| Package | ca.on.health.sadie |
| Resource Type | Questionnaire |
| Id | 17e05ce5-651a-49c9-aecd-c14bc9d4dc23 |
| FHIR Version | R4 |
| Source | https://simplifier.net/resolve?scope=ca.on.health.sadie@1.4.11&canonical=http://health.gov.on.ca/sadie/fhir/FlexForm/HealthStatusReport/Version1 |
| URL | http://health.gov.on.ca/sadie/fhir/FlexForm/HealthStatusReport/Version1 |
| Status | active |
| Name | HealthStatusReport |
| Title | Health Status Report |
No resources found
No resources found
Note: links and images are rebased to the (stated) source
FHIR{
"resourceType": "Questionnaire",
"id": "17e05ce5-651a-49c9-aecd-c14bc9d4dc23",
"meta": {
"versionId": "97",
"lastUpdated": "2022-03-22T13:13:50+00:00"
},
"text": {
"status": "empty",
"div": "<!-- snip (see above) -->"
},
"url": "http://health.gov.on.ca/sadie/fhir/FlexForm/HealthStatusReport/Version1",
"identifier": [
{
"use": "official",
"system": "http://health.gov.on.ca/sadie/fhir/ValueSet/ODSP-Questionnaires",
"value": "HSR"
}
],
"name": "HealthStatusReport",
"title": "Health Status Report",
"status": "active",
"experimental": false,
"subjectType": [
"Patient"
],
"publisher": "ODSP",
"effectivePeriod": {
"start": "2021-06-14T05:00:00.000Z"
},
"code": [
{
"system": "https://health.gov.on.ca/sadie/fhir/CodeSystem/FlexForms-Internal-Complete",
"code": "DocumentType",
"display": "DDP"
},
{
"system": "https://health.gov.on.ca/sadie/fhir/CodeSystem/FlexForms-Internal-Complete",
"code": "DocumentSubType",
"display": "HSR"
}
],
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "header",
"display": "Header"
}
],
"text": "Header"
}
}
],
"linkId": "0",
"text": "General",
"type": "group",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-displayCategory",
"valueCode": "display-in-progress"
}
],
"linkId": "attachment_error_guide_general",
"text": "If you encounter an upload error or failure, please try again or fax the attachment to the Disability Adjudication Unit at 416-326-3374. The fax must include the client's first and last name, Member ID and Referral ID on the document or fax cover page.",
"type": "display",
"required": false,
"repeats": false,
"readOnly": false
},
{
"linkId": "0.1",
"text": "Health Care Professional Details",
"type": "group",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"linkId": "0.1.1",
"text": "Profession/Specialty",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 100
}
]
},
{
"linkId": "0.2",
"text": "Applicant's Social Assistance Identification",
"type": "group",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"linkId": "0.2.1",
"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 application started with the ministry, you cannot complete this form.",
"type": "display",
"required": false,
"repeats": false,
"readOnly": false
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "[0-9]*"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/minLength",
"valueInteger": 9
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "Matches*%context.item.where(linkId='0').item.where(linkId='0.2').item.where(linkId='odsp-member-id-referral-id').answer.valueString='fail'*errors.id.invalid"
}
],
"linkId": "odsp-member-id",
"definition": "https://www.hl7.org/fhir/patient-definitions.html#Patient.identifier[1].value",
"text": "Member ID (9 digits)",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 9
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "[0-9]*"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/minLength",
"valueInteger": 12
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "Matches*%context.item.where(linkId='0').item.where(linkId='0.2').item.where(linkId='odsp-member-id-referral-id').answer.valueString='fail'*errors.id.invalid"
}
],
"linkId": "odsp-referral-id",
"definition": "https://www.hl7.org/fhir/servicerequest-definitions.html#ServiceRequest.identifier[1].value",
"text": "Referral ID (12 to 16 digits)",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 16
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-referenceFilter",
"valueString": "IDValidator*DocumentReference?type=ODSP-Referral-Record&identifier:urn:sadie:request:odsp=%1%&identifier:urn:sadie:patient:odsp=%2%"
},
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression",
"valueExpression": {
"description": "Member ID and Referral ID concatenation",
"language": "text/fhirpath",
"expression": "iif(%context.item.where(linkId='0').item.where(linkId='0.2').item.where(linkId='odsp-member-id').answer.valueString.exists() and %context.item.where(linkId='0').item.where(linkId='0.2').item.where(linkId='odsp-referral-id').answer.valueString.exists(), %context.item.where(linkId='0').item.where(linkId='0.2').item.where(linkId='odsp-member-id').answer.valueString + '*' + %context.item.where(linkId='0').item.where(linkId='0.2').item.where(linkId='odsp-referral-id').answer.valueString)"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "^[0-9]{9}\\*{1}[0-9]{12,16}[%content%]quot;
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "odsp-member-id-referral-id",
"definition": "https://www.hl7.org/fhir/patient-definitions.html#Patient.identifier[1].value",
"text": "Member ID + Referral ID (hidden field for validation purpose)",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 26
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-displayCategory",
"valueCode": "display-error"
}
],
"linkId": "odsp-member-id-referral-id-display-error",
"text": "The referral ID and member ID combination you entered is invalid.<br/>Note: These ID's can be found at the top of the paper DDP forms. If you do not have access to this information, please contact your patient who can contact their ODSP caseworker to confirm the ID's. Requests with invalid combination ID's cannot be submitted.",
"type": "display",
"enableWhen": [
{
"question": "odsp-member-id-referral-id",
"operator": "=",
"answerString": "fail"
}
],
"required": false,
"repeats": false,
"readOnly": false
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-displayCategory",
"valueCode": "display-success"
}
],
"linkId": "odsp-member-id-referral-id-display-success",
"text": "The referral ID and member ID combination you entered is valid.",
"type": "display",
"enableWhen": [
{
"question": "odsp-member-id-referral-id",
"operator": "=",
"answerString": "success"
}
],
"required": false,
"repeats": false,
"readOnly": false
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-displayCategory",
"valueCode": "display-error"
}
],
"linkId": "odsp-member-id-referral-id-display-system-error",
"text": "There was a problem verifying the Member ID and Referral ID. Please enter the values again.",
"type": "display",
"enableWhen": [
{
"question": "odsp-member-id-referral-id",
"operator": "=",
"answerString": "error"
}
],
"required": false,
"repeats": false,
"readOnly": false
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-displayCategory",
"valueCode": "display-in-progress"
}
],
"linkId": "odsp-member-id-referral-id-display-in-progress",
"text": "Please wait while Referral ID and Member ID are validated.",
"type": "display",
"enableWhen": [
{
"question": "odsp-member-id-referral-id",
"operator": "=",
"answerString": "in-progress"
}
],
"required": false,
"repeats": false,
"readOnly": false
}
]
},
{
"linkId": "0.3",
"text": "Applicant Forms",
"type": "group",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"linkId": "0.3.1",
"text": "Do you have a \"Consent to the Release of Medical and Related Information\" form to attach?",
"type": "boolean",
"required": true,
"repeats": false,
"readOnly": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Help-Button"
}
}
],
"linkId": "0.3.1-help",
"text": "Very important: If 'No', please ensure the applicant sends their completed/signed Consent form directly to the DAU. Missing information may impact adjudication timelines.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/vnd.openxmlformats-officedocument.wordprocessingml.document"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/msword"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/rtf"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/tiff"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/pdf"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/gif"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 10
}
],
"linkId": "0.3.2",
"text": "Attach your patient's consent form.",
"type": "attachment",
"enableWhen": [
{
"question": "0.3.1",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": false,
"readOnly": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "0.3.2-DocumentType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "DDP"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "0.3.2-DocumentSubType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "Consent"
}
]
}
]
},
{
"linkId": "0.3.3",
"text": "Do you have a \"Client Self Report Form\" to attach?",
"type": "boolean",
"required": true,
"repeats": false,
"readOnly": false
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/vnd.openxmlformats-officedocument.wordprocessingml.document"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/msword"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/rtf"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/tiff"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/pdf"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/gif"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 10
}
],
"linkId": "0.3.4",
"text": "Attach your patient's Self Report form.",
"type": "attachment",
"enableWhen": [
{
"question": "0.3.3",
"operator": "=",
"answerBoolean": true
}
],
"enableBehavior": "any",
"required": true,
"repeats": false,
