FHIR IG analytics| Package | ca.on.oh.setp.iar.dev |
| Resource Type | Questionnaire |
| Id | Questionnaire-iar-interrai-chymh-screener-v.2.0.0-oh.json |
| FHIR Version | R4 |
| Source | https://simplifier.net/resolve?scope=ca.on.oh.setp.iar.dev@1.0.0-ballot1-dev&canonical=http://ontariohealth.ca/fhir/iar/Questionnaire/oh-interrai-child-and-youth-mental-health-screener |
| URL | http://ontariohealth.ca/fhir/iar/Questionnaire/oh-interrai-child-and-youth-mental-health-screener |
| Version | 9.3.0_OH |
| Status | active |
| Date | 2026-02-01T21:47:22.96+00:00 |
| Title | interRAI™ Child and Youth Mental Health - Screener (ChYMH-S) 9.3.0_OH |
| Realm | ca |
| Authority | hl7 |
| Description | This assessment is the interRAI™ Child and Youth Mental Health Screener (ChYMH-S) 9.3.0_OH. The core content of the assessment was developed by interRAI with modifications from OntarioHealth. The FHIR artifact is maintained and published by Ontario Health. |
No resources found
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No narrative content found in resource
FHIR
FHIRsmith{
"resourceType": "Questionnaire",
"id": "oh-interrai-child-and-youth-mental-health-screener",
"language": "en",
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-entryMode",
"valueCode": "random"
}
],
"url": "http://ontariohealth.ca/fhir/iar/Questionnaire/oh-interrai-child-and-youth-mental-health-screener",
"version": "9.3.0_OH",
"title": "interRAI™ Child and Youth Mental Health - Screener (ChYMH-S) 9.3.0_OH",
"_title": {
"extension": [
{
"url": "http://ontariohealth.ca/fhir/eforms/StructureDefinition/core-short-string",
"valueString": "interRAIChYMHS 9.3.0_OH"
}
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},
"description": "This assessment is the interRAI™ Child and Youth Mental Health Screener (ChYMH-S) 9.3.0_OH. The core content of the assessment was developed by interRAI with modifications from OntarioHealth. The FHIR artifact is maintained and published by Ontario Health.",
"_description": {
"extension": [
{
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"valueString": "interRAI™ Child and Youth Mental Health Screener (ChYMH-S) 9.3.0_OH"
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},
"status": "active",
"experimental": false,
"date": "2026-02-01T21:47:22.96+00:00",
"publisher": "Ontario Health",
"approvalDate": "2026-01-09",
"effectivePeriod": {
"start": "2026-10-01"
},
"subjectType": [
"Patient"
],
"code": [
{
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"code": "interRAIChYMHS",
"display": "interRAI™ Child and Youth Mental Health Screener"
}
],
"item": [
{
"linkId": "A",
"text": "Section A: Identification Information",
"type": "group",
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"item": [
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"linkId": "A1",
"text": "1. NAME",
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"text": "(First)",
"prefix": "a."
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{
"type": "string",
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"text": "(Middle)",
"prefix": "b."
},
{
"type": "string",
"linkId": "A1c",
"text": "(Last)",
"prefix": "c."
},
{
"type": "string",
"linkId": "A1d",
"text": "(Jr./Sr.)",
"prefix": "d."
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},
{
"linkId": "A2",
"text": "2. SEX/GENDER IDENTITY",
"type": "group",
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"linkId": "A2a",
"text": "Sex",
"prefix": "a.",
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"type": "choice",
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"linkId": "A2b",
"text": "Gender Identity",
"prefix": "b.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/gender-identity"
},
{
"type": "string",
"linkId": "A2c",
"maxLength": 25,
"text": "Young person self-identifies gender as - Enter up to 25 characters. Do not include any names (full or partial) or the young person’s Health Care Identification Number or date of birth.",
"prefix": "c."
}
]
},
{
"type": "date",
"extension": [
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"url": "http://hl7.org/fhir/StructureDefinition/entryFormat",
"valueString": "yyyy/MM/dd"
}
],
"linkId": "A3",
"text": "BIRTHDATE",
"prefix": "3."
