| Package | hl7.fhir.us.sdoh-clinicalcare |
| Resource Type | Questionnaire |
| Id | SDOHCC-QuestionnairePRAPARE |
| FHIR Version | R4 |
| Source | http://hl7.org/fhir/us/sdoh-clinicalcare/https://build.fhir.org/ig/HL7/fhir-sdoh-clinicalcare/Questionnaire-SDOHCC-QuestionnairePRAPARE.html |
| URL | http://hl7.org/fhir/us/sdoh-clinicalcare/Questionnaire/SDOHCC-QuestionnairePRAPARE |
| Version | 2.3.0 |
| Status | draft |
| Date | 2021-04-01T04:01:34+00:00 |
| Name | SDOHCCQuestionnairePRAPARE |
| Title | SDOHCC Questionnaire PRAPARE |
| Realm | us |
| Authority | hl7 |
No resources found
No resources found
Note: links and images are rebased to the (stated) source
Generated Narrative: Questionnaire SDOHCC-QuestionnairePRAPARE
Structure| LinkID | Text | Cardinality | Type | Description & Constraints |
|---|---|---|---|---|
  SDOHCCQuestionnairePRAPARE | Questionnaire | http://hl7.org/fhir/us/sdoh-clinicalcare/Questionnaire/SDOHCC-QuestionnairePRAPARE#2.3.0 | ||
  /93025-5 | Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE] | 0..1 | group | |
  /93043-8 | Personal characteristics | 0..1 | group | |
  /93043-8/56051-6 | Hispanic or Latino | 0..1 | choice | Options: 3 options |
| /93043-8/32624-9 | Race | 0..* | choice | Options: 8 options |
| /93043-8/93035-4 | Has season or migrant farm work been your or your family's main source of income at any point in past 2 years? | 0..1 | choice | Options: 3 options |
| /93043-8/93034-7 | Have you been discharged from the armed forces of the United States? | 0..1 | choice | Options: 3 options |
| /93043-8/54899-0 | Preferred language | 0..1 | choice | Options: 3 options |
| /93042-0 | Family and home | 0..1 | group | |
 /93042-0/63512-8 | How many people are living or staying at this address? | 0..1 | integer | |
| /93042-0/71802-3 | Housing status | 0..1 | choice | Options: 3 options |
 /93042-0/71802-3-help | Describes patients living arrangement | 0..1 | display | |
| /93042-0/93033-9 | Are you worried about losing your housing? | 0..1 | choice | Options: 3 options |
 /93042-0/56799-0 | Address | 0..1 | string | |
| /93041-2 | Money and resources | 0..1 | group | |
| /93041-2/82589-3 | Highest level of educ | 0..1 | choice | Options: 4 options |
| /93041-2/67875-5 | Employment status current | 0..1 | choice | Options: 5 options |
| /93041-2/76437-3 | Primary insurance | 0..1 | choice | Options: 7 options |
 /93041-2/63586-2 | What was your best estimate of the total income of all family members from all sources, before taxes, in last year? | 0..1 | decimal | |
| /93041-2/93031-3 | In the past year, have you or any family members you live with been unable to get any of the following when it was really needed? | 0..* | choice | Options: 8 options |
| /93041-2/93030-5 | Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? | 0..* | choice | Options: 4 options |
| /93040-4 | Social and emotional health | 0..1 | group | |
| /93040-4/93029-7 | How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)? | 0..1 | choice | Options: 5 options |
| /93040-4/93038-8 | Stress is when someone feels tense, nervous, anxious or can't sleep at night because their mind is troubled. How stressed are you? | 0..1 | choice | Options: 6 options |
| /93039-6 | Optional additional questions | 0..1 | group | |
| /93039-6/93028-9 | In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility? | 0..1 | choice | Options: 3 options |
| /93039-6/93027-1 | Are you a refugee? | 0..1 | choice | Options: 3 options |
| /93039-6/93026-3 | Do you feel physically and emotionally safe where you currently live? | 0..1 | choice | Options: 4 options |
| /93039-6/76501-6 | Within the last year, have you been afraid of your partner or ex-partner? | 0..1 | choice | Options: 2 options |
| Documentation for this format | ||||
Options Sets
Answer options for /93043-8/56051-6
Answer options for /93043-8/32624-9
Answer options for /93043-8/93035-4
Answer options for /93043-8/93034-7
Answer options for /93043-8/54899-0
Answer options for /93042-0/71802-3
Answer options for /93042-0/93033-9
Answer options for /93041-2/82589-3
Answer options for /93041-2/67875-5
Answer options for /93041-2/76437-3
Answer options for /93041-2/93031-3
Answer options for /93041-2/93030-5
Answer options for /93040-4/93029-7
Answer options for /93040-4/93038-8
Answer options for /93039-6/93028-9
Answer options for /93039-6/93027-1
Answer options for /93039-6/93026-3
Answer options for /93039-6/76501-6
FHIR{
"resourceType": "Questionnaire",
"id": "SDOHCC-QuestionnairePRAPARE",
"meta": {
"profile": [
"http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-extr-smap"
]
},
"text": {
"status": "extensions",
"div": "<!-- snip (see above) -->"
},
"extension": [
{
"url": "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-targetStructureMap",
"valueCanonical": "http://hl7.org/fhir/us/sdoh-clinicalcare/StructureMap/SDOHCC-StructureMapPRAPARE"
}
],
"url": "http://hl7.org/fhir/us/sdoh-clinicalcare/Questionnaire/SDOHCC-QuestionnairePRAPARE",
"version": "2.3.0",
"name": "SDOHCCQuestionnairePRAPARE",
"title": "SDOHCC Questionnaire PRAPARE",
"status": "draft",
"subjectType": [
"Patient"
],
"date": "2021-04-01T04:01:34+00:00",
