FHIR IG analytics| Package | ca.on.oh-eforms |
| Resource Type | QuestionnaireResponse |
| Id | Universal_Questionnaire-1.json |
| FHIR Version | R4 |
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FHIR
FHIRsmith{
"resourceType": "QuestionnaireResponse",
"id": "Universal-QR",
"text": {
"status": "generated",
"div": "<!-- snip (see above) -->"
},
"questionnaire": "urn:uuid:1b12e576-c039-4395-ad20-2d7e8633fe70|1.1.0",
"status": "completed",
"subject": {
"reference": "Patient/pat-53234",
"display": "MOMO ABBAS"
},
"authored": "2026-01-08T19:01:48.738Z",
"author": {
"reference": "Practitioner/smart-Practitioner-71482713",
"type": "Practitioner",
"display": "Susan Clark"
},
"item": [
{
"linkId": "patient_header",
"text": "Patient Information",
"item": [
{
"linkId": "patient_surname",
"text": "Surname:",
"answer": [
{
"valueString": "Patel"
}
]
},
{
"linkId": "patient_firstname",
"text": "First Name:",
"answer": [
{
"valueString": "Alisha"
}
]
},
{
"linkId": "patient_date_of_birth",
"text": "DOB:",
"answer": [
{
"valueDate": "1987-04-12"
}
]
},
{
"linkId": "patient_gender",
"text": "Gender:",
"answer": [
{
"valueCoding": {
"system": "http://hl7.org/fhir/administrative-gender",
"code": "female",
"display": "Female"
}
}
]
},
{
"linkId": "patient_hc_number",
"text": "HN:",
"answer": [
{
"valueString": "1234567890"
}
]
},
{
"linkId": "patient_hc_vc",
"text": "HN VC:",
"answer": [
{
"valueString": "AB"
}
]
},
{
"linkId": "patient_address_line1",
"text": "Address (Line 1):",
"answer": [
{
"valueString": "2453 Dundas St W"
}
]
},
{
"linkId": "patient_address_line2",
"text": "Address (Line 2):",
"answer": [
{
"valueString": "Apt 708"
}
]
},
{
"linkId": "patient_address_city",
"text": "City:",
"answer": [
{
"valueString": "Toronto"
}
]
},
{
"linkId": "patient_address_province",
"text": "Province:",
"answer": [
{
"valueString": "ON"
}
]
},
{
"linkId": "patient_address_postalcode",
"text": "Postal Code:",
"answer": [
{
"valueString": "M6P 1X3"
}
]
},
{
"linkId": "patient_phone_mobile",
"text": "Mobile #:",
"answer": [
{
"valueString": "416-555-0198"
}
]
},
{
"linkId": "patient_phone_home",
"text": "Home #:",
"answer": [
{
"valueString": "416-555-0131"
}
]
},
{
"linkId": "patient_email",
"text": "Email:",
"answer": [
{
"valueString": "alisha.patel87@example.com"
}
]
}
]
},
{
"linkId": "additionalinfo_header",
"text": "[Optional] Additional Patient Information",
"item": [
{
"linkId": "additionalinfo_sexassignedatbirth",
"text": "Sex assigned at birth:",
"answer": [
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA3-6",
"display": "Female"
}
}
]
},
{
"linkId": "additionalinfo_pronouns",
"text": "Pronouns:",
"answer": [
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA29519-8",
"display": "She/Her"
}
}
]
},
{
"linkId": "additionalinfo_preferredlanguage",
"text": "Preferred language:",
"answer": [
{
"valueCoding": {
"display": "Other"
}
}
]
},
{
"linkId": "additionalinfo_preferredlanguage_specify",
"text": "Specify:",
"answer": [
{
"valueString": "Urdu"
}
]
},
{
"linkId": "additionalinfo_preferredlanguage_translatorrequired",
"text": "Translator required",
"answer": [
{
"valueCoding": {
"display": "Translator Required"
}
}
]
},
{
"linkId": "additionalinfo_bestmethodofcontact",
"text": "Best method of contact:",
"answer": [
{
"valueCoding": {
"system": "http://hl7.org/fhir/contact-point-system",
"code": "phone",
"display": "Mobile"
}
}
]
},
{
"linkId": "additionalinfo_bestmethodofcontact_voicemails",
"text": "Voicemails acceptable",
"answer": [
{
"valueCoding": {
"display": " Voicemails acceptable"
}
}
]
},
{
"linkId": "additionalinfo_alternatecontact_select",
"text": "Alternate contact",
"answer": [
{
"valueCoding": {
"display": "Alternate contact"
}
}
]
},
{
"linkId": "additionalinfo_alternatecontact_name",
"text": "Name:",
"answer": [
{
"valueString": "Imran Patel"
}
]
},
{
"linkId": "additionalinfo_alternatecontact_phone",
"text": "Alternate contact phone #:",
"answer": [
{
"valueString": "416-555-0144"
}
]
},
{
"linkId": "additionalinfo_alternatecontact_relationship",
"text": "Relationship:",
"answer": [
{
"valueString": "Spouse"
}
]
},
{
"linkId": "additionalinfo_alternatecontact_bookingcontact",
"text": "Is Alternate contact the appointment booking contact?:",
"answer": [
{
"valueCoding": {
"display": "Yes"
}
}
]
},
{
"linkId": "additionalinfo_accessibilityconcernsordisability_selectt",
"text": "Accessibility concerns or disability",
"answer": [
{
"valueCoding": {
"display": "Accessibility concerns or disability"
}
}
]
},
{
"linkId": "additionalinfo_accessibilityconcernsordisability",
"text": "Accessibility concerns Options",
"answer": [
{
"valueCoding": {
"system": "http://snomed.info/sct",
"code": "105503008",
"display": "Wheelchair"
}
}
]
},
{
"linkId": "additionalinfo_specialconsiderations_select",
"text": "Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)",
"answer": [
{
"valueCoding": {
"display": "Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)"
}
}
]
},
{
"linkId": "additionalinfo_specialconsiderations",
"text": "Details of special considerations:",
"answer": [
{
"valueString": "Patient has significant anxiety in medical settings. Please explain steps in advance; prefers a quiet waiting area when possible."
