FHIR IG analytics| Package | ca.on.oh-eforms |
| Resource Type | Questionnaire |
| Id | 20250321Hematology.json |
| FHIR Version | R4 |
| Source | https://simplifier.net/resolve?scope=ca.on.oh-eforms@1.0.0-interim&canonical=urn:uuid:c22adf2b-46ea-4581-9aa9-dc1f005ea464 |
| URL | urn:uuid:c22adf2b-46ea-4581-9aa9-dc1f005ea464 |
| Version | 2.0 |
| Status | active |
| Date | 2025-03-21T21:47:22.96+00:00 |
| Title | Hematology - Standardized Provincial Form Template |
| Realm | ca |
| Description | A 'standard' form developed using FHIR-based Questionnaire tools intended to demonstrate the range of Questionnaire capabilities needed by form fillers |
No resources found
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No narrative content found in resource
FHIR
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{
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{
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"text": "City:"
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{
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{
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"type": "string",
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{
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{
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "(?:[a-z0-9!#$%&'*+/=?^_`{|}~-]+(?:\\.[a-z0-9!#$%&'*+/=?^_`{|}~-]+)*|\"(?:[\\x01-\\x08\\x0b\\x0c\\x0e-\\x1f\\x21\\x23-\\x5b\\x5d-\\x7f]|\\\\[\\x01-\\x09\\x0b\\x0c\\x0e-\\x7f])*\")@(?:(?:[a-z0-9](?:[a-z0-9-]*[a-z0-9])?\\.)+[a-z0-9](?:[a-z0-9-]*[a-z0-9])?|\\[(?:(?:(2(5[0-5]|[0-4][0-9])|1[0-9][0-9]|[1-9]?[0-9]))\\.){3}(?:(2(5[0-5]|[0-4][0-9])|1[0-9][0-9]|[1-9]?[0-9])|[a-z0-9-]*[a-z0-9]:(?:[\\x01-\\x08\\x0b\\x0c\\x0e-\\x1f\\x21-\\x5a\\x53-\\x7f]|\\\\[\\x01-\\x09\\x0b\\x0c\\x0e-\\x7f])+)\\])"
}
],
"linkId": "patient_email",
"text": "Email:"
}
],
"type": "group",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "list",
"display": "List"
}
]
}
}
],
"linkId": "patient_header",
"text": "Patient Information",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<b>Patient Information</b>"
}
]
}
},
{
"item": [
{
"type": "choice",
"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"
}
]
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/preferredTerminologyServer",
"valueUrl": "http://example.org/mytxserver"
}
],
"linkId": "additionalinfo_sexassignedatbirth",
"text": "Sex assigned at birth:",
"answerOption": [
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA3-6",
"display": "Female"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA2-8",
"display": "Male"
}
},
{
"valueCoding": {
"display": "Intersex"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA4489-6",
"display": "Unknown"
}
}
]
},
{
"item": [
{
"type": "string",
"linkId": "additionalinfo_pronouns_other",
"text": "Other pronouns:",
"enableWhen": [
{
"question": "additionalinfo_pronouns",
"operator": "=",
"answerCoding": {
"display": "Other"
}
}
],
"enableBehavior": "all",
"required": true
}
],
"type": "choice",
"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"
}
]
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/preferredTerminologyServer",
"valueUrl": "http://terminology.hl7.org/ValueSet/pronouns"
}
],
"linkId": "additionalinfo_pronouns",
"text": "Pronouns:",
"answerOption": [
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA29519-8",
"display": "she/her/her/hers/herself"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA29518-0",
"display": "he/him/his/his/himself"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA29520-6",
"display": "they/them/their/theirs/themselves"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA46-8",
"display": "Other"
}
}
]
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "additionalinfo_preferredname_select",
"text": "Preferred name",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<p style=\"display:none;\"></p>"
}
]
},
"repeats": true,
"answerOption": [
{
"valueCoding": {
"display": "Preferred Name"
}
}
]
},
{
"type": "string",
"linkId": "additionalinfo_preferredname",
"text": "Prefered name String",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<p style=\"display:none;\"></p>"
}
]
},
"enableWhen": [
{
"question": "additionalinfo_preferredname_select",
"operator": "=",
"answerCoding": {
"display": "Preferred Name"
}
}
],
"enableBehavior": "all"
},
{
"item": [
{
"type": "string",
"linkId": "additionalinfo_preferredlanguage_specify",
"text": "Specify:",
"enableWhen": [
{
"question": "additionalinfo_preferredlanguage",
"operator": "=",
"answerCoding": {
"display": "Other"
}
}
],
"enableBehavior": "all",
"required": true
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "additionalinfo_preferredlanguage_translatorrequired",
"text": "Translator required",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<p style=\"display:none;\"></p>"
}
]
},
"enableWhen": [
{
"question": "additionalinfo_preferredlanguage",
"operator": "=",