"readOnly": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "0.3.4-DocumentType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "DDP"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "0.3.4-DocumentSubType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "Self Report"
}
]
}
]
}
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}
]
},
{
"extension": [
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"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "header",
"display": "Header"
}
],
"text": "Header"
}
}
],
"linkId": "1",
"text": "Applicant",
"type": "group",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"linkId": "1.1",
"text": "Applicant's Information",
"type": "group",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"linkId": "1.1.1",
"type": "group",
"repeats": false,
"item": [
{
"linkId": "1.1.1.1",
"text": "Specify the requested patient information:",
"type": "display",
"required": false,
"repeats": false,
"readOnly": false
},
{
"linkId": "patient-first-name",
"definition": "https://www.hl7.org/fhir/patient-definitions.html#Patient.name.given",
"text": "First Name",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 25
},
{
"linkId": "1.1.1.2",
"text": "Middle Initial",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 2
},
{
"linkId": "patient-last-name",
"definition": "https://www.hl7.org/fhir/patient-definitions.html#Patient.name.family",
"text": "Last Name",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 25
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today()"
}
}
]
},
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today() - 200 year"
}
}
]
}
],
"linkId": "patient-date-of-birth",
"definition": "https://www.hl7.org/fhir/patient-definitions.html#Patient.birthDate",
"text": "Date of Birth",
"type": "date",
"required": true,
"repeats": false,
"readOnly": false
}
]
}
]
},
{
"linkId": "1.2",
"text": "Applicant's Current Address",
"type": "group",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "[A-Za-z0-9]*"
}
],
"linkId": "1.2.1",
"text": "Unit Number",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 10
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "[0-9]*"
}
],
"linkId": "1.2.2",
"text": "Street Number",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 10
},
{
"linkId": "1.2.3",
"text": "Street Name",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 25
},
{
"linkId": "1.2.4",
"text": "City/Town",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 25
},
{
"linkId": "1.2.5",
"text": "Province",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 25
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/minLength",
"valueInteger": 6
},
{
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "[A-Za-z][0-9][A-Za-z] ?[0-9][A-Za-z][0-9]"
}
],
"linkId": "1.2.6",
"text": "Postal Code",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 6
}
]
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "header",
"display": "Header"
}
],
"text": "Header"
}
}
],
"linkId": "2",
"text": "Form",
"type": "group",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-displayCategory",
"valueCode": "display-in-progress"
}
],
"linkId": "attachment_error_guide_form",
"text": "If you encounter an upload error or failure, please try again or fax the attachment to the Disability Adjudication Unit at 416-326-3374. The fax must include the client's first and last name, Member ID and Referral ID on the document or fax cover page.",
"type": "display",
"required": false,
"repeats": false,
"readOnly": false
},
{
"linkId": "2.1",
"text": "1. Medical Conditions that Contribute to the Applicant's Current Status",
"type": "group",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "details",
"definition": "https://www.hl7.org/fhir/servicerequest-definitions.html#ServiceRequest.orderDetail[0].text",
"type": "string",
"initial": [
{
"valueString": "Health Status Report"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
},
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression",
"valueExpression": {
"description": "ODSP Referral Id",
"language": "text/fhirpath",
"expression": "%context.item.where(linkId='0').item.where(linkId='0.2').item.where(linkId='odsp-referral-id').answer.valueString"
}
}
],
"linkId": "additional-details",
"definition": "https://www.hl7.org/fhir/servicerequest-definitions.html#ServiceRequest.orderDetail[1].text",
"type": "string"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-displayCategory",
"valueCode": "display"
}
],
"linkId": "2.1.1",
"text": "Please provide information below.",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassLegend"
},
{
"linkId": "2.1.2",
"text": "Provide information about the applicant's medical conditions, associated impairments, durations and restrictions",
"type": "group",
"required": false,
"repeats": true,
"readOnly": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Help-Button"
}
}
],
"linkId": "2.1.2-help",
"text": "To add additional conditions or associated impairments, click on the '+' button",
"type": "display"
},
{
"linkId": "2.1.2.1",
"text": "Medical Condition",
"type": "text",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 100
},
{
"linkId": "2.1.2.2",
"text": "Describe associated impairment(s)",
"type": "text",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 500,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Help-Button"
}
}
],
"linkId": "2.1.2.2-help",
"text": "Refers to any loss or deviation in psychological, physiological or anatomical structure or function.",
"type": "display"
}
]
},
{
"linkId": "2.1.2.3",
"text": "Describe associated restriction(s)",
"type": "text",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 500,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Help-Button"
}
}
],
"linkId": "2.1.2.1.3-help",
"text": "Refers to a limitation in activities of daily living caused directly by the impairment.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
],
"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "vertical"
}
],
"linkId": "2.1.2.4",
"text": "Prognosis - condition is likely to:",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-PrognosisTypes"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
],
"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "vertical"
}
],
"linkId": "2.1.2.5",
"text": "Duration of impairment",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-Durations"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
],
"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "vertical"
}
],
"linkId": "2.1.2.6",
"text": "Frequency of impairment(s) - are the impairments:",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-RecurrentTypes"
}
]
}
]
},
{
"linkId": "2.2",
"text": "2. Additional Information",
"type": "group",
"repeats": false,
"item": []
},
{
"linkId": "2.1.0",
"text": "2.1",
"type": "group",
"repeats": false,
"item": [
{
"linkId": "2.2.0",
"text": "Indicate whether any of the medical conditions reported in section 1 include conditions described below.",
"type": "display",
"required": false,
"repeats": false,
"readOnly": false
},
{
"linkId": "2.2.1",
"text": "Mental health condition",
"type": "boolean",
"required": true,
"repeats": false,
"readOnly": false
},
{
"linkId": "2.2.2",
"text": "Substance-related or addictive disorder",
"type": "boolean",
"required": true,
"repeats": false,
"readOnly": false
},
{
"linkId": "2.2.3",
"text": "Neurodevelopmental disorder (e.g., intellectual disability, autism spectrum disorder, developmental delay, specific learning disability, attention-deficit/hyperactivity disorder, Fetal Alcohol Spectrum Disorder",
"type": "boolean",
"required": true,
"repeats": false,
"readOnly": false
},
{
"linkId": "2.2.4",
"text": "Other medical condition presenting with a mental or cognitive impairment (e.g., traumatic brain injury, stroke, seizure disorder)",
"type": "boolean",
"required": true,
"repeats": false,
"readOnly": false
},
{
"linkId": "2.2.5",
"text": "If there is additional information that might be useful in understanding the applicant's mental or cognitive impairments please describe or attach copies of available reports (e.g., psychology, psychiatry, educational assessment, individual education plan, neuropsychological assessment, other mental health consult).",
"type": "text",
"required": false,
"repeats": true,
"readOnly": false,
"maxLength": 8000,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Help-Button"
}
}
],
"linkId": "2.2.5-help",
"text": "Relevant additional information may include: History, interventions, access to treatment, services, housing, homelessness, etc. that might be useful to understand the presenting impairments and their impact.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/vnd.openxmlformats-officedocument.wordprocessingml.document"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/msword"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/rtf"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/tiff"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/pdf"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/gif"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 10
}
],
"linkId": "2.2.6",
"text": "Attach related documents",
"type": "attachment",
"required": false,
"repeats": true,
"readOnly": false,
"item": [
{
"linkId": "2.2.6-categories",
"text": "Attachment Categories",
"type": "choice",
"required": false,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-AttachmentCategories"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "2.2.6-DocumentType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "AMI"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "2.2.6-DocumentSubType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "Regular or IR AMI"
