
"resourceType" : "Questionnaire",
"id" : "COVIDVaccinationSurveyQuestionnaire",
"text" : {
"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Questionnaire COVIDVaccinationSurveyQuestionnaire</b></p><a name=\"COVIDVaccinationSurveyQuestionnaire\"> </a><a name=\"hcCOVIDVaccinationSurveyQuestionnaire\"> </a><a name=\"hcCOVIDVaccinationSurveyQuestionnaire-en-NZ\"> </a><b>Structure</b><table border=\"1\" cellpadding=\"0\" cellspacing=\"0\" style=\"border: 1px #F0F0F0 solid; font-size: 11px; font-family: verdana; vertical-align: top;\"><tr style=\"border: 2px #F0F0F0 solid; font-size: 11px; font-family: verdana; vertical-align: top\"><th style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/formats.html#table\" title=\"The linkID for the item\">LinkID</a></th><th style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/formats.html#table\" title=\"Text for the item\">Text</a></th><th style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/formats.html#table\" title=\"Minimum and Maximum # of times the item can appear in the instance\">Cardinality</a></th><th style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/formats.html#table\" title=\"The type of the item\">Type</a></th><th style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/formats.html#table\" title=\"Additional information about the item\">Description & Constraints</a><span style=\"float: right\"><a href=\"http://hl7.org/fhir/R4/formats.html#table\" title=\"Legend for this format\"><img src=\"data:image/png;base64,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\" alt=\"doco\" style=\"background-color: inherit\"/></a></span></th></tr><tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck1.png)\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon_q_root.gif\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"QuestionnaireRoot\" class=\"hierarchy\"/> COVIDVaccinationSurveyQuestionnaire</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Te Whatu Ora post COVID-19 vaccination survey.</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"></td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Questionnaire</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">https://build.fhir.org/ig/tewhatuora/cinc-fhir-ig/Questionnaire/COVIDVaccinationSurveyQuestionnaire#0.4.0</td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)\" id=\"item.p01\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-display.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"display\" class=\"hierarchy\"/> p01</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">page 1. Thanks for taking part in our survey to understand the side effects you experienced after your Pfizer COVID-19 vaccination. Please note this is a survey only and your answers will not result in a medical response to your situation. If you have concerns about your health since your vaccination, particularly if you have had chest pain, racing heartbeat, or trouble breathing, please seek medical attention. You may ring the Healthline at 0800 358 5453 or speak to your healthcare professional. This survey is optional and will take approximately 5 minutes to complete. Your responses will help us to monitor the safety of the Pfizer COVID-19 vaccine in Aotearoa New Zealand. For more information about this survey, visit http://medsafe.govt.nz/covid-safety-reporting/.</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/codesystem-item-type.html#item-type-display\">display</a></td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck11.png)\" id=\"item.p02\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-group.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"group\" class=\"hierarchy\"/> p02</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">page 2. Side Effects</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group\">group</a></td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.p02-q01-SideEffects\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-coding.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"coding\" class=\"hierarchy\"/> p02-q01-SideEffects</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">page 2 question 1. Select all the side effects you experienced after your recent COVID-19 vaccination</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..*</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/codesystem-item-type.html#item-type-choice\">choice</a></td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Options: <a href=\"#opt-item.p02-q01-SideEffects\">11 options</a></td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.p02-q02-SideEffects.Rash\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-boolean.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"boolean\" class=\"hierarchy\"/> p02-q02-SideEffects.Rash</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">page 2 question 2. Rash not near injection site</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">1..1</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/codesystem-item-type.html#item-type-boolean\">boolean</a></td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.p02-q02-1-SideEffects.Rash.WhenStarted\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-coding.