"answerCoding": {
"display": "Other"
}
}
],
"repeats": true,
"answerOption": [
{
"valueCoding": {
"code": "true",
"display": "Translator Required"
}
}
]
}
],
"type": "choice",
"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"
}
]
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/preferredTerminologyServer",
"valueUrl": "http://ehealthontario.ca/fhir/ValueSet/human-language"
}
],
"linkId": "additionalinfo_preferredlanguage",
"text": "Preferred language:",
"required": false,
"answerOption": [
{
"valueCoding": {
"code": "en",
"display": "English"
}
},
{
"valueCoding": {
"code": "fr",
"display": "French"
}
},
{
"valueCoding": {
"display": "Other"
}
}
]
},
{
"item": [
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "additionalinfo_bestmethodofcontact_voicemails",
"text": "Voicemails acceptable",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<p style=\"display:none;\"></p>"
}
]
},
"enableWhen": [
{
"question": "additionalinfo_bestmethodofcontact",
"operator": "=",
"answerCoding": {
"system": "http://hl7.org/fhir/contact-point-use",
"code": "mobile",
"display": "Mobile"
}
}
],
"enableBehavior": "any",
"repeats": true,
"answerOption": [
{
"valueCoding": {
"display": "Voicemails acceptable"
}
}
]
}
],
"type": "choice",
"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"
}
]
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/preferredTerminologyServer",
"valueUrl": "http://hl7.org/fhir/ValueSet/contact-point-system"
}
],
"linkId": "additionalinfo_bestmethodofcontact",
"text": "Best method of contact:",
"answerOption": [
{
"valueCoding": {
"system": "http://hl7.org/fhir/contact-point-use",
"code": "mobile",
"display": "Mobile"
}
},
{
"valueCoding": {
"system": "http://hl7.org/fhir/contact-point-use",
"code": "home",
"display": "Home"
}
},
{
"valueCoding": {
"system": "http://hl7.org/fhir/contact-point-use",
"code": "work",
"display": "Work"
}
},
{
"valueCoding": {
"system": "http://hl7.org/fhir/contact-point-system",
"code": "email",
"display": "Email"
}
}
]
},
{
"type": "choice",
"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"
}
]
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/preferredTerminologyServer",
"valueUrl": "https://fhir.infoway-inforoute.ca/ValueSet/sharedyesnounknown"
}
],
"linkId": "additionalinfo_alternatecontact_select",
"text": "Alternate contact",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<p style=\"display:none;\"></p>"
}
]
},
"repeats": true,
"answerOption": [
{
"valueCoding": {
"system": "http://terminology.hl7.org/CodeSystem/v2-0532",
"code": "Y",
"display": "Alternate contact"
}
}
]
},
{
"type": "string",
"linkId": "additionalinfo_alternatecontact_name",
"text": "Name:",
"enableWhen": [
{
"question": "additionalinfo_alternatecontact_select",
"operator": "=",
"answerCoding": {
"system": "http://terminology.hl7.org/CodeSystem/v2-0532",
"code": "Y",
"display": "Alternate contact"
}
}
],
"enableBehavior": "all",
"required": true
},
{
"type": "string",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/regex",
"valueString": "^(\\+\\d{1,2}\\s?)?\\(?\\d{3}\\)?[\\s.-]?\\d{3}[\\s.-]?\\d{4}[%content%]quot;
}
],
"linkId": "additionalinfo_alternatecontact_phone",
"text": "Alternate contact phone #:",
"enableWhen": [
{
"question": "additionalinfo_alternatecontact_select",
"operator": "=",
"answerCoding": {
"system": "http://terminology.hl7.org/CodeSystem/v2-0532",
"code": "Y",
"display": "Alternate contact"
}
}
],
"enableBehavior": "all"
},
{
"type": "string",
"linkId": "additionalinfo_alternatecontact_relationship",
"text": "Relationship:",
"enableWhen": [
{
"question": "additionalinfo_alternatecontact_select",
"operator": "=",
"answerCoding": {
"system": "http://terminology.hl7.org/CodeSystem/v2-0532",
"code": "Y",
"display": "Alternate contact"
}
}
],
"enableBehavior": "all"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "additionalinfo_alternatecontact_bookingcontact",
"text": "Is Alternate contact the appointment booking contact?:",
"enableWhen": [
{
"question": "additionalinfo_alternatecontact_select",
"operator": "=",
"answerCoding": {
"display": "Alternate contact"
}
}
],
"enableBehavior": "all",
"answerOption": [
{
"valueCoding": {
"display": "Yes"
}
},
{
"valueCoding": {
"display": "No"
}
}
]
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "additionalinfo_unsafecontacts_select",
"text": "Unsafe contact persons (do not speak with)",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<p style=\"display:none;\"></p>"
}
]
},
"repeats": true,
"answerOption": [
{
"valueCoding": {
"display": "Unsafe contact persons (do not speak with)"
}
}
]
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "additionalinfo_unsafecontacts_speakwithpatientdirectly",
"text": "Only speak with patient directly",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<p style=\"display:none;\"></p>"
}
]
},
"enableWhen": [
{
"question": "additionalinfo_unsafecontacts_select",
"operator": "=",