}
]
}
]
}
]
},
{
"linkId": "2.3",
"text": "2.2 Intellectual and Emotional Wellness ",
"type": "group",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"linkId": "2.3.1b",
"text": "Intellectual and Emotional Wellness Scale (IEWS)",
"type": "display",
"required": true,
"repeats": false,
"readOnly": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Help-Button"
}
}
],
"linkId": "2.3.1b-help",
"text": "The list below consists of some features or symptoms that might be seen in mental health, substance use, neurocognitive and related conditions that can impact daily functioning. Rate the symptoms in the context of the applicant's presenting conditions and impairments. For episodic symptoms, please describe how fluctuations in the severity level affect the patient.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "table",
"display": "Group table"
}
],
"text": "Group table"
}
}
],
"linkId": "2.3.2",
"type": "group",
"repeats": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-displayCategory",
"valueCode": "display"
}
],
"linkId": "2.3.2.1",
"text": "Rating Scale",
"type": "choice",
"required": false,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClass"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "gtable",
"display": "Group gtable"
}
],
"text": "Group gtable"
}
}
],
"linkId": "2.3.2.2",
"type": "group",
"repeats": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
],
"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.2.1",
"text": "Amotivation",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "gtable",
"display": "Group gtable"
}
],
"text": "Group gtable"
}
}
],
"linkId": "2.3.2.3",
"type": "group",
"repeats": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
],
"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.3.1",
"text": "Anxiety",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "gtable",
"display": "Group gtable"
}
],
"text": "Group gtable"
}
}
],
"linkId": "2.3.2.4",
"type": "group",
"repeats": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
],
"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.4.1",
"text": "Appetite Change",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
],
"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
},
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-enableWhenExpression",
"valueExpression": {
"language": "text/fhirpath",
"expression": "%context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.4').item.where(linkId='2.3.2.4.1').answer.valueCoding.code='1' or %context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.4').item.where(linkId='2.3.2.4.1').answer.valueCoding.code='2' or %context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.4').item.where(linkId='2.3.2.4.1').answer.valueCoding.code='3'"
}
}
],
"linkId": "2.3.2.4.2",
"text": "How has the appetite changed?",
"type": "choice",
"required": false,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-IncreaseDecrease"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "gtable",
"display": "Group gtable"
}
],
"text": "Group gtable"
}
}
],
"linkId": "2.3.2.5",
"type": "group",
"repeats": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
],
"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.5.1",
"text": "Attention deficit",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "gtable",
"display": "Group gtable"
}
],
"text": "Group gtable"
}
}
],
"linkId": "2.3.2.6",
"type": "group",
"repeats": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
],
"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.6.1",
"text": "Comprehension deficit",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "gtable",
"display": "Group gtable"
}
],
"text": "Group gtable"
}
}
],
"linkId": "2.3.2.7",
"type": "group",
"repeats": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
],
"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.7.1",
"text": "Concentration deficit",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "gtable",
"display": "Group gtable"
}
],
"text": "Group gtable"
}
}
],
"linkId": "2.3.2.8",
"type": "group",
"repeats": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
],
"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.8.1",
"text": "Delusions",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "gtable",
"display": "Group gtable"
}
],
"text": "Group gtable"
}
}
],
"linkId": "2.3.2.9",
"type": "group",
"repeats": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
],
"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.9.1",
"text": "Depressive mood",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "gtable",
"display": "Group gtable"
}
],
"text": "Group gtable"
}
}
],
"linkId": "2.3.2.10",
"type": "group",
"repeats": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
],
"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.10.1",
"text": "Disinhibition",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "gtable",
"display": "Group gtable"
}
],
"text": "Group gtable"
}
}
],
"linkId": "2.3.2.11",
"type": "group",
"repeats": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
],
"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.11.1",
"text": "Disorientation (person, place or time)",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
}
]
},
{
"extension": [
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"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "gtable",
"display": "Group gtable"
}
],
"text": "Group gtable"
}
}
],
"linkId": "2.3.2.12",
"type": "group",
"repeats": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
],
"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.12.1",
"text": "Dissociative symptoms",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
}
]
},
{
"extension": [
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"valueCodeableConcept": {
"coding": [
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"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "gtable",
"display": "Group gtable"
}
],
"text": "Group gtable"
}
}
],
"linkId": "2.3.2.13",
"type": "group",
"repeats": false,
"item": [
{
"extension": [
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"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
],
"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.13.1",
"text": "Emotional dysregulation",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
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},
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"extension": [
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"coding": [
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"code": "gtable",
"display": "Group gtable"
}
],
"text": "Group gtable"
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],
"linkId": "2.3.2.14",
"type": "group",
"repeats": false,
"item": [
{
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"system": "http://hl7.org/fhir/questionnaire-item-control",
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"display": "Radio Button"
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"text": "Radio Button"
}
},
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"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.14.1",
"text": "Energy change",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
},
{
"extension": [
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"valueCodeableConcept": {
"coding": [
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"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
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"text": "Radio Button"
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"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
},
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-enableWhenExpression",
"valueExpression": {
"language": "text/fhirpath",
"expression": "%context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.14').item.where(linkId='2.3.2.14.1').answer.valueCoding.code='1' or %context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.14').item.where(linkId='2.3.2.14.1').answer.valueCoding.code='2' or %context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.14').item.where(linkId='2.3.2.14.1').answer.valueCoding.code='3'"
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],
"linkId": "2.3.2.14.2",
"text": "How has the energy changed?",
"type": "choice",
"required": false,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-IncreaseDecrease"
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]
},
{
"extension": [
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"valueCodeableConcept": {
"coding": [
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"code": "gtable",
"display": "Group gtable"
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"text": "Group gtable"
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"linkId": "2.3.2.15",
"type": "group",
"repeats": false,
"item": [
{
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"code": "radio-button",
"display": "Radio Button"
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"text": "Radio Button"
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},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.15.1",
"text": "Euphoria/Elation (elevated mood)",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
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},
{
"extension": [
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"coding": [
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"code": "gtable",
"display": "Group gtable"
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"text": "Group gtable"
