| Package | ca.on.health.sadie |
| Resource Type | Questionnaire |
| Id | 9cc3ae17-359c-4df6-be26-01e977b705aa |
| 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/ActivitiesofDailyLivingIndex/Version1 |
| URL | http://health.gov.on.ca/sadie/fhir/FlexForm/ActivitiesofDailyLivingIndex/Version1 |
| Status | active |
| Name | ActivitiesofDailyLivingIndex |
| Title | Activities of Daily Living Index |
No resources found
No resources found
Note: links and images are rebased to the (stated) source
FHIR{
"resourceType": "Questionnaire",
"id": "9cc3ae17-359c-4df6-be26-01e977b705aa",
"meta": {
"versionId": "27",
"lastUpdated": "2022-03-15T18:24:19+00:00",
"source": "#thSVcqfzMi8kQ32b",
"profile": [
"http://health.gov.on.ca/sadie/fhir/StructureDefinition/FlexForm"
]
},
"text": {
"status": "empty",
"div": "<!-- snip (see above) -->"
},
"url": "http://health.gov.on.ca/sadie/fhir/FlexForm/ActivitiesofDailyLivingIndex/Version1",
"identifier": [
{
"use": "official",
"system": "https://health.gov.on.ca/sadie/fhir/CodeSystem/FlexForms-Internal-Complete",
"value": "ADLI"
}
],
"name": "ActivitiesofDailyLivingIndex",
"title": "Activities of Daily Living Index",
"status": "active",
"experimental": false,
"subjectType": [
"Patient"
],
"publisher": "ODSP",
"effectivePeriod": {
"start": "2021-07-14T04:00:00.000Z"
},
"code": [
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"display": "DDP"
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"text": "General",
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],
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"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",
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},
{
"linkId": "0.1",
"text": "Health Care Professional Details",
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{
"linkId": "0.2",
"text": "Applicant's Social Assistance Identification",
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{
"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",
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{
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}
],
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"definition": "https://www.hl7.org/fhir/patient-definitions.html#Patient.identifier[1].value",
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"required": true,
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{
"extension": [
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}
],
"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,
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"readOnly": false,
"maxLength": 16
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{
"extension": [
{
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{
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{
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"valueBoolean": true
}
],
"linkId": "odsp-member-id-referral-id",
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"text": "Member ID + Referral ID (hidden field for validation purpose)",
"type": "string",
"required": true,
"repeats": false,
"readOnly": false,
"maxLength": 26
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{
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"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",
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{
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{
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"linkId": "odsp-member-id-referral-id-display-success",
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{
"question": "odsp-member-id-referral-id",
"operator": "=",
"answerString": "success"
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{
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"type": "display",
"enableWhen": [
{
"question": "odsp-member-id-referral-id",
"operator": "=",
"answerString": "error"
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{
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"valueCode": "display-in-progress"
}
],
"linkId": "odsp-member-id-referral-id-display-in-progress",
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{
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],
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}
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{
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"valueBoolean": true
},
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression",
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"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"
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"type": "string"
}
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},
{
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"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": [
{
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"code": "help",
"display": "Help-Button"
}
],
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}
}
],
"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": [
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"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "application/vnd.openxmlformats-officedocument.wordprocessingml.document"
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"valueCode": "image/tiff"
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"valueCode": "application/pdf"
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"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/gif"
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{
"url": "http://hl7.org/fhir/StructureDefinition/maxSize",
"valueDecimal": 10
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],
"linkId": "0.3.2",
"text": "Attach your patient's consent form.",
"type": "attachment",
"enableWhen": [
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"question": "0.3.1",
"operator": "=",
"answerBoolean": true
}
],
"required": true,
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"item": [
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"valueBoolean": true
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"required": false,
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"valueBoolean": true