},
{
"linkId": "A4",
"text": "4. NUMERIC IDENTIFIERS",
"type": "group",
"item": [
{
"type": "string",
"linkId": "A4a",
"text": "Health Care Identifcation Number",
"prefix": "a."
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{
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"linkId": "A4b",
"text": "Province or Territory Issuing Health Care Identifcation Number",
"prefix": "b.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/issuing-jurisdiction"
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{
"type": "string",
"linkId": "A4c",
"text": "Case Record Number",
"prefix": "c."
}
]
},
{
"type": "string",
"linkId": "A5",
"maxLength": 11,
"text": "AGENCY IDENTIFIER [EXAMPLE - CANADA]",
"prefix": "5."
},
{
"type": "date",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/entryFormat",
"valueString": "yyyy/MM/dd"
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],
"linkId": "A6",
"text": "ASSESSMENT REFERENCE DATE",
"prefix": "6."
},
{
"type": "choice",
"extension": [
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],
"linkId": "A7",
"text": "PRIMARY LANGUAGE [EXAMPLE – CANADA]",
"prefix": "7.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/languages"
},
{
"type": "string",
"linkId": "A8",
"text": "INTERPRETER NEEDED – For child / youth",
"prefix": "8."
},
{
"type": "choice",
"extension": [
{
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}
],
"linkId": "A9",
"text": "LEGAL GUARDIANSHIP [EXAMPLE – CANADA]",
"prefix": "9.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/legal-guardianship"
},
{
"type": "choice",
"extension": [
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}
],
"linkId": "A10",
"text": "LIVING ARRANGEMENT",
"prefix": "10.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-living-arrangement1"
},
{
"type": "string",
"linkId": "A11",
"text": "POSTAL CODE OF USUAL LIVING ARRANGEMENT [EXAMPLE CANADA]",
"prefix": "11.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/postal-code"
},
{
"type": "choice",
"extension": [
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}
],
"linkId": "A12",
"text": "INTELLECTUAL DISABILITY - e.g., Down syndrome",
"prefix": "12.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "choice",
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],
"linkId": "A13",
"text": "CHILD / YOUTH HAS SERIOUS COMORBID MEDICAL CONDITION - e.g., cerebral palsy, diabetes",
"prefix": "13.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
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"type": "choice",
"extension": [
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}
}
],
"linkId": "A14",
"text": "TIME SINCE LAST CONTACT WITH COMMUNITY MENTAL HEALTH AGENCY OR PROFESSIONAL IN LAST YEAR - e.g., psychiatrist, social worker",
"prefix": "14.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-since-last-contact"
},
{
"type": "string",
"linkId": "A15",
"text": "REASONS FOR REFERRAL / PRESENTATION",
"prefix": "15."
},
{
"linkId": "A16",
"text": "16. ACCESS ARRANGEMENT [EXAMPLE-CANADA]",
"type": "group",
"item": [
{
"linkId": "A16a",
"text": "a. Relationship to child/youth",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
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]
}
}
],
"linkId": "A16a1",
"text": "Relationship to child/youth - Parent 1",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/chymh-relationship"
},
{
"type": "choice",
"extension": [
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"valueCodeableConcept": {
"coding": [
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"code": "drop-down",
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]
}
}
],
"linkId": "A16a2",
"text": "Relationship to child/youth - Parent 2",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/chymh-relationship"
}
]
},
{
"linkId": "A16b",
"text": "b. Parent lives with child/youth",
"type": "group",
"item": [
{
"type": "choice",
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}
}
],
"linkId": "A16b1",
"text": "Parent lives with child/youth - Parent 1",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/parent-lives-with-child-youth"
},
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"type": "choice",
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]
}
}
],
"linkId": "A16b2",
"text": "Parent lives with child/youth - Parent 2",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/parent-lives-with-child-youth"
}
]
}
]
},
{
"linkId": "A18",
"text": "18. Indigenous Identity",
"type": "group",
"item": [
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"type": "choice",
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],
"linkId": "A18a",
"text": "First Nations",
"prefix": "a.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/indigenous-identity"
},
{
"type": "choice",
"extension": [
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],
"linkId": "A18b",
"text": "Metis",
"prefix": "b.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/indigenous-identity"
},
{
"type": "choice",
"extension": [
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"valueCodeableConcept": {
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],
"linkId": "A18c",