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}
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"linkId": "2.3.2.16",
"type": "group",
"repeats": false,
"item": [
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"code": "radio-button",
"display": "Radio Button"
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"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.16.1",
"text": "Executive function deficits (e.g., self-regulation, planning and organization)",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
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},
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"extension": [
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"coding": [
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"code": "gtable",
"display": "Group gtable"
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"text": "Group gtable"
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"linkId": "2.3.2.17",
"type": "group",
"repeats": false,
"item": [
{
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"valueCodeableConcept": {
"coding": [
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"display": "Radio Button"
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"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.17.1",
"text": "Grandiosity",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
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},
{
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"text": "Group gtable"
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],
"linkId": "2.3.2.18",
"type": "group",
"repeats": false,
"item": [
{
"extension": [
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"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
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"code": "radio-button",
"display": "Radio Button"
}
],
"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.18.1",
"text": "Hallucination",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
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},
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],
"text": "Group gtable"
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],
"linkId": "2.3.2.19",
"type": "group",
"repeats": false,
"item": [
{
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"display": "Radio Button"
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"text": "Radio Button"
}
},
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"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.19.1",
"text": "Impulse control deficit",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
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"code": "gtable",
"display": "Group gtable"
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"text": "Group gtable"
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],
"linkId": "2.3.2.20",
"type": "group",
"repeats": false,
"item": [
{
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"text": "Radio Button"
}
},
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"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.20.1",
"text": "Insight deficit",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
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},
{
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"code": "gtable",
"display": "Group gtable"
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"text": "Group gtable"
}
}
],
"linkId": "2.3.2.21",
"type": "group",
"repeats": false,
"item": [
{
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"coding": [
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"display": "Radio Button"
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"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.21.1",
"text": "Judgement deficit",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
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"text": "Group gtable"
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"linkId": "2.3.2.22",
"type": "group",
"repeats": false,
"item": [
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"display": "Radio Button"
}
],
"text": "Radio Button"
}
},
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"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
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"linkId": "2.3.2.22.1",
"text": "Learning deficits",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
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{
"extension": [
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"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-enableWhenExpression",
"valueExpression": {
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"expression": "%context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.22').item.where(linkId='2.3.2.22.1').answer.valueCoding.code='1' or %context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.22').item.where(linkId='2.3.2.22.1').answer.valueCoding.code='2' or %context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.22').item.where(linkId='2.3.2.22.1').answer.valueCoding.code='3'"
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"linkId": "2.3.2.22.2",
"text": "Describe the learning deficits:",
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"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 200
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{
"extension": [
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"linkId": "2.3.2.23",
"type": "group",
"repeats": false,
"item": [
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"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
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"linkId": "2.3.2.23.1",
"text": "Memory deficit",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
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{
"extension": [
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"valueCodeableConcept": {
"coding": [
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"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "check-box",
"display": "Check box"
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"text": "Check box"
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{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
},
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-enableWhenExpression",
"valueExpression": {
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"text": "Memory Deficit - select all that apply: ",
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"repeats": false,
"readOnly": false,
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"text": "Group gtable"
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"linkId": "2.3.2.24",
"type": "group",
"repeats": false,
"item": [
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"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
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"linkId": "2.3.2.24.1",
"text": "Psychomotor retardation",
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"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
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"text": "Radio Button"
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"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
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"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-enableWhenExpression",
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"linkId": "2.3.2.24.2",
"text": "Agitation or retardation?",
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"required": false,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-Psychomotor"
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]
},
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"linkId": "2.3.2.25",
"type": "group",
"repeats": false,
"item": [
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"code": "radio-button",
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"text": "Radio Button"
}
},
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"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.25.1",
"text": "Sleep dysfunction",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
},
{
"extension": [
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],
"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
},
{
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"valueExpression": {
"language": "text/fhirpath",
"expression": "%context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.25').item.where(linkId='2.3.2.25.1').answer.valueCoding.code='1' or %context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.25').item.where(linkId='2.3.2.25.1').answer.valueCoding.code='2' or %context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.25').item.where(linkId='2.3.2.25.1').answer.valueCoding.code='3'"
}
}
],
"linkId": "2.3.2.25.2",
"text": "Difficulty sleeping or excessive sleeping?",
"type": "choice",
"required": false,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-Sleep"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "gtable",
"display": "Group gtable"
}
],
"text": "Group gtable"
}
}
],
"linkId": "2.3.2.26",
"type": "group",
"repeats": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
],
"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.26.1",
"text": "Speech deficit (not due to language barrier)",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
},
{
"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='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.26').item.where(linkId='2.3.2.26.1').answer.valueCoding.code='1' or %context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.26').item.where(linkId='2.3.2.26.1').answer.valueCoding.code='2' or %context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.26').item.where(linkId='2.3.2.26.1').answer.valueCoding.code='3'"