"publisher": "HL7 International / Patient Care",
"contact": [
{
"name": "HL7 International / Patient Care",
"telecom": [
{
"system": "url",
"value": "http://www.hl7.org/Special/committees/patientcare"
},
{
"system": "email",
"value": "patientcare@lists.hl7.org"
}
]
}
],
"jurisdiction": [
{
"coding": [
{
"system": "urn:iso:std:iso:3166",
"code": "US",
"display": "United States of America"
}
]
}
],
"item": [
{
"linkId": "/93025-5",
"code": [
{
"system": "http://loinc.org",
"code": "93025-5",
"display": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]"
}
],
"text": "Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]",
"type": "group",
"required": false,
"item": [
{
"linkId": "/93043-8",
"code": [
{
"system": "http://loinc.org",
"code": "93043-8",
"display": "Personal characteristics [PRAPARE]"
}
],
"text": "Personal characteristics",
"type": "group",
"required": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
],
"text": "Drop down"
}
}
],
"linkId": "/93043-8/56051-6",
"code": [
{
"system": "http://loinc.org",
"code": "56051-6",
"display": "Hispanic or Latino"
}
],
"text": "Hispanic or Latino",
"type": "choice",
"required": false,
"answerOption": [
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA33-6",
"display": "Yes"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA32-8",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30122-8",
"display": "I choose not to answer this question"
}
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
],
"text": "Drop down"
}
}
],
"linkId": "/93043-8/32624-9",
"code": [
{
"system": "http://loinc.org",
"code": "32624-9",
"display": "Race"
}
],
"text": "Race",
"type": "choice",
"required": false,
"repeats": true,
"answerOption": [
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA6156-9",
"display": "Asian"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA14045-1",
"display": "Native Hawaiian"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30187-1",
"display": "Pacific Islander"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA14042-8",
"display": "Black/African American"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA4457-3",
"display": "White"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA4-4",
"display": "American Indian/Alaskan Native"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA46-8",
"display": "Other"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30122-8",
"display": "I choose not to answer this question"
}
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
],
"text": "Drop down"
}
}
],
"linkId": "/93043-8/93035-4",
"code": [
{
"system": "http://loinc.org",
"code": "93035-4",
"display": "Has season or migrant farm work been your or your family's main source of income at any point in past 2 years [PRAPARE]"
}
],
"text": "Has season or migrant farm work been your or your family's main source of income at any point in past 2 years?",
"type": "choice",
"required": false,
"answerOption": [
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA33-6",
"display": "Yes"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA32-8",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30122-8",
"display": "I choose not to answer this question"
}
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
],
"text": "Drop down"
}
}
],
"linkId": "/93043-8/93034-7",
"code": [
{
"system": "http://loinc.org",
"code": "93034-7",
"display": "Discharged from the U.S. Armed Forces"
}
],
"text": "Have you been discharged from the armed forces of the United States?",
"type": "choice",
"required": false,
"answerOption": [
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA33-6",
"display": "Yes"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA32-8",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30122-8",
"display": "I choose not to answer this question"
}
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
],
"text": "Drop down"
}
}
],
"linkId": "/93043-8/54899-0",
"code": [
{
"system": "http://loinc.org",
"code": "54899-0",
"display": "Preferred language"
}
],
"text": "Preferred language",
"type": "choice",
"required": false,
"answerOption": [
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA43-5",
"display": "English"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30188-9",
"display": "Language other than English"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30122-8",
"display": "I choose not to answer this question"
}
}
]
}
]
},
{
"linkId": "/93042-0",
"code": [
{
"system": "http://loinc.org",
"code": "93042-0",
"display": "Family and home [PRAPARE]"
}
],
"text": "Family and home",
"type": "group",
"required": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unit",
"valueCoding": {
"system": "http://unitsofmeasure.org",
"code": "{#}",
"display": "{#}"
}
}
],
"linkId": "/93042-0/63512-8",
"code": [
{
"system": "http://loinc.org",
"code": "63512-8",
"display": "How many people are living or staying at this address [#]"
}
],
"text": "How many people are living or staying at this address?",
"type": "integer",
"required": false
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
],
"text": "Drop down"
}
}
],
"linkId": "/93042-0/71802-3",
"code": [
{
"system": "http://loinc.org",
"code": "71802-3",
"display": "Housing status"