"text": "Inuit",
"prefix": "c.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/indigenous-identity"
}
]
},
{
"type": "choice",
"extension": [
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],
"linkId": "A19",
"text": "Ethnicty and Race",
"prefix": "19.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/ethnicity-race"
}
]
},
{
"linkId": "B",
"text": "Section B: Mental State indicators",
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"_text": {
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"valueString": "<b>Section B: Mental State indicators 1</b>"
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},
"item": [
{
"linkId": "Ba",
"text": "1. MENTAL STATE INDICATORS Code for indicators observed in the last 3 days, irrespective of the assumed cause [Note: Whenever possible, ask child / youth]",
"type": "group",
"item": [
{
"type": "group",
"linkId": "B1",
"text": "Distraction and Hyperactivity",
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],
"linkId": "B1a",
"text": "Impulsive - e.g., running into traffic; takes risky actions without thinking; difficulty taking turns; interrupts",
"prefix": "a.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
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"type": "choice",
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],
"linkId": "B1b",
"text": "Easily distracted - e.g., episodes of difficulty paying attention; gets sidetracked",
"prefix": "b.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"extension": [
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}
],
"linkId": "B1c",
"text": "Hyperactivity - Excessive level of activity",
"prefix": "c.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"extension": [
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],
"linkId": "B1d",
"text": "Disorganization - e.g., problems organizing personal belongings; difficulty adhering to schedule",
"prefix": "d.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
}
]
},
{
"linkId": "B2",
"text": "Mood Distrubance",
"type": "group",
"item": [
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"type": "choice",
"extension": [
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],
"linkId": "B1e",
"text": "Sad, pained, or worried facial expressions - e.g., furrowed brow, constant frowning",
"prefix": "e.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"extension": [
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"valueCodeableConcept": {
"coding": [
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"display": "Drop down"
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}
],
"linkId": "B1f",
"text": "Crying, Tearfulness",
"prefix": "f.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
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"code": "drop-down",
"display": "Drop down"
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]
}
}
],
"linkId": "B1g",
"text": "Made negative statements - e.g., “Nothing matters; No one likes me; I hate my life; Would rather be dead; What’s the use; Let me die”",
"prefix": "g.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"extension": [
{
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"valueCodeableConcept": {
"coding": [
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"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "B1h",
"text": "Self-deprecation - e.g., “I am stupid; I am bad; I can’t do anything right; I am nothing; I am of no use to anyone”",
"prefix": "h.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"extension": [
{
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"valueCodeableConcept": {
"coding": [
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"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "B1i",
"text": "Expressions of guilt or shame - e.g., “I’ve done something awful; This is all my fault; I am a terrible person”",
"prefix": "i.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"extension": [
{
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"valueCodeableConcept": {
"coding": [
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"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "B1j",
"text": "Expressions of hopelessness - e.g., “There’s no hope for the future; Nothing’s going to change for the better”",
"prefix": "j.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"extension": [
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"valueCodeableConcept": {
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"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "B1k",
"text": "Irritability-Marked increase in being short-tempered or easily upset",
"prefix": "k.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"extension": [
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"display": "Drop down"
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]
}
}
],
"linkId": "B1l",
"text": "Labile affect-Affect fluctuates frequently with or without an external explanation",
"prefix": "l.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
}
]
},
{
"linkId": "B3",
"text": "Anxiety",
"type": "group",
"item": [
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "B1m",