}
]
},
{
"linkId": "additionalinfo_sendcopiestoadditionalproviders",
"text": "Send copies of reports to additional providers",
"answer": [
{
"valueCoding": {
"display": "Send copies of reports to additional providers"
}
}
]
},
{
"linkId": "additionalinfo_sendcopiestoadditionalproviders_names",
"text": "Name(s):",
"answer": [
{
"valueString": "Dr. Farah Alvi (Endocrinology)"
}
]
},
{
"linkId": "additionalinfo_sendcopiestoadditionalproviders_contactinfo",
"text": "Contact information:",
"answer": [
{
"valueString": "Fax 416-555-0187"
}
]
}
]
},
{
"linkId": "274716928898",
"text": "Referral Details",
"item": [
{
"linkId": "836886186557",
"text": "Triage Considerations",
"item": [
{
"linkId": "referral_requestedpriority",
"text": "Requested Priority:",
"answer": [
{
"valueCoding": {
"system": "http://hl7.org/fhir/request-priority",
"code": "urgent",
"display": "Urgent"
}
}
]
},
{
"linkId": "referral_requestedpriority_urgentreason",
"text": "Reason for urgent triage:",
"answer": [
{
"valueString": "Progressive exertional chest tightness with reduced exercise tolerance over the past 3 weeks."
}
]
}
]
},
{
"linkId": "200848944281",
"text": "Name of the suspected diagnosis/problem triggering referral:",
"answer": [
{
"valueString": "New exertional chest tightness; rule out stable angina / ischemic heart disease."
}
]
},
{
"linkId": "602158378622",
"text": "Brief Description of Referral, History, Management, and Investigations",
"answer": [
{
"valueString": "38F with 3-month history of exertional substernal chest tightness when climbing stairs, relieved by rest in 3–5 minutes. No syncope. Occasional palpitations. Risk factors: type 2 diabetes (A1c 7.6%), hypertension, dyslipidemia, strong family history (father MI at 52). Vitals today: BP 146/92, HR 82. Physical exam unremarkable. Baseline ECG in clinic: normal sinus rhythm, no acute ischemic changes. Started ASA 81 mg daily and optimized statin (rosuvastatin 20 mg)."
}
]
}
]
},
{
"linkId": "preferredconsultlocation_header",
"text": "Preferred Consultant or Location All patients will be triaged to the shortest wait time unless a preferred consultant or location is entered.",
"item": [
{
"linkId": "preferredconsultlocation_selector",
"text": "Preferred consultant or location",
"answer": [
{
"valueCoding": {
"display": "Preferred consultant or location"
}
}
]
},
{
"linkId": "preferredconsultlocation_specify",
"text": "Please specify either a preferred consultant or location",
"item": [
{
"linkId": "preferredconsultlocation_consultant",
"text": "Consultant:",
"answer": [
{
"valueString": "Dr. Samantha Chen"
}
]
},
{
"linkId": "preferredconsultlocation_location",
"text": "Location:",
"answer": [
{
"valueString": "Toronto General Hospital – Cardiology Clinic"
}
]
}
]
},
{
"linkId": "preferredconsultlocation_willingtotravel",
"text": "Patient willing to travel for shorter wait time",
"answer": [
{
"valueCoding": {
"display": "Patient willing to travel for shorter wait time"
}
}
]
},
{
"linkId": "preferredconsultlocation_otherconsiderations",
"text": "Other considerations:",
"answer": [
{
"valueString": "Prefers weekday mornings; relies on translator services."
}
]
}
]
},
{
"linkId": "referrer_header",
"text": "Referrer's Information",
"item": [
{
"linkId": "referrer_sitename",
"text": "Site Name:",
"answer": [
{
"valueString": "Parkdale Family Health Team"
}
]
},
{
"linkId": "referrer_address_line1",
"text": "Address (Line 1):",
"answer": [
{
"valueString": "123 Brock Ave"
}
]
},
{
"linkId": "referrer_address_line2",
"text": "Address (Line 2):",
"answer": [
{
"valueString": "Suite 401"
}
]
},
{
"linkId": "referrer_address_city",
"text": "City:",
"answer": [
{
"valueString": "Toronto"
}
]
},
{
"linkId": "referrer_address_province",
"text": "Province:",
"answer": [
{
"valueString": "ON"
}
]
},
{
"linkId": "referrer_address_postalcode",
"text": "Postal Code:",
"answer": [
{
"valueString": "M6K 2L5"
}
]
},
{
"linkId": "referrer_phone",
"text": "Phone #:",
"answer": [
{
"valueString": "416-555-0101"
}
]
},
{
"linkId": "referrer_fax",
"text": "Fax #:",
"answer": [
{
"valueString": "416-555-0102"
}
]
},
{
"linkId": "referrer_professionalid",
"text": "Professional ID:",
"answer": [
{
"valueInteger": 7654321
}
]
},
{
"linkId": "referrer_signature",
"text": "Signed:",
"answer": [
{
"valueString": "Dr. Nadia Rahman, MD CCFP"
}
]
},
{
"linkId": "referrer_role",
"text": "Role:",
"answer": [
{
"valueCoding": {
"system": "http://snomed.info/sct",
"code": "449161006",
"display": "Physician Assistant"
}
}
]
}
]
}
]
}