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"coding\" class=\"hierarchy\"/> p02-q02-1-SideEffects.Rash.WhenStarted</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">page 2 question 2.1. When did the rash appear?</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">1..1</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/codesystem-item-type.html#item-type-choice\">choice</a></td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Enable When: <span><a href=\"#item.p02-q02-SideEffects.Rash\">p02-q02-SideEffects.Rash</a> = </span><br/>Options: <a href=\"#opt-item.p02-q02-1-SideEffects.Rash.WhenStarted\">3 options</a></td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.p02-q02-2-SideEffects.Rash.HowLong\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-coding.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"coding\" class=\"hierarchy\"/> p02-q02-2-SideEffects.Rash.HowLong</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">page 2 question 2.2. How long did the rash last?</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">1..1</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/codesystem-item-type.html#item-type-choice\">choice</a></td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Enable When: <span><a href=\"#item.p02-q02-SideEffects.Rash\">p02-q02-SideEffects.Rash</a> = </span><br/>Options: <a href=\"#opt-item.p02-q02-2-SideEffects.Rash.HowLong\">3 options</a></td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.p02-q03-SideEffects.Other\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-boolean.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"boolean\" class=\"hierarchy\"/> p02-q03-SideEffects.Other</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">page 2 question 3. Other or not listed side effect?</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">1..1</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/codesystem-item-type.html#item-type-boolean\">boolean</a></td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck100.png)\" id=\"item.p02-q03-1-SideEffects.Other.Description\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-text.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"text\" class=\"hierarchy\"/> p02-q03-1-SideEffects.Other.Description</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">page 2 question 3.1. What other side effects did you experience?</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/codesystem-item-type.html#item-type-text\">text</a></td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Enable When: <span><a href=\"#item.p02-q03-SideEffects.Other\">p02-q03-SideEffects.Other</a> = </span></td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck11.png)\" id=\"item.p03\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-group.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"group\" class=\"hierarchy\"/> p03</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">page 3. Symptom Relief</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group\">group</a></td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.p03-q01-SymptomRelief.Medicines\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-boolean.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"boolean\" class=\"hierarchy\"/> p03-q01-SymptomRelief.Medicines</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">page 3 question 1. Did you take any medicines to ease your symptoms for example paracetamol or ibuprofen?</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">1..1</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/codesystem-item-type.html#item-type-boolean\">boolean</a></td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.p03-q01-1-Medicines.ReducedSymptoms\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-boolean.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"boolean\" class=\"hierarchy\"/> p03-q01-1-Medicines.ReducedSymptoms</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">page 3 question 1.1. Did the medicines help ease your symptoms?</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">1..1</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/codesystem-item-type.html#item-type-boolean\">boolean</a></td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Enable When: <span><a href=\"#item.p03-q01-SymptomRelief.Medicines\">p03-q01-SymptomRelief.Medicines</a> = </span></td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.p03-q02-Medicines.SawDoctor\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-boolean.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"boolean\" class=\"hierarchy\"/> p03-q02-Medicines.SawDoctor</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">page 3 question 2. Did you see a healthcare provider for your symptoms?