}
}
],
"linkId": "2.3.2.26.2",
"text": "Specify:",
"type": "text",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 200
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "gtable",
"display": "Group gtable"
}
],
"text": "Group gtable"
}
}
],
"linkId": "2.3.2.27",
"type": "group",
"repeats": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
],
"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.27.1",
"text": "Suicidality",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "check-box",
"display": "Check box"
}
],
"text": "Check box"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
},
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-enableWhenExpression",
"valueExpression": {
"language": "text/fhirpath",
"expression": "%context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.27').item.where(linkId='2.3.2.27.1').answer.valueCoding.code='1' or %context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.27').item.where(linkId='2.3.2.27.1').answer.valueCoding.code='2' or %context.item.where(linkId='2').item.where(linkId='2.3').item.where(linkId='2.3.2').item.where(linkId='2.3.2.27').item.where(linkId='2.3.2.27.1').answer.valueCoding.code='3'"
}
}
],
"linkId": "2.3.2.27.2",
"text": "Suicidal behaviours - select all that apply:",
"type": "choice",
"required": false,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-Suicidal"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "gtable",
"display": "Group gtable"
}
],
"text": "Group gtable"
}
}
],
"linkId": "2.3.2.28",
"type": "group",
"repeats": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
],
"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.28.1",
"text": "Thought disorganization",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "gtable",
"display": "Group gtable"
}
],
"text": "Group gtable"
}
}
],
"linkId": "2.3.2.29",
"type": "group",
"repeats": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "radio-button",
"display": "Radio Button"
}
],
"text": "Radio Button"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "horizontal"
}
],
"linkId": "2.3.2.29.1",
"text": "Withdrawn",
"type": "choice",
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-SymptomClassCodes"
}
]
}
]
},
{
"linkId": "2.3.3",
"text": "For episodic symptoms, describe how fluctuations in severity level affect the patient",
"type": "text",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 4000
}
]
},
{
"linkId": "2.4",
"text": "3. Available Medical and Other Information Related to Section 1",
"type": "group",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"linkId": "2.4.1",
"text": "Note: You do not have to repeat the information already provided in previous sections.",
"type": "display",
"required": false,
"repeats": false,
"readOnly": false
},
{
"linkId": "2.4.2",
"text": "How long have you known the applicant?",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 100,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Section 3.1"
}
}
],
"linkId": "2.4.2-help",
"text": "Section 3.1",
"type": "display"
}
]
},
{
"linkId": "2.4.3",
"text": "How often do you see the applicant for the conditions and/or impairments listed in Section 1?",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 100,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Section 3.2"
}
}
],
"linkId": "2.4.3-help",
"text": "Section 3.2",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unit",
"valueCoding": {
"code": "cm"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"valueInteger": 0
},
{
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "^[^eE]*[%content%]quot;
}
],
"linkId": "2.4.4",
"text": "If relevant, state the applicant's height in centimetres",
"type": "decimal",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 255,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Section 3.3"
}
}
],
"linkId": "2.4.4-help",
"text": "Section 3.3",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unit",
"valueCoding": {
"code": "kg"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"valueInteger": 0
},
{
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "^[^eE]*[%content%]quot;
}
],
"linkId": "2.4.5",
"text": "If relevant, state the applicant's weight in kilograms",
"type": "decimal",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 255
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression",
"valueExpression": {
"description": "BMI Calculation",
"language": "text/fhirpath",
"expression": "iif(%context.item.where(linkId='2').item.where(linkId='2.4').item.where(linkId='2.4.4').answer.valueDecimal.exists() and %context.item.where(linkId='2').item.where(linkId='2.4').item.where(linkId='2.4.5').answer.valueDecimal.exists(), (%context.item.where(linkId='2').item.where(linkId='2.4').item.where(linkId='2.4.5').answer.valueDecimal / ((%context.item.where(linkId='2').item.where(linkId='2.4').item.where(linkId='2.4.4').answer.valueDecimal / 100.0) * (%context.item.where(linkId='2').item.where(linkId='2.4').item.where(linkId='2.4.4').answer.valueDecimal / 100.0))).round(1))"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxDecimalPlaces",
"valueInteger": 1
}
],
"linkId": "2.4.6",
"text": "Body Mass Index (BMI)",
"type": "decimal",
"required": false,
"repeats": false,
"readOnly": true,
"maxLength": 10
},
{
"linkId": "2.4.7",
"text": "Other relevant Patient details (i.e. Blood Pressure)",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 100
},
{
"linkId": "2.4.8",
"text": "Are there examination findings that you wish to include?",
"type": "boolean",
"required": true,
"repeats": false,
"readOnly": false
},
{
"linkId": "2.4.9",
"text": "Enter examination findings:",
"type": "text",
"enableWhen": [
{
"question": "2.4.8",
"operator": "=",
"answerBoolean": true
}
],
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 4000
},
{
"linkId": "2.4.10",
"text": "For recurrent or episodic impairments listed, describe how fluctuations in severity level affect the patient.",
"type": "text",
"enableWhen": [
{
"question": "2.4.8",
"operator": "=",
"answerBoolean": true
}
],
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 4000
},
{
"linkId": "2.4.11",
"text": "Have any consultations or assessments been completed by another health care professional?",
"type": "boolean",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Section 3.4"
}
}
],
"linkId": "2.4.11-help",
"text": "Section 3.4",
"type": "display"
}
]
},
{
"linkId": "2.4.12N",
"text": "Comment (e.g., pending or waiting list, not available)",
"type": "text",
"enableWhen": [
{
"question": "2.4.11",
"operator": "=",
"answerBoolean": false
}
],
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 1000
},
{
"linkId": "2.4.12",
"text": "Describe diagnostic tests or investigations",
"type": "text",
"enableWhen": [
{
"question": "2.4.11",
"operator": "=",
"answerBoolean": true
}
],
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 4000,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Help-Button"
}
}
],
"linkId": "2.4.12-help",
"text": "For example, laboratory, biopsy, sleep study, ultrasound, imaging, stress test",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/vnd.openxmlformats-officedocument.wordprocessingml.document"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/msword"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/rtf"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/tiff"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/pdf"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/gif"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 10
}
],
"linkId": "2.4.12-attachment",
"text": "Attach relevant diagnostic tests or investigations",
"type": "attachment",
"enableWhen": [
{
"question": "2.4.11",
"operator": "=",
"answerBoolean": true
}
],
"required": false,
"repeats": true,
"readOnly": false,
"item": [
{
"linkId": "2.4.12-categories",
"text": "Attachment Categories",
"type": "choice",
"required": false,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-AttachmentCategories"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "2.4.12-DocumentType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "AMI"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "2.4.12-DocumentSubType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "Regular or IR AMI"
}
]
}
]
},
{
"linkId": "2.4.13",
"text": "Describe specialist consults",
"type": "text",
"enableWhen": [
{
"question": "2.4.11",
"operator": "=",
"answerBoolean": true
}
],
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 4000,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Help-Button"
}
}
],
"linkId": "2.4.13-help",
"text": "For example, cardiology, neurology, oncology, psychiatry, psychology, rheumatology",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/vnd.openxmlformats-officedocument.wordprocessingml.document"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/msword"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/rtf"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/tiff"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/pdf"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/gif"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 10
}
],
"linkId": "2.4.13-attachment",
"text": "Attach relevant specialist consults",
"type": "attachment",
"enableWhen": [
{
"question": "2.4.11",
"operator": "=",
"answerBoolean": true
}
],
"required": false,
"repeats": true,
"readOnly": false,
"item": [
{
"linkId": "2.4.13-categories",
"text": "Attachment Categories",