"answerCoding": {
"display": "Unsafe contact persons (do not speak with)"
}
}
],
"enableBehavior": "all",
"repeats": true,
"answerOption": [
{
"valueCoding": {
"display": "Only speak with patient directly"
}
}
]
},
{
"type": "string",
"linkId": "additionalinfo_unsafecontacts_donotspeakwith",
"text": "Do not speak with:",
"enableWhen": [
{
"question": "additionalinfo_unsafecontacts_select",
"operator": "=",
"answerCoding": {
"display": "Unsafe contact persons (do not speak with)"
}
}
],
"enableBehavior": "all"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "additionalinfo_accessibilityconcernsordisability_select",
"text": "Accessibility concerns or disability",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<p style=\"display:none;\"></p>"
}
]
},
"repeats": true,
"answerOption": [
{
"valueCoding": {
"display": "Accessibility concerns or disability"
}
}
]
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "additionalinfo_accessibilityconcernsordisability",
"text": "Accessibility concerns Options",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<br>"
}
]
},
"enableWhen": [
{
"question": "additionalinfo_accessibilityconcernsordisability_select",
"operator": "=",
"answerCoding": {
"display": "Accessibility concerns or disability"
}
}
],
"repeats": true,
"answerOption": [
{
"valueCoding": {
"display": "Falls risk"
}
},
{
"valueCoding": {
"display": "Patient requires lift"
}
},
{
"valueCoding": {
"display": "Wheelchair"
}
},
{
"valueCoding": {
"display": "Hearing impaired"
}
}
]
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "additionalinfo_specialconsiderations_select",
"text": "Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<p style=\"display:none;\"></p>"
}
]
},
"repeats": true,
"answerOption": [
{
"valueCoding": {
"display": "Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)"
}
}
]
},
{
"type": "text",
"linkId": "additionalinfo_specialconsiderations",
"text": "Details of special considerations:",
"enableWhen": [
{
"question": "additionalinfo_specialconsiderations_select",
"operator": "=",
"answerCoding": {
"display": "Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)"
}
}
]
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "additionalinfo_sendcopiestoadditionalproviders",
"text": "Send copies of reports to additional providers",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<p style=\"display:none;\"></p>"
}
]
},
"repeats": true,
"answerOption": [
{
"valueCoding": {
"display": "Send copies of reports to additional providers"
}
}
]
},
{
"item": [
{
"type": "string",
"linkId": "additionalinfo_sendcopiestoadditionalproviders_contactinfo",
"text": "Contact information:",
"enableWhen": [
{
"question": "additionalinfo_sendcopiestoadditionalproviders",
"operator": "=",
"answerCoding": {
"display": "Send copies of reports to additional providers"
}
}
],
"enableBehavior": "all",
"required": true
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "additionalinfo_sendcopiestoadditionalproviders_ispcp",
"text": "This is the Primary Care Provider",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<p style=\"display:none;\"></p>"
}
]
},
"enableWhen": [
{
"question": "additionalinfo_sendcopiestoadditionalproviders",
"operator": "=",
"answerCoding": {
"display": "Send copies of reports to additional providers"
}
}
],
"enableBehavior": "all",
"repeats": true,
"answerOption": [
{
"valueCoding": {
"display": "This is the Primary Care Provider"
}
}
]
}
],
"type": "string",
"linkId": "additionalinfo_sendcopiestoadditionalproviders_names",
"text": "Name(s):",
"enableWhen": [
{
"question": "additionalinfo_sendcopiestoadditionalproviders",
"operator": "=",
"answerCoding": {
"display": "Send copies of reports to additional providers"
}
}
],
"enableBehavior": "all",
"required": true
}
],
"type": "group",
"linkId": "additionalinfo_header",
"text": "[Optional] Additional Patient Information",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<p><strong>[Optional] Additional Patient Information</strong></p>"
}
]
}
},
{
"item": [
{
"type": "group",
"linkId": "552020330847",
"text": "Triage Considerations",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<p><strong>Triage Considerations</strong></p>"
}
]
},
"item": [
{
"item": [
{
"type": "string",
"linkId": "referral_requestedpriority_urgentreason",
"text": "Reason for urgent triage",
"enableWhen": [
{
"question": "referral_requestedpriority",
"operator": "=",
"answerCoding": {
"display": "Urgent"
}
}
],
"required": true
}
],
"type": "choice",
"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"
}
]
}
}
],
"linkId": "referral_requestedpriority",
"text": "Requested Priority:",
"required": true,
"answerOption": [
{
"valueCoding": {
"display": "Urgent"
}
},
{
"valueCoding": {
"display": "Routine"
},
"initialSelected": true
}
]
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "check-box",
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