</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">1..1</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/codesystem-item-type.html#item-type-boolean\">boolean</a></td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.p03-q03-MissedActivities\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-boolean.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"boolean\" class=\"hierarchy\"/> p03-q03-MissedActivities</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">page 3 question 3. Did your symptoms cause you to miss any normal daily or normal daily activities? For example, work, school, exercise or other activities.</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">1..1</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/codesystem-item-type.html#item-type-boolean\">boolean</a></td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck100.png)\" id=\"item.p03-q03-1-MissedActivities.Period\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-coding.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"coding\" class=\"hierarchy\"/> p03-q03-1-MissedActivities.Period</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">page 3 question 3.1. How many days did you miss?</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">1..1</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/codesystem-item-type.html#item-type-choice\">choice</a></td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Enable When: <span><a href=\"#item.p03-q03-MissedActivities\">p03-q03-MissedActivities</a> = </span><br/>Options: <a href=\"#opt-item.p03-q03-1-MissedActivities.Period\">4 options</a></td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck11.png)\" id=\"item.p04\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-group.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"group\" class=\"hierarchy\"/> p04</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">page 4. Health Conditions</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group\">group</a></td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.p04-q01-Pregnant\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-boolean.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"boolean\" class=\"hierarchy\"/> p04-q01-Pregnant</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">page 4 question 1. Are you pregnant or have you given birth in the last 6 weeks?</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">1..1</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/codesystem-item-type.html#item-type-boolean\">boolean</a></td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.p04-q02-LongTermConditions\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-coding.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"coding\" class=\"hierarchy\"/> p04-q02-LongTermConditions</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">page 4 question 2. Do you have any of the following conditions?</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..*</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/codesystem-item-type.html#item-type-choice\">choice</a></td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Options: <a href=\"#opt-item.p04-q02-LongTermConditions\">11 options</a></td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck110.png)\" id=\"item.p04-q02-1-LongTermConditions.Other\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-boolean.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"boolean\" class=\"hierarchy\"/> p04-q02-1-LongTermConditions.Other</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">page 4 question 2.1. Other or not listed long term condition?</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">1..1</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/codesystem-item-type.html#item-type-boolean\">boolean</a></td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7\"><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck100.png)\" id=\"item.p04-q02-2-LongTermConditions.Other.Description\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vline.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-text.png\" alt=\".\" style=\"background-color: #F7F7F7; background-color: inherit\" title=\"text\" class=\"hierarchy\"/> p04-q02-2-LongTermConditions.Other.Description</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">page 4 question 2.2. Please list any other long term condition(s) you have</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/codesystem-item-type.html#item-type-text\">text</a></td><td style=\"vertical-align: top; text-align : left; background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">Enable When: <span><a href=\"#item.p04-q02-1-LongTermConditions.Other\">p04-q02-1-LongTermConditions.Other</a> = </span></td></tr>\r\n<tr style=\"border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white\"><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck00.png)\" id=\"item.p05\" class=\"hierarchy\"><img src=\"tbl_spacer.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"tbl_vjoin_end.png\" alt=\".\" style=\"background-color: inherit\" class=\"hierarchy\"/><img src=\"icon-q-display.png\" alt=\".