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"linkId": "0.3.2-DocumentSubType",
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{
"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"
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"valueCode": "application/msword"
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{
"url": "http://hl7.org/fhir/StructureDefinition/mimeType",
"valueCode": "image/tiff"
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{
"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
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],
"linkId": "0.3.4",
"text": "Attach your patient's Self Report form.",
"type": "attachment",
"enableWhen": [
{
"question": "0.3.3",
"operator": "=",
"answerBoolean": true
}
],
"enableBehavior": "any",
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"readOnly": false,
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"valueBoolean": true
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"valueBoolean": true
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],
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"text": "Applicant",
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"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"linkId": "1.1",
"text": "Applicant's Information",
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"required": false,
"repeats": false,
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{
"linkId": "1.1.1",
"type": "group",
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"item": [
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"linkId": "1.1.1.1",
"text": "Specify the requested patient information:",
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"repeats": false,
"readOnly": false
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{
"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
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{
"linkId": "1.1.1.2",
"text": "Middle Initial",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 2
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{
"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
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{
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{
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"valueExpression": {
"language": "text/fhirpath",
"expression": "today() - 200 year"
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}
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}
],
"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": [
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"text": "Unit Number",
"type": "string",
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"readOnly": false,
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{
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"valueString": "[0-9]*"
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"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": [
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"url": "http://hl7.org/fhir/StructureDefinition/minLength",
"valueInteger": 6
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{
"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
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},
{
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"display": "Header"
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}
],
"linkId": "2",
"text": "Form",
"type": "group",
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"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": "Activities of Daily Living Index (ADLI)",
"type": "group",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"linkId": "2.1.1",
"text": "This section consists of a list of activities that seeks to understand the impact of the presenting impairments on the applicant's restrictions.",
"type": "display",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
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"code": "help",
"display": "Help-Button"
}
],
"text": "Help-Button"
}
}
],
"linkId": "2.1.1-help",
"text": "This information helps the ministry understand the direct impact of the impairments and restrictions listed in Section 1 on the applicant's current ability to perform and carry out each activity.",
"type": "display",
"required": false,
"repeats": false,
"readOnly": false
}
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{
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}
],
"linkId": "2.1.2.1",
"text": "Please rate the limitation for each activity",
"type": "choice",
"required": false,
"repeats": false,
"readOnly": false,
"answerValueSet": "http://health.on.ca/sadie/fhir/ValueSet/ODSP-SymptomClassHelp"
},
{
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"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "gtable",
"display": "Group gtable"
}
],
"text": "Group gtable"
}
}
],
"linkId": "2.1.2.22",
"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": "2.1.2.22.1",
"text": "21. Managing medication (if applicable)",
"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='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.22').item.where(linkId='2.1.2.22.1').answer.valueCoding.code='1' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.22').item.where(linkId='2.1.2.22.1').answer.valueCoding.code='2' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.22').item.where(linkId='2.1.2.22.1').answer.valueCoding.code='3'"
}
}
],
"linkId": "2.1.2.22.2",
"text": "Describe limitation, if needed",
"type": "text",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 500
}
]
},
{
"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": "2.1.2.23",
"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": "2.1.2.23.1",
"text": "22. Communication using phone, text, email, etc.",
"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='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.23').item.where(linkId='2.1.2.23.1').answer.valueCoding.code='1' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.23').item.where(linkId='2.1.2.23.1').answer.valueCoding.code='2' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.23').item.where(linkId='2.1.2.23.1').answer.valueCoding.code='3'"