"text": "Repetitive anxious complaints/concerns (non-health-related) - e.g., persistently seeks attention/reassurance regarding schedules, school, sports, clothing, relationships",
"prefix": "m.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "B1n",
"text": "Expressions, including non-verbal, of what appear to be unrealistic fears - e.g., fear of being abandoned, being left alone, being with others; intense fear of specific objects or situations",
"prefix": "n.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "B1o",
"text": "Obsessive thoughts - Unwanted ideas or thoughts that cannot be eliminated",
"prefix": "o.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "B1p",
"text": "Compulsive behaviour - e.g., hand washing, repetitive checking of room, counting, hoarding",
"prefix": "p.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "B1q",
"text": "Intrusive thoughts or flashbacks - Disturbing memories or images that intrude into thoughts, unexpected recall of adverse events",
"prefix": "q.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "B1r",
"text": "Episodes of panic - Cascade of symptoms of fear, anxiety, loss of control",
"prefix": "r.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "B1s",
"text": "Nightmares - e.g., reports frightening dreams, wakes from sleep with expressions of fear (including non-verbal)",
"prefix": "s.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "B1t",
"text": "Hypervigilance - “Jumpiness” or feeling as though in danger",
"prefix": "t.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "B1u",
"text": "Converses only in specific social situations - e.g., speaks at home but not at school",
"prefix": "u.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
}
]
},
{
"linkId": "B4",
"text": "Psychosis",
"type": "group",
"item": [
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "B1v",
"text": "Hallucinations - False sensory perception, of any type, with or without insight, without corresponding stimuli (e.g., auditory, visual, tactile, olfactory, gustatory, excluding command hallucinations)",
"prefix": "v.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "B1w",
"text": "Command hallucinations - Hallucinations directing the child / youth to do something or to act in a particular manner (e.g., to harm self or others)",
"prefix": "w.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "B1x",
"text": "Delusions - Fixed false beliefs (e.g., grandiose, paranoid, somatic, excluding beliefs specific to child’s / youth’s culture or religion)",
"prefix": "x.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "B1y",
"text": "Abnormal thought process - e.g., loosening of associations, blocking, fight of ideas, tangentiality, circumstantiality",
"prefix": "y.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
}
]
},
{
"linkId": "B5",
"text": "Negative Symptoms",
"type": "group",
"item": [
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "B1z",
"text": "Lack of Interest in Social Interaction",
"prefix": "z.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "B1aa",
"text": "Lack of motivation - Absence of spontaneous goal-directed activity",
"prefix": "aa.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "B1bb",
"text": "Expressions, including non-verbal, of a lack of pleasure in life (anhedonia) - e.g., “I don’t have fun anymore”; gloomy during favourite activities",
"prefix": "bb.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "B1cc",
"text": "Withdrawal from activities of interest - e.g., long-standing activities, being with family/friends",
"prefix": "cc.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
}
]
},
{
"linkId": "B6",
"text": "Other Indicators",
"type": "group",
"item": [
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "B1dd",
"text": "Hygiene - Unusually poor hygiene, unkempt, dishevelled",
"prefix": "dd.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "B1ee",
"text": "Difficulty falling asleep or staying asleep; waking up too early; restlessness; non-restful sleep",
"prefix": "ee.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
}
]
}
]
}
]
},
{
"linkId": "C",
"text": "Section C: Substance Use OR Excessive Behaviour",
"type": "group",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<b>Section C: Substance Use OR Excessive Behaviour</b>"
}
]
},
"item": [
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "C1",
"text": "Alchohol - Highest number of drinks in any “single sitting” in LAST 14 DAYS",
"prefix": "1.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-of-alcohol-intake"
},
{
"linkId": "C2",
"text": "2. SUBSTANCE USE IN LAST 14 DAYS",
"type": "group",
"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"
}
]
}
}
],
"linkId": "C2a",
"text": "Drug use - Includes both illegal and legal (e.g., inhalants) street",
"prefix": "a.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"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": "C2b",
"text": "Intentional misuse of prescription or over-the-counter medication",
"prefix": "b.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
},
{
"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": "C3",