\" style=\"background-color: white; background-color: inherit\" title=\"display\" class=\"hierarchy\"/> p05</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">page 5. Thank you for taking part in this survey. The information you provide is confidential and is protected by the Privacy Act 2020 and by the safeguards we have put in place. Remember this is a survey only and your answers will not result in a medical response to your situation. If you have concerns about your health since your vaccination, particularly if you have had chest pain, racing heartbeat, or trouble breathing, please seek medical attention. You may ring the Healthline at 0800 358 5453 or speak to your healthcare professional. Results from the survey will be published on the Medsafe website at http://medsafe.govt.nz/covid-safety-reporting/as the survey progresses.</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\">0..1</td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"><a href=\"http://hl7.org/fhir/R4/codesystem-item-type.html#item-type-display\">display</a></td><td style=\"vertical-align: top; text-align : left; background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px\" class=\"hierarchy\"/></tr>\r\n<tr><td colspan=\"5\" class=\"hierarchy\"><br/><a href=\"http://hl7.org/fhir/R4/formats.html#table\" title=\"Legend for this format\"><img src=\"data:image/png;base64,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\" alt=\"doco\" style=\"background-color: inherit\"/> Documentation for this format</a></td></tr></table><hr/><p><b>Options Sets</b></p><a name=\"opt-item.p02-q01-SideEffects\"> </a><p><b>Answer options for p02-q01-SideEffects </b></p><ul><li style=\"font-size: 11px\">http://snomed.info/sct#95376002 ("Pain, redness, swelling, itching at or near the injection site")</li><li style=\"font-size: 11px\">http://snomed.info/sct#386661006 ("Fever")</li><li style=\"font-size: 11px\">http://snomed.info/sct#25064002 ("Headache")</li><li style=\"font-size: 11px\">http://snomed.info/sct#68962001 ("Muscle pain")</li><li style=\"font-size: 11px\">http://snomed.info/sct#57676002 ("Joint pain")</li><li style=\"font-size: 11px\">http://snomed.info/sct#274640006 ("Chills and fever")</li><li style=\"font-size: 11px\">http://snomed.info/sct#422587007 ("Nausea")</li><li style=\"font-size: 11px\">http://snomed.info/sct#422400008 ("Vomiting")</li><li style=\"font-size: 11px\">http://snomed.info/sct#62315008 ("Diarrhoea")</li><li style=\"font-size: 11px\">http://snomed.info/sct#271681002 ("Stomach pain")</li><li style=\"font-size: 11px\">http://snomed.info/sct#84229001 ("Fatigue")</li></ul><a name=\"opt-item.p02-q02-1-SideEffects.Rash.WhenStarted\"> </a><p><b>Answer options for p02-q02-1-SideEffects.Rash.WhenStarted </b></p><ul><li style=\"font-size: 11px\">null#null ("Within 1 hour after vaccination")</li><li style=\"font-size: 11px\">null#null ("Within a day after vaccination")</li><li style=\"font-size: 11px\">null#null ("More than a day after vaccination")</li></ul><a name=\"opt-item.p02-q02-2-SideEffects.Rash.HowLong\"> </a><p><b>Answer options for p02-q02-2-SideEffects.Rash.HowLong </b></p><ul><li style=\"font-size: 11px\">null#null ("Less than 30 minutes")</li><li style=\"font-size: 11px\">null#null ("30 minutes to 24 hours")</li><li style=\"font-size: 11px\">null#null ("More than 24 hours")</li></ul><a name=\"opt-item.p03-q03-1-MissedActivities.Period\"> </a><p><b>Answer options for p03-q03-1-MissedActivities.Period </b></p><ul><li style=\"font-size: 11px\">null#null ("Less than 1 day")</li><li style=\"font-size: 11px\">null#null ("1 day")</li><li style=\"font-size: 11px\">null#null ("2 days")</li><li style=\"font-size: 11px\">null#null ("3 days or more")</li></ul><a name=\"opt-item.p04-q02-LongTermConditions\"> </a><p><b>Answer options for p04-q02-LongTermConditions </b></p><ul><li style=\"font-size: 11px\">http://snomed.info/sct#4301008 ("Autoimmune conditions (eg. arthritis)")</li><li style=\"font-size: 11px\">http://snomed.info/sct#32709003 ("Alcohol or other drug addictions")</li><li style=\"font-size: 11px\">http://snomed.info/sct#195967001 ("Asthma")</li><li style=\"font-size: 11px\">http://snomed.info/sct#363346000 ("Cancer")</li><li style=\"font-size: 11px\">http://snomed.info/sct#82423001 ("Chronic pain")</li><li style=\"font-size: 11px\">http://snomed.info/sct#13645005 ("Chronic obstructive pulmonary disease")</li><li style=\"font-size: 11px\">http://snomed.info/sct#73211009 ("Diabetes mellitus")</li><li style=\"font-size: 11px\">http://snomed.info/sct#770924008 ("Acute Gout (disorder)")</li><li style=\"font-size: 11px\">http://snomed.info/sct#56265001 ("Heart disease")</li><li style=\"font-size: 11px\">http://snomed.info/sct#74732009 ("Mental health condition")</li><li style=\"font-size: 11px\">http://snomed.info/sct#414916001 ("Obesity")</li></ul></div>"
},
"url" : "https://build.fhir.org/ig/tewhatuora/cinc-fhir-ig/Questionnaire/COVIDVaccinationSurveyQuestionnaire",
"identifier" : [
{
"use" : "official",
"value" : "COVIDVaccinationSurveyQuestionnaire",