"type": "choice",
"required": false,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-AttachmentCategories"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "2.4.13-DocumentType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "AMI"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "2.4.13-DocumentSubType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "Regular or IR AMI"
}
]
}
]
},
{
"linkId": "2.4.14",
"text": "Describe other assessments or reports",
"type": "text",
"enableWhen": [
{
"question": "2.4.11",
"operator": "=",
"answerBoolean": true
}
],
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 4000,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Help-Button"
}
}
],
"linkId": "2.4.14-help",
"text": "For example, vocational assessment, occupational therapy report",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/vnd.openxmlformats-officedocument.wordprocessingml.document"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/msword"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/rtf"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/tiff"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/pdf"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/gif"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 10
}
],
"linkId": "2.4.14-attachment",
"text": "Attach relevant other assessments or reports",
"type": "attachment",
"enableWhen": [
{
"question": "2.4.11",
"operator": "=",
"answerBoolean": true
}
],
"required": false,
"repeats": true,
"readOnly": false,
"item": [
{
"linkId": "2.4.14-categories",
"text": "Attachment Categories",
"type": "choice",
"required": false,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-AttachmentCategories"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "2.4.14-DocumentType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "AMI"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "2.4.14-DocumentSubType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "Regular or IR AMI"
}
]
}
]
},
{
"linkId": "2.4.15",
"text": "For recurrent or episodic impairments listed, describe how fluctuations in severity level affect the patient.",
"type": "text",
"enableWhen": [
{
"question": "2.4.11",
"operator": "=",
"answerBoolean": true
}
],
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 4000
}
]
},
{
"linkId": "2.5",
"text": "4. Visual",
"type": "group",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"linkId": "2.5.1",
"text": "Does the patient have a visual impairment as described in Section 1 of this request?",
"type": "boolean",
"required": true,
"repeats": false,
"readOnly": false
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today()"
}
}
]
},
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today() - 200 year"
}
}
]
}
],
"linkId": "2.5.2",
"text": "Date of Diagnosis (if known) ",
"type": "date",
"enableWhen": [
{
"question": "2.5.1",
"operator": "=",
"answerBoolean": true
}
],
"required": false,
"repeats": false,
"readOnly": false
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today()"
}
}
]
},
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today() - 200 year"
}
}
]
}
],
"linkId": "2.5.3",
"text": "Most Recent Assessment Date",
"type": "date",
"enableWhen": [
{
"question": "2.5.1",
"operator": "=",
"answerBoolean": true
}
],
"required": false,
"repeats": false,
"readOnly": false
},
{
"linkId": "2.5.5-display",
"text": "Snellen Visual Acuity Chart Details",
"type": "display",
"enableWhen": [
{
"question": "2.5.1",
"operator": "=",
"answerBoolean": true
}
],
"required": false,
"repeats": false,
"readOnly": false
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "gtable",
"display": "Group gtable"
}
],
"text": "Group gtable"
}
}
],
"linkId": "2.5.5-gtable",
"type": "group",
"enableWhen": [
{
"question": "2.5.1",
"operator": "=",
"answerBoolean": true
}
],
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "table",
"display": "Group table"
}
],
"text": "Group table"
}
}
],
"linkId": "2.5.5-left-group-table",
"type": "group",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"linkId": "2.5.5-left-display",
"text": "Left eye",
"type": "display",
"required": false,
"repeats": false,
"readOnly": false
},
{
"linkId": "2.5.5.2-left",
"text": "Uncorrected - Near",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 100
},
{
"linkId": "2.5.5.3-left",
"text": "Uncorrected - Distance",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 100
},
{
"linkId": "2.5.5.4-left",
"text": "Corrected - Near",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 100
},
{
"linkId": "2.5.5.5-left",
"text": "Corrected - Distance",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 100
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "table",
"display": "Group table"
}
],
"text": "Group table"
}
}
],
"linkId": "2.5.5-right-group-table",
"type": "group",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"linkId": "2.5.5-right-display",
"text": "Right eye",
"type": "display",
"required": false,
"repeats": false,
"readOnly": false
},
{
"linkId": "2.5.5.2-right",
"text": "Uncorrected - Near",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 100
},
{
"linkId": "2.5.5.3-right",
"text": "Uncorrected - Distance",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 100
},
{
"linkId": "2.5.5.4-right",
"text": "Corrected - Near",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 100
},
{
"linkId": "2.5.5.5-right",
"text": "Corrected - Distance",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 100
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "table",
"display": "Group table"
}
],
"text": "Group table"
}
}
],
"linkId": "2.5.5-both-group-table",
"type": "group",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"linkId": "2.5.5-both-display",
"text": "Both eyes",
"type": "display",
"required": false,
"repeats": false,
"readOnly": false
},
{
"linkId": "2.5.5.2-both",
"text": "Uncorrected - Near",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 100
},
{
"linkId": "2.5.5.3-both",
"text": "Uncorrected - Distance",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 100
},
{
"linkId": "2.5.5.4-both",
"text": "Corrected - Near",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 100
},
{
"linkId": "2.5.5.5-both",
"text": "Corrected - Distance",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 100
}
]
}
]
},
{
"linkId": "2.5.6",
"text": "Is there a visual field defect component in the visual impairment?",
"type": "boolean",
"enableWhen": [
{
"question": "2.5.1",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": false,
"readOnly": false
},
{
"linkId": "2.5.7",
"type": "group",
"enableWhen": [
{
"question": "2.5.6",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": false,
"readOnly": false,
"item": [
{
"linkId": "2.5.7.1",
"text": "Describe the visual field defect of the patient",
"type": "display",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Help-Button"
}
}
],
"linkId": "2.5.7.1-help",
"text": "Please describe the visual field defect component and/or attach reports.",
"type": "display"
}
]
},
{
"linkId": "2.5.7.1b",
"text": "Visual Field Defect",
"type": "text",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 1000
}
]
},
{
"linkId": "2.5.8",
"text": "Is there a change in ocular mobility (e.g., diplopia, strabismus) or deformities of the orbit that alter function?",
"type": "boolean",
"enableWhen": [
{
"question": "2.5.1",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": false,
"readOnly": false
},
{
"linkId": "2.5.9",
"type": "group",
"enableWhen": [
{
"question": "2.5.8",
"operator": "=",
"answerBoolean": true
}
],
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"linkId": "2.5.9.1",
"text": "Describe the ocular mobility defect of the patient",
"type": "display",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Help-Button"
}
}
],
"linkId": "2.5.9.1-help",
"text": "Please describe the change in ocular mobility or deformities and/or attach reports.",
"type": "display"
}
]
},
{
"linkId": "2.5.9.1b",
"text": "Ocular Mobility Defect",
"type": "text",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 1000
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/vnd.openxmlformats-officedocument.wordprocessingml.document"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/msword"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/rtf"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/tiff"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/pdf"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/gif"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 10
}
],
"linkId": "2.5.10",
"text": "Attach copies of Visual report(s) pertaining to the patient's diagnosis/condition. You may also wish to attach consult notes.",
"type": "attachment",
"enableWhen": [
{
"question": "2.5.1",
"operator": "=",
"answerBoolean": true
}
],
"required": false,
"repeats": true,
"readOnly": false,
"item": [
{
"linkId": "2.5.10-categories",
"text": "Attachment Categories",
"type": "choice",
"required": false,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-AttachmentCategories"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "2.5.10-DocumentType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "AMI"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "2.5.10-DocumentSubType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "Regular or IR AMI"
}
]
}
]
}
]
},
{
"linkId": "2.6",
"text": "5. Auditory",
"type": "group",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"linkId": "2.6.1",
"text": "Does the patient have an auditory impairment as described in Section 1 of this request?",
"type": "boolean",
"required": true,