"text": "ANY INDICATOR OF EATING DISORDER IN LAST 30 DAYS - e.g., binge eating, purging, major restriction of diet",
"prefix": "3.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "C4",
"text": "PROBLEM VIDEO GAMING IN LAST 90 DAYS - Code for disruption caused by child’s / youth’s usual video gaming pattern",
"prefix": "4.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/video-gaming"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "C5",
"text": "PROBLEM INTERNET USE IN LAST 90 DAYS - Code for disruption caused by child’s/youth’s usual pattern of Internet use",
"prefix": "5.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/internet-usage-problems"
}
]
},
{
"linkId": "D",
"text": "Section D: Harm to Self and Others",
"type": "group",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<b>Section D: Harm to Self and Others</b>"
}
]
},
"item": [
{
"linkId": "D1",
"text": "1. SELF-INJURIOUS IDEATION OR ATTEMPT",
"type": "group",
"item": [
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "D1a",
"text": "Considered Performing Self-Injurious Act",
"prefix": "a.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "D1b",
"text": "Most Recent Self-Injurious Attempt",
"prefix": "b.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
}
]
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "D2",
"text": "Intent of Any Self-Injurious Attempt Was to Kill Self",
"prefix": "2.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-intent-to-kill-self"
},
{
"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": "D3",
"text": "Family/Caregiver/Friend/Staff Express Concern Person at Risk for Self-Injury",
"prefix": "3.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "D4",
"text": "4. VIOLENCE",
"type": "group",
"item": [
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "D4a",
"text": "Violent Ideation - e.g., reports of premeditated thoughts, statements, plans to commit violence",
"prefix": "a.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "D4b",
"text": "Cruelty to animals - Deliberate mistreatment of or physical injury to animals - EXCLUDE BEHAVIOURS THAT ARE CONSISTENT WITH CULTURAL NORMS",
"prefix": "b.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "D4c",
"text": "Intimidation of others or threatened violence - Intentionally makes threatening gestures, verbalizations or stance with no physical contact (e.g., throwing furniture, explicit threats)",
"prefix": "c.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "D4d",
"text": "Violence to Others - Acts with purposeful, malicious, or vicious intent, resulting in physical harm to another (e.g., stabbing, choking, beating)",
"prefix": "d.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
}
]
}
]
},
{
"linkId": "E",
"text": "Section E: Behaviour",
"type": "group",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<b>Section E: Behaviour</b>"
}
]
},
"item": [
{
"linkId": "E1",
"text": "1. BEHAVIOUR SYMPTOMS",
"type": "group",
"item": [
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "E1a",
"text": "Verbal abuse - e.g., others were threatened, cursed at",
"prefix": "a.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "E1b",
"text": "Physical abuse - e.g., others were hit, shoved, scratched",
"prefix": "b.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "E1c",
"text": "Socially inappropriate or disruptive behaviour - e.g., screamed out, smeared or threw food or feces",
"prefix": "c.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "E1d",
"text": "Self-injurious behaviour - e.g., bangs head; pinching, biting, scratching, hitting self; pulling own hair",
"prefix": "d.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "E1e",
"text": "Destructive behaviour toward property - e.g., throwing or breaking objects, turning over beds or tables, vandalism",
"prefix": "e.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-frequency-with-time-period3"
}
]
},
{
"linkId": "E2",
"text": "2. CONDUCT PROBLEMS",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
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"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "E2a",
"text": "Stealing - e.g., theft from family, shoplifting",
"prefix": "a.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "E2b",
"text": "Bullying peers - Pattern of repeated oppression or victimization of others",
"prefix": "b.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "E2c",
"text": "Fire setting or misuse of ignition materials or accelerants",
"prefix": "c.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
}
]
},
{
"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": "E3",
"text": "FAMILY, CAREGIVER, FRIEND, OR STAFF EXPRESS CONCERN ABOUT HIGHLY RISKY OR PROBLEMATIC SEXUAL BEHAVIOUR",
"prefix": "3.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
},
{
"linkId": "F",
"text": "Section F: Cognitive Communication and Development",
"type": "group",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<b>Section F: Cognitive Communication and Development</b>"
}
]
},
"item": [
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "F1",