"period" : {
"start" : "2023-07-19"
}
},
{
"use" : "temp",
"value" : "Questionnaire-COVID-VaccinationSurveyQuestionnaire",
"period" : {
"end" : "2023-07-19"
}
}
],
"version" : "0.4.0",
"name" : "COVIDVaccinationSurveyQuestionnaire",
"title" : "COVID19 Vaccination Side Effects Questionnaire",
"status" : "draft",
"experimental" : false,
"subjectType" : [
"Patient"
],
"date" : "2023-07-19",
"publisher" : "Te Whatu Ora",
"contact" : [
{
"name" : "Te Whatu Ora",
"telecom" : [
{
"system" : "url",
"value" : "https://www.tewhatuora.govt.nz/"
}
]
},
{
"name" : "David Grainger",
"telecom" : [
{
"system" : "email",
"value" : "david.grainger@middleware.co.nz",
"use" : "work"
}
]
}
],
"description" : "Te Whatu Ora post COVID-19 vaccination survey.",
"useContext" : [
{
"code" : {
"system" : "http://terminology.hl7.org/CodeSystem/usage-context-type",
"code" : "workflow",
"display" : "Workflow Setting"
},
"valueCodeableConcept" : {
"text" : "Vaccination Side Effect Questionnaire"
}
}
],
"jurisdiction" : [
{
"coding" : [
{
"system" : "urn:iso:std:iso:3166",
"code" : "NZ",
"display" : "New Zealand"
}
]
}
],
"purpose" : "Survey of side effects experienced after COVID-19 vaccination",
"code" : [
{
"system" : "http://snomed.info/sct",
"code" : "293104008",
"display" : "Vaccine adverse reaction"
}
],
"item" : [
{
"linkId" : "p01",
"prefix" : "page 1",
"text" : "Thanks for taking part in our survey to understand the side effects you experienced after your Pfizer COVID-19 vaccination. Please note this is a survey only and your answers will not result in a medical response to your situation. If you have concerns about your health since your vaccination, particularly if you have had chest pain, racing heartbeat, or trouble breathing, please seek medical attention. You may ring the Healthline at 0800 358 5453 or speak to your healthcare professional. This survey is optional and will take approximately 5 minutes to complete. Your responses will help us to monitor the safety of the Pfizer COVID-19 vaccine in Aotearoa New Zealand. For more information about this survey, visit http://medsafe.govt.nz/covid-safety-reporting/.",
"type" : "display"
},
{
"linkId" : "p02",
"prefix" : "page 2",
"text" : "Side Effects",
"type" : "group",
"item" : [
{
"linkId" : "p02-q01-SideEffects",
"prefix" : "page 2 question 1",
"text" : "Select all the side effects you experienced after your recent COVID-19 vaccination",
"type" : "choice",
"required" : false,
"repeats" : true,
"answerOption" : [
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "95376002",
"display" : "Pain, redness, swelling, itching at or near the injection site"
}
},
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "386661006",
"display" : "Fever"
}
},
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "25064002",
"display" : "Headache"
}
},
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "68962001",
"display" : "Muscle pain"
}
},
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "57676002",
"display" : "Joint pain"
}
},
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "274640006",
"display" : "Chills and fever"
}
},
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "422587007",
"display" : "Nausea"
}
},
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "422400008",
"display" : "Vomiting"
}
},
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "62315008",
"display" : "Diarrhoea"
}
},
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "271681002",
"display" : "Stomach pain"
}
},
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "84229001",
"display" : "Fatigue"
}
}
]
},
{
"linkId" : "p02-q02-SideEffects.Rash",
"code" : [
{
"system" : "http://snomed.info/sct",
"code" : "271807003",
"display" : "Rash"
}
],
"prefix" : "page 2 question 2",
"text" : "Rash not near injection site",
"type" : "boolean",
"required" : true
},
{
"linkId" : "p02-q02-1-SideEffects.Rash.WhenStarted",
"prefix" : "page 2 question 2.1",
"text" : "When did the rash appear?",
"type" : "choice",
"enableWhen" : [
{
"question" : "p02-q02-SideEffects.Rash",
"operator" : "=",
"answerBoolean" : true
}
],
"enableBehavior" : "all",
"required" : true,
"answerOption" : [
{
"valueCoding" : {
"display" : "Within 1 hour after vaccination"
}
},
{
"valueCoding" : {
"display" : "Within a day after vaccination"
}
},
{
"valueCoding" : {
"display" : "More than a day after vaccination"
}
}
]
},
{
"linkId" : "p02-q02-2-SideEffects.Rash.HowLong",
"prefix" : "page 2 question 2.2",
"text" : "How long did the rash last?",
"type" : "choice",
"enableWhen" : [
{
"question" : "p02-q02-SideEffects.Rash",
"operator" : "=",
"answerBoolean" : true
}
],
"enableBehavior" : "all",
"required" : true,
"answerOption" : [
{
"valueCoding" : {
"display" : "Less than 30 minutes"
}
},
{
"valueCoding" : {
"display" : "30 minutes to 24 hours"
}
},
{
"valueCoding" : {
"display" : "More than 24 hours"
}
}
]
},
{
"linkId" : "p02-q03-SideEffects.Other",
"prefix" : "page 2 question 3",
"text" : "Other or not listed side effect?",
"type" : "boolean",
"required" : true
},
{
"linkId" : "p02-q03-1-SideEffects.Other.Description",