}
}
],
"linkId": "2.1.2.23.2",
"text": "Describe limitation, if needed",
"type": "text",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 500
}
]
},
{
"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": "2.1.2.24",
"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": "2.1.2.24.1",
"text": "23. Cognitive based activities (i.e., reading, writing, understanding or following simple instructions)",
"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='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.24').item.where(linkId='2.1.2.24.1').answer.valueCoding.code='1' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.24').item.where(linkId='2.1.2.24.1').answer.valueCoding.code='2' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.24').item.where(linkId='2.1.2.24.1').answer.valueCoding.code='3'"
}
}
],
"linkId": "2.1.2.24.2",
"text": "Describe limitation, if needed",
"type": "text",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 500
}
]
},
{
"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": "2.1.2.25",
"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": "2.1.2.25.1",
"text": "24. Safety: ability to maintain personal safety",
"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='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.25').item.where(linkId='2.1.2.25.1').answer.valueCoding.code='1' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.25').item.where(linkId='2.1.2.25.1').answer.valueCoding.code='2' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.25').item.where(linkId='2.1.2.25.1').answer.valueCoding.code='3'"
}
}
],
"linkId": "2.1.2.25.2",
"text": "Describe limitation, if needed",
"type": "text",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 500
}
]
},
{
"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": "2.1.2.26",
"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": "2.1.2.26.1",
"text": "25. Social interactions (getting along with others, maintaining social boundaries)",
"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='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.26').item.where(linkId='2.1.2.26.1').answer.valueCoding.code='1' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.26').item.where(linkId='2.1.2.26.1').answer.valueCoding.code='2' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.26').item.where(linkId='2.1.2.26.1').answer.valueCoding.code='3'"
}
}
],
"linkId": "2.1.2.26.2",
"text": "Describe limitation, if needed",
"type": "text",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 500
}
]
},
{
"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": "2.1.2.27",
"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": "2.1.2.27.1",
"text": "26. Hobbies/taking part in activities for relaxation or pleasure",
"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='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.27').item.where(linkId='2.1.2.27.1').answer.valueCoding.code='1' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.27').item.where(linkId='2.1.2.27.1').answer.valueCoding.code='2' or %context.item.where(linkId='2').item.where(linkId='2.1').item.where(linkId='2.1.2').item.where(linkId='2.1.2.27').item.where(linkId='2.1.2.27.1').answer.valueCoding.code='3'"
}
}
],
"linkId": "2.1.2.27.2",
"text": "Describe limitation, if needed",
"type": "text",
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 500
}
]
}
]
}
]
},
{
"linkId": "2.2",
"type": "group",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"linkId": "2.2.3",
"text": "Does the applicant require assistive devices or equipment?",
"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": "2.2.3-help",
"text": "For example, cane, wheelchair, continuous positive airway pressure (CPAP)",
"type": "display"
}
]
},
{
"linkId": "2.2.4",
"text": "Please provide details",
"type": "text",
"enableWhen": [
{
"question": "2.2.3",
"operator": "=",
"answerBoolean": true
}
],
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 1000
},
{
"linkId": "2.2.5",
"text": "Does the applicant require support services or resources?",
"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": "2.2.5-help",
"text": "For example, case management, developmental services, personal support worker",
"type": "display"
}
]
},
{
"linkId": "2.2.6",
"text": "Please provide details",
"type": "text",
"enableWhen": [
{
"question": "2.2.5",
"operator": "=",
"answerBoolean": true
}
],
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 1000
},
{
"linkId": "2.2.7",
"text": "Does the applicant require a service or guide animal?",
"type": "boolean",
"required": true,
"repeats": false,
"readOnly": false
},
{
"linkId": "2.2.8",
"text": "Please provide details",
"type": "text",
"enableWhen": [
{
"question": "2.2.7",
"operator": "=",
"answerBoolean": true
}
],
"required": false,
"repeats": false,
"readOnly": false,
"maxLength": 1000
}
]
},
{
"linkId": "2.3",
"type": "group",
"required": false,
"repeats": false,
"readOnly": false,
"item": [
{
"linkId": "2.3.1",
"text": "Do you have any additional comments/information about the applicant's activities of daily living?",
"type": "boolean",
"required": true,
"repeats": false,
"readOnly": false
},
{
"linkId": "2.3.2",
"text": "Please provide additional comments/information about activities of daily living:",
"type": "text",
"enableWhen": [
{
"question": "2.3.1",
"operator": "=",
"answerBoolean": true
}
],
"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": "2.3.3",
"text": "Attach any relevant documentation pertaining to the applicant's activities of daily living.",
"type": "attachment",
"required": false,
"repeats": true,
"readOnly": false,
"item": [
{
"linkId": "2.3.3-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": "2.3.3-DocumentType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "AMI"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-hidden",
"valueBoolean": true
}
],
"linkId": "2.3.3-DocumentSubType",
"type": "string",
"required": false,
"repeats": false,
"readOnly": false,
"initial": [
{
"valueString": "Regular or IR AMI"
}
]
}
]
}
]
}
]
}
]
}