"repeats": false,
"readOnly": false
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today()"
}
}
]
},
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today() - 200 year"
}
}
]
}
],
"linkId": "2.6.2",
"text": "Date of Diagnosis (if known)",
"type": "date",
"enableWhen": [
{
"question": "2.6.1",
"operator": "=",
"answerBoolean": true
}
],
"required": false,
"repeats": false,
"readOnly": false
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today()"
}
}
]
},
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today() - 200 year"
}
}
]
}
],
"linkId": "2.6.3",
"text": "Most Recent Assessment Date",
"type": "date",
"enableWhen": [
{
"question": "2.6.1",
"operator": "=",
"answerBoolean": true
}
],
"required": false,
"repeats": false,
"readOnly": false
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop down",
"display": "Drop down"
}
],
"text": "Drop down"
}
}
],
"linkId": "2.6.4",
"text": "What type is the hearing loss?",
"type": "choice",
"enableWhen": [
{
"question": "2.6.1",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-Hearing",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Section 5.1"
}
}
],
"linkId": "2.6.4-help",
"text": "Section 5.1",
"type": "display"
}
]
},
{
"linkId": "2.6.5",
"text": "Has there been any change in hearing loss over the last 5 years?",
"type": "boolean",
"enableWhen": [
{
"question": "2.6.1",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": false,
"readOnly": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Section 5.2"
}
}
],
"linkId": "2.6.5-help",
"text": "Section 5.2",
"type": "display"
}
]
},
{
"linkId": "2.6.6",
"text": "Describe the auditory impairment the patient experienced",
"type": "text",
"enableWhen": [
{
"question": "2.6.5",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 4000
},
{
"linkId": "2.6.7",
"text": "Does the applicant have difficulty understanding speech in a quiet environment?",
"type": "boolean",
"enableWhen": [
{
"question": "2.6.1",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": false,
"readOnly": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Section 5.3"
}
}
],
"linkId": "2.6.7-help",
"text": "Section 5.3",
"type": "display"
}
]
},
{
"linkId": "2.6.8",
"text": "Describe the patient's difficulty understanding speech in a quiet environment.",
"type": "text",
"enableWhen": [
{
"question": "2.6.7",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 4000
},
{
"linkId": "2.6.9",
"text": "Does the applicant have difficulty understanding conversational speech in the presence of background noise? ",
"type": "boolean",
"enableWhen": [
{
"question": "2.6.1",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": false,
"readOnly": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Section 5.4"
}
}
],
"linkId": "2.6.9-help",
"text": "Section 5.4",
"type": "display"
}
]
},
{
"linkId": "2.6.10",
"text": "Describe the applicant's difficulty understanding conversational speech in the presence of background noise.",
"type": "text",
"enableWhen": [
{
"question": "2.6.9",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 4000
},
{
"linkId": "2.6.11",
"text": "Are there safety concerns related to hearing (e.g., unable to localize sound of approaching vehicles)?",
"type": "boolean",
"enableWhen": [
{
"question": "2.6.1",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": false,
"readOnly": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Section 5.5"
}
}
],
"linkId": "2.6.11-help",
"text": "Section 5.5",
"type": "display"
}
]
},
{
"linkId": "2.6.12",
"text": "Describe the safety concerns related to hearing.",
"type": "text",
"enableWhen": [
{
"question": "2.6.11",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 4000
},
{
"linkId": "2.6.13",
"text": "Does the applicant have a constant/annoying ringing (tinnitus) in ears?",
"type": "boolean",
"enableWhen": [
{
"question": "2.6.1",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": false,
"readOnly": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Section 5.6"
}
}
],
"linkId": "2.6.13-help",
"text": "Section 5.6",
"type": "display"
}
]
},
{
"linkId": "2.6.14",
"text": "Describe the applicant's tinnitus.",
"type": "text",
"enableWhen": [
{
"question": "2.6.13",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 4000
},
{
"linkId": "2.6.15",
"text": "Does the applicant wear hearing aids?",
"type": "boolean",
"enableWhen": [
{
"question": "2.6.1",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": false,
"readOnly": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Section 5.7"
}
}
],
"linkId": "2.6.15-help",
"text": "Section 5.7",
"type": "display"
}
]
},
{
"linkId": "2.6.16",
"text": "Describe the applicant's hearing aids.",
"type": "text",
"enableWhen": [
{
"question": "2.6.15",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 4000
},
{
"linkId": "2.6.17",
"text": "With the hearing aid(s), could or can the applicant function within normal limits?",
"type": "boolean",
"enableWhen": [
{
"question": "2.6.1",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": false,
"readOnly": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Section 5.8"
}
}
],
"linkId": "2.6.15-help",
"text": "Section 5.8",
"type": "display"
}
]
},
{
"linkId": "2.6.18",
"text": "If no, describe",
"type": "text",
"enableWhen": [
{
"question": "2.6.17",
"operator": "=",
"answerBoolean": false
}
],
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 4000
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/vnd.openxmlformats-officedocument.wordprocessingml.document"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/msword"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/rtf"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/tiff"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/pdf"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/gif"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 10
}
],
"linkId": "2.6.19",
"text": "Attach copies of Auditory report(s) pertaining to the patient's diagnosis/condition. You may also wish to attach consult notes. ",
"type": "attachment",
"enableWhen": [
{
"question": "2.6.1",
"operator": "=",
"answerBoolean": true
}
],
"required": false,
"repeats": true,
"readOnly": false,
"item": [
{
"linkId": "2.6.19-categories",
"text": "Attachment Categories",
"type": "choice",
"required": false,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-AttachmentCategories"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "2.6.19-DocumentType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "AMI"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "2.6.19-DocumentSubType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "Regular or IR AMI"
}
]
}
]
}
]
},
{
"linkId": "2.7",
"text": "6. Intervention and Treatment",
"type": "group",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"linkId": "2.7.1",
"text": "6.1 Is the applicant receiving any interventions and treatment for conditions and impairments listed in section 1 (e.g. Admission, Emergency Room Visit, Surgery, Pharmacotherapy, Interventions and Services.)",
"type": "boolean",
"required": true,
"repeats": false,
"readOnly": false
},
{
"linkId": "2.7.9",
"text": "If no, provide additional information: (e.g., pending, side effects, no definitive diagnosis, not available, poor insight)",
"type": "text",
"enableWhen": [
{
"question": "2.7.1",
"operator": "=",
"answerBoolean": false
}
],
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 1000
},
{
"linkId": "2.7.2",
"text": "Does the applicant have any relevant admissions, emergency room visits or surgeries?",
"type": "boolean",
"enableWhen": [
{
"question": "2.7.1",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": false,
"readOnly": false
},
{
"linkId": "2.7.3",
"text": "Describe admissions, emergency room visits or surgeries, completing relevant sections below and comment on progress.",
"type": "group",
"enableWhen": [
{
"question": "2.7.2",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": true,
"readOnly": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Help-Button"
}
}
],
"linkId": "2.7.3-help",
"text": "To add additional treatments/interventions, click on the '+' button",
"type": "display"
},
{
"linkId": "2.7.3.1",
"text": "Admission, Emergency Room Visit or, Surgery",
"type": "text",
"enableWhen": [
{
"question": "2.7.2",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 4000,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Help-Button"
}
}
],
"linkId": "GEN-DH-DRUG-TXT-help",
"text": "Describe the nature of the visit (admission, emergency room visit, surgery)",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today()"
}
}
]
},
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today() - 200 year"
}
}
]
}
],
"linkId": "2.7.3.2",
"text": "Date of Visit",
"type": "date",
"required": false,
"repeats": false,
"readOnly": false
},
{
"linkId": "2.7.3.3",
"text": "Duration",
"type": "text",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 500
},
{
"linkId": "2.7.3.4",
"text": "Describe Purpose or Attach Admission/Discharge Report",
"type": "text",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 4000
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/vnd.openxmlformats-officedocument.wordprocessingml.document"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/msword"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/rtf"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/tiff"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/pdf"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/gif"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "vertical"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 10
}
],