"prefix" : "page 2 question 3.1",
"text" : "What other side effects did you experience?",
"type" : "text",
"enableWhen" : [
{
"question" : "p02-q03-SideEffects.Other",
"operator" : "=",
"answerBoolean" : true
}
],
"enableBehavior" : "all",
"required" : false
}
]
},
{
"linkId" : "p03",
"prefix" : "page 3",
"text" : "Symptom Relief",
"type" : "group",
"item" : [
{
"linkId" : "p03-q01-SymptomRelief.Medicines",
"prefix" : "page 3 question 1",
"text" : "Did you take any medicines to ease your symptoms for example paracetamol or ibuprofen?",
"type" : "boolean",
"required" : true
},
{
"linkId" : "p03-q01-1-Medicines.ReducedSymptoms",
"prefix" : "page 3 question 1.1",
"text" : "Did the medicines help ease your symptoms?",
"type" : "boolean",
"enableWhen" : [
{
"question" : "p03-q01-SymptomRelief.Medicines",
"operator" : "=",
"answerBoolean" : true
}
],
"enableBehavior" : "all",
"required" : true
},
{
"linkId" : "p03-q02-Medicines.SawDoctor",
"prefix" : "page 3 question 2",
"text" : "Did you see a healthcare provider for your symptoms?",
"type" : "boolean",
"required" : true
},
{
"linkId" : "p03-q03-MissedActivities",
"prefix" : "page 3 question 3",
"text" : "Did your symptoms cause you to miss any normal daily or normal daily activities? For example, work, school, exercise or other activities.",
"type" : "boolean",
"required" : true
},
{
"linkId" : "p03-q03-1-MissedActivities.Period",
"prefix" : "page 3 question 3.1",
"text" : "How many days did you miss?",
"type" : "choice",
"enableWhen" : [
{
"question" : "p03-q03-MissedActivities",
"operator" : "=",
"answerBoolean" : true
}
],
"enableBehavior" : "all",
"required" : true,
"repeats" : false,
"answerOption" : [
{
"valueCoding" : {
"display" : "Less than 1 day"
}
},
{
"valueCoding" : {
"display" : "1 day"
}
},
{
"valueCoding" : {
"display" : "2 days"
}
},
{
"valueCoding" : {
"display" : "3 days or more"
}
}
]
}
]
},
{
"linkId" : "p04",
"prefix" : "page 4",
"text" : "Health Conditions",
"type" : "group",
"item" : [
{
"linkId" : "p04-q01-Pregnant",
"code" : [
{
"system" : "http://snomed.info/sct",
"code" : "77386006",
"display" : "Pregnancy"
}
],
"prefix" : "page 4 question 1",
"text" : "Are you pregnant or have you given birth in the last 6 weeks?",
"type" : "boolean",
"required" : true
},
{
"linkId" : "p04-q02-LongTermConditions",
"prefix" : "page 4 question 2",
"text" : "Do you have any of the following conditions?",
"type" : "choice",
"required" : false,
"repeats" : true,
"answerOption" : [
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "4301008",
"display" : "Autoimmune conditions (eg. arthritis)"
}
},
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "32709003",
"display" : "Alcohol or other drug addictions"
}
},
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "195967001",
"display" : "Asthma"
}
},
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "363346000",
"display" : "Cancer"
}
},
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "82423001",
"display" : "Chronic pain"
}
},
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "13645005",
"display" : "Chronic obstructive pulmonary disease"
}
},
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "73211009",
"display" : "Diabetes mellitus"
}
},
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "770924008",
"display" : "Acute Gout (disorder)"
}
},
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "56265001",
"display" : "Heart disease"
}
},
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "74732009",
"display" : "Mental health condition"
}
},
{
"valueCoding" : {
"system" : "http://snomed.info/sct",
"code" : "414916001",
"display" : "Obesity"
}
}
]
},
{
"linkId" : "p04-q02-1-LongTermConditions.Other",
"prefix" : "page 4 question 2.1",
"text" : "Other or not listed long term condition?",
"type" : "boolean",
"required" : true
},
{
"linkId" : "p04-q02-2-LongTermConditions.Other.Description",
"prefix" : "page 4 question 2.2",
"text" : "Please list any other long term condition(s) you have",
"type" : "text",
"enableWhen" : [
{
"question" : "p04-q02-1-LongTermConditions.Other",
"operator" : "=",
"answerBoolean" : true
}
],
"enableBehavior" : "all",
"required" : false
}
]
},
{
"linkId" : "p05",
"prefix" : "page 5",
"text" : "Thank you for taking part in this survey. The information you provide is confidential and is protected by the Privacy Act 2020 and by the safeguards we have put in place. Remember this is a survey only and your answers will not result in a medical response to your situation. If you have concerns about your health since your vaccination, particularly if you have had chest pain, racing heartbeat, or trouble breathing, please seek medical attention. You may ring the Healthline at 0800 358 5453 or speak to your healthcare professional. Results from the survey will be published on the Medsafe website at http://medsafe.govt.nz/covid-safety-reporting/as the survey progresses.",
"type" : "display"
}
]
}
XIG built as of ??metadata-date??. Found ??metadata-resources?? resources in ??metadata-packages?? packages.