"text": "COGNITIVE SKILLS FOR DAILY DECISION MAKING - Making decisions regarding tasks of daily life - e.g., when to get up or have meals, which clothes to wear or activities to do",
"prefix": "1.",
"answerValueSet": "http://ontariohealth.ca/fhir/iar/ValueSet/congitive-decision-making"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "F2",
"text": "MAKING SELF UNDERSTOOD (Expression) - Expressing information content - both verbal and nonverbal",
"prefix": "2.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-understanding-self1"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "F3",
"text": "ABILITY TO UNDERSTAND OTHERS (Comprehension) - Understanding verbal information content (however able; with hearing appliance normally used)",
"prefix": "3.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-understanding-other1"
},
{
"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": "F4",
"text": "FAMILY, CAREGIVER, OR STAFF EXPRESS CONCERN ABOUT CHILD/YOUTH’S SELF-CARE ABILITY - e.g., how performs daily hygiene routine, feeds self, uses toilet appropriately",
"prefix": "4.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
},
{
"linkId": "G",
"text": "Section G: Stress, Trauma and Social Relationships",
"type": "group",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<b>Section G: Stress, Trauma and Social Relationships</b>"
}
]
},
"item": [
{
"linkId": "G1",
"text": "1. LIFE EVENTS",
"type": "group",
"item": [
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "G1a",
"text": "Death or loss of parent or primary caregiver",
"prefix": "a.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "G1b",
"text": "Victim of sexual assault or abuse",
"prefix": "b.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "G1c",
"text": "Victim of physical assault or abuse",
"prefix": "c.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "G1d",
"text": "Victim of emotional abuse",
"prefix": "d.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "G1e",
"text": "Victim of bullying",
"prefix": "e.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "G1f",
"text": "Witnessed domestic violence",
"prefix": "f.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "G1g",
"text": "Parental addiction or substance abuse",
"prefix": "g.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period1"
}
]
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "G2",
"text": "DESCRIBES ONE OR MORE OF THESE LIFE EVENTS (ITEM G1) AS INVOKING A SENSE OF HORROR OR INTENSE FEAR",
"prefix": "2.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-or-na-could-not-respond"
},
{
"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": "G3",
"text": "STRONG AND SUPPORTIVE RELATIONSHIP WITH FAMILY",
"prefix": "3.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "G4",
"text": "BELIEF THAT PARENT(S) / PRIMARY CAREGIVER(S) ARE NOT ADEQUATELY ENGAGED IN CHILD’S / YOUTH’S LIFE",
"prefix": "4.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-presence-of-belief"
},
{
"linkId": "G5",
"text": "5. UNSETTLED RELATIONSHIPS",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
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"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "G5a",
"text": "Conflict with or repeated criticism of family",
"prefix": "a.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-not-applicable"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "G5b",
"text": "Family are persistently hostile or critical of child/youth",
"prefix": "b.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-not-applicable"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "G5c",
"text": "Friends are persistently hostile or critical of child/youth",
"prefix": "c.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-not-applicable"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "G5d",
"text": "Pervasive conflict with peers (exclude close friends)",
"prefix": "d.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-not-applicable"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "G5e",
"text": "Family members report feeling overwhelmed by child/youth’s condition - e.g., severe behaviour problems",
"prefix": "e.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-not-applicable"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "G5f",
"text": "Parent/primary caregiver is unable or unwilling to continue in caring activities - e.g., decline in the health of the caregiver makes it difficult to continue; lack of desire; competing responsibilities",
"prefix": "f.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-not-applicable"
}
]
},
{
"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": "G6",
"text": "PARENT/PRIMARY CAREGIVER HAS CURRENT DEVELOPMENTAL OR MENTAL HEALTH ISSUES",
"prefix": "6.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
},
{
"linkId": "H",
"text": "Section H: Education",
"type": "group",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<b>Section H: Education</b>"
}
]
},
"item": [
{
"linkId": "H1",
"text": "1. RISK OF DISRUPTED EDUCATION IN LAST 90 DAYS",
"type": "group",
"item": [
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
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"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "H1a",