"linkId": "2.7.3.5",
"text": "Discharge Report",
"type": "attachment",
"required": false,
"repeats": true,
"readOnly": false,
"item": [
{
"linkId": "2.7.3.5-categories",
"text": "Attachment Categories",
"type": "choice",
"required": false,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-AttachmentCategories"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "2.7.3.5-DocumentType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "AMI"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "2.7.3.5-DocumentSubType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "Regular or IR AMI"
}
]
}
]
}
]
},
{
"linkId": "2.7.6",
"text": "Does the applicant have any relevant pharmacological interventions?",
"type": "boolean",
"enableWhen": [
{
"question": "2.7.1",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": false,
"readOnly": false
},
{
"linkId": "2.7.7",
"text": "Describe pharmacological interventions, completing relevant sections below.",
"type": "group",
"enableWhen": [
{
"question": "2.7.6",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": true,
"readOnly": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Help-Button"
}
}
],
"linkId": "2.7.7-help",
"text": "To add additional medications, click on the \"+\" button ",
"type": "display"
},
{
"linkId": "2.7.7.1",
"text": "Pharmacotherapy treatment",
"type": "text",
"enableWhen": [
{
"question": "2.7.6",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 255,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Help-Button"
}
}
],
"linkId": "2.7.7.1-help",
"text": "Enter name of pharmacotherapy treatment.",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today()"
}
}
]
},
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today() - 200 year"
}
}
]
}
],
"linkId": "2.7.7.2",
"text": "Start Date (if known)",
"type": "date",
"required": false,
"repeats": false,
"readOnly": false
},
{
"linkId": "2.7.7.3",
"text": "Dosage",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 100
},
{
"linkId": "2.7.7.4",
"text": "Frequency",
"type": "text",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 500
},
{
"linkId": "2.7.7.5",
"text": "List Conditions or Impairments being treated",
"type": "text",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 4000
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/vnd.openxmlformats-officedocument.wordprocessingml.document"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/msword"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/rtf"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/tiff"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/pdf"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/gif"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "vertical"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 10
}
],
"linkId": "2.7.7.6",
"text": "Attach Report",
"type": "attachment",
"required": false,
"repeats": true,
"readOnly": false,
"item": [
{
"linkId": "2.7.7.6-categories",
"text": "Attachment Categories",
"type": "choice",
"required": false,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-AttachmentCategories"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "2.7.7.6-DocumentType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "AMI"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "2.7.7.6-DocumentSubType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "Regular or IR AMI"
}
]
}
]
}
]
},
{
"linkId": "2.7.4",
"text": "Does the applicant have any relevant interventions or services?",
"type": "boolean",
"enableWhen": [
{
"question": "2.7.1",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": false,
"readOnly": false
},
{
"linkId": "2.7.10",
"text": "If no, provide additional information: (e.g., pending, side effects, no definitive diagnosis, not available, poor insight)",
"type": "text",
"enableWhen": [
{
"question": "2.7.4",
"operator": "=",
"answerBoolean": false
}
],
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 1000
},
{
"linkId": "2.7.5",
"text": "Describe interventions and services, completing relevant sections below and comment on progress.",
"type": "group",
"enableWhen": [
{
"question": "2.7.4",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": true,
"readOnly": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Help-Button"
}
}
],
"linkId": "2.7.5-help",
"text": "To add additional interventions and services, click on the \"+\" button",
"type": "display"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop down",
"display": "Drop down"
}
],
"text": "Drop down"
}
}
],
"linkId": "2.7.5.1",
"text": "Interventions and Services",
"type": "choice",
"enableWhen": [
{
"question": "2.7.4",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 500,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-Intervention",
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "help",
"display": "Help-Button"
}
],
"text": "Help-Button"
}
}
],
"linkId": "2.7.5.1-help",
"text": "Select an intervention or service from the list below:",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-enableWhenExpression",
"valueExpression": {
"description": "Show if one of the 'other' options are selected",
"language": "text/fhirpath",
"expression": "%context.item.where(linkId='2').item.where(linkId='2.7').item.where(linkId='2.7.5')[%repeatingGroupIndex%].item.where(linkId='2.7.5.1').answer.valueCoding.code='Intervention-9'"
}
}
],
"linkId": "2.7.5.1a",
"type": "text",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 500
},
{
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-enableWhenExpression",
"valueExpression": {
"description": "Show if one of the 'other' options are selected",
"language": "text/fhirpath",
"expression": "%context.item.where(linkId='2').item.where(linkId='2.7').item.where(linkId='2.7.5')[%repeatingGroupIndex%].item.where(linkId='2.7.5.1').answer.valueCoding.code='Intervention-10'"
}
}
],
"linkId": "2.7.5.1b",
"type": "text",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 500
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today() + 1 day"
}
}
]
},
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today() - 200 year"
}
}
]
}
],
"linkId": "2.7.5.2",
"text": "Start Date (Approximate start date)",
"type": "date",
"required": false,
"repeats": false,
"readOnly": false
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/maxValue",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today() + 1 day"
}
}
]
},
{
"url": "http://hl7.org/fhir/StructureDefinition/minValue",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/cqf-calculatedValue",
"valueExpression": {
"language": "text/fhirpath",
"expression": "today() - 200 year"
}
}
]
}
],
"linkId": "2.7.5.3",
"text": "End Date (Approximate end date)",
"type": "date",
"required": false,
"repeats": false,
"readOnly": false
},
{
"linkId": "2.7.5.4",
"text": "Describe Response to Treatment",
"type": "text",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 4000
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/vnd.openxmlformats-officedocument.wordprocessingml.document"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/msword"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/rtf"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/tiff"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/pdf"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/gif"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation",
"valueCode": "vertical"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 10
}
],
"linkId": "2.7.5.5",
"text": "Attach Report",
"type": "attachment",
"required": false,
"repeats": true,
"readOnly": false,
"item": [
{
"linkId": "2.7.5.5-categories",
"text": "Attachment Categories",
"type": "choice",
"required": false,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-AttachmentCategories"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "2.7.5.5-DocumentType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "AMI"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "2.7.5.5-DocumentSubType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "Regular or IR AMI"
}
]
}
]
}
]
},
{
"linkId": "2.7.8",
"text": "6.2 Describe any relevant past treatment and reason for discontinuation (e.g., remission, failed treatment, change in treatment, side effects)",
"type": "text",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 4000
},
{
"linkId": "2.8.1.1",
"text": "6.3 Provide any other information that might be useful in understanding the applicant's current situation.",
"type": "text",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 8000
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/vnd.openxmlformats-officedocument.wordprocessingml.document"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/msword"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/rtf"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/tiff"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/pdf"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/gif"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 10
}
],
"linkId": "2.8.1.2",
"text": "Attach related documents here.",
"type": "attachment",
"required": false,
"repeats": true,
"readOnly": false,
"item": [
{
"linkId": "2.8.1.2-categories",
"text": "Attachment Categories",
"type": "choice",
"required": false,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/HSR-AttachmentCategories"
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "2.8.1.2-DocumentType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "AMI"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "2.8.1.2-DocumentSubType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "Regular or IR AMI"
}
]
}
]
}
]
}
]
}
]
}