"text": "Increase in lateness or absenteeism",
"prefix": "a.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-not-applicable"
},
{
"type": "choice",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
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"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
]
}
}
],
"linkId": "H1b",
"text": "Poor productivity or disruptiveness at school",
"prefix": "b.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-not-applicable"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "H1c",
"text": "Expresses intent to quit school",
"prefix": "c.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-not-applicable"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "H1d",
"text": "Conflict with school staff - e.g., persistent arguing with teachers; threatening principal",
"prefix": "d.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no-not-applicable"
}
]
},
{
"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": "H2",
"text": "CHILD/YOUTH CURRENTLY REMOVED FROM SCHOOL DUE TO DISRUPTIVE BEHAVIOUR - e.g., currently suspended or expelled",
"prefix": "2.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
},
{
"linkId": "I",
"text": "Section I: Summary",
"type": "group",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<b>Section I: Summary</b>"
}
]
},
"item": [
{
"linkId": "I1",
"text": "1. SUMMARY OF RISK - (See manual for a description of coding guidelines)",
"type": "group",
"item": [
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "I1a",
"text": "Danger to self",
"prefix": "a.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-severity-of-risk"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "I1b",
"text": "Danger to others",
"prefix": "b.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-severity-of-risk"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "I1c",
"text": "Abuse by others",
"prefix": "c.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-severity-of-risk"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "I1d",
"text": "Family/placement breakdown",
"prefix": "d.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-severity-of-risk"
}
]
},
{
"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": "I2",
"text": "MENTAL HEALTH SERVICES REQUIRED FOR THIS CHILD/ YOUTH",
"prefix": "2.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"linkId": "I3",
"text": "3. URGENCY - Urgency for comprehensive, face-to-face mental health assessment or for initiation of mental health services",
"type": "group",
"item": [
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "I3a",
"text": "Mental health assessment",
"prefix": "a.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period-in-days1"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "I3b",
"text": "Mental health services",
"prefix": "b.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-time-period-in-days1"
}
]
},
{
"linkId": "I4",
"text": "4. SOURCES OF INFORMATION USED TO COMPLETE CHYMH-S",
"type": "group",
"item": [
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "I4a",
"text": "Client",
"prefix": "a.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "I4b",
"text": "Parent / primary caregiver",
"prefix": "b.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "I4c",
"text": "Other relative",
"prefix": "c.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "I4d",
"text": "Physician",
"prefix": "d.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "I4e",
"text": "Staff at School",
"prefix": "e.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
},
{
"type": "choice",
"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"
}
]
}
}
],
"linkId": "I4f",
"text": "Other",
"prefix": "f.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-source-of-information"
}
]
},
{
"linkId": "I5",
"text": "5. TYPE OF COMMUNICATION USED TO COMPLETE ChYMH-S",
"type": "group",
"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"
}
]
}
}
],
"linkId": "I5a",
"text": "Telephone",
"prefix": "a.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"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": "I5b",
"text": "In person",
"prefix": "b.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
},
{
"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": "5c",
"text": "Fax / written / e-mail",
"prefix": "c.",
"answerValueSet": "http://cihi.ca/fhir/irrs/ValueSet/irrs-yes-no"
}
]
}
]
},
{
"linkId": "J",
"text": "Section J: Assessment Information",
"type": "group",
"_text": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/rendering-xhtml",
"valueString": "<b>Section J: Assessment Information</b>"
}
]
},
"item": [
{
"type": "string",
"linkId": "J1",
"text": "SIGNATURE OF PERSON COORDINATING / COMPLETING THE ASSESSMENT",
"prefix": "1."
},
{
"type": "date",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/entryFormat",
"valueString": "yyyy/MM/dd"
}
],
"linkId": "J2",
"text": "DATE ASSESSMENT SIGNED AS COMPLETE",
"prefix": "2."
},
{
"type": "date",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/entryFormat",
"valueString": "yyyy/MM/dd"
}
],
"linkId": "J3",
"text": "Last Day of Stay",
"prefix": "3."
}
]
}
]
}