}
],
"text": "Housing status",
"type": "choice",
"required": false,
"answerOption": [
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30189-7",
"display": "I have housing"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30190-5",
"display": "I do not have housing (staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, or in a park)"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30122-8",
"display": "I choose not to answer this question"
}
}
],
"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": "/93042-0/71802-3-help",
"text": "Describes patients living arrangement",
"type": "display"
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
],
"text": "Drop down"
}
}
],
"linkId": "/93042-0/93033-9",
"code": [
{
"system": "http://loinc.org",
"code": "93033-9",
"display": "Are you worried about losing your housing [PRAPARE]"
}
],
"text": "Are you worried about losing your housing?",
"type": "choice",
"required": false,
"answerOption": [
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA33-6",
"display": "Yes"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA32-8",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30122-8",
"display": "I choose not to answer this question"
}
}
]
},
{
"linkId": "/93042-0/56799-0",
"code": [
{
"system": "http://loinc.org",
"code": "56799-0",
"display": "Address"
}
],
"text": "Address",
"type": "string",
"required": false
}
]
},
{
"linkId": "/93041-2",
"code": [
{
"system": "http://loinc.org",
"code": "93041-2",
"display": "Money and resources [PRAPARE]"
}
],
"text": "Money and resources",
"type": "group",
"required": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
],
"text": "Drop down"
}
}
],
"linkId": "/93041-2/82589-3",
"code": [
{
"system": "http://loinc.org",
"code": "82589-3",
"display": "Highest level of educ"
}
],
"text": "Highest level of educ",
"type": "choice",
"required": false,
"answerOption": [
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30191-3",
"display": "Less than high school degree"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30192-1",
"display": "High school diploma or GED"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30193-9",
"display": "More than high school"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30122-8",
"display": "I choose not to answer this question"
}
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
],
"text": "Drop down"
}
}
],
"linkId": "/93041-2/67875-5",
"code": [
{
"system": "http://loinc.org",
"code": "67875-5",
"display": "Employment status current"
}
],
"text": "Employment status current",
"type": "choice",
"required": false,
"answerOption": [
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA17956-6",
"display": "Unemployed"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30138-4",
"display": "Part-time or temporary work"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30136-8",
"display": "Full-time work"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30137-6",
"display": "Otherwise unemployed but not seeking work (ex: student, retired, disabled, unpaid primary care giver)"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30122-8",
"display": "I choose not to answer this question"
}
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
],
"text": "Drop down"
}
}
],
"linkId": "/93041-2/76437-3",
"code": [
{
"system": "http://loinc.org",
"code": "76437-3",
"display": "Primary insurance"
}
],
"text": "Primary insurance",
"type": "choice",
"required": false,
"answerOption": [
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30194-7",
"display": "None/uninsured"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA17849-3",
"display": "Medicaid"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30195-4",
"display": "CHIP Medicaid"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA15652-3",
"display": "Medicare"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30196-2",
"display": "Other public insurance (not CHIP)"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30197-0",
"display": "Other public insurance (CHIP)"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA6350-8",
"display": "Private insurance"
}
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unit",
"valueCoding": {
"system": "http://unitsofmeasure.org",
"code": "/a",
"display": "/a"
}
}
],
"linkId": "/93041-2/63586-2",
"code": [
{
"system": "http://loinc.org",
"code": "63586-2",
"display": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year [PhenX]"
}
],
"text": "What was your best estimate of the total income of all family members from all sources, before taxes, in last year?",
"type": "decimal",
"required": false
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
],
"text": "Drop down"
}
}
],
"linkId": "/93041-2/93031-3",
"code": [
{
"system": "http://loinc.org",
"code": "93031-3",
"display": "Have you or any family members you live with been unable to get any of the following when it was really needed in past 1 year [PRAPARE]"
}
],
"text": "In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?",
"type": "choice",
"required": false,
"repeats": true,
"answerOption": [
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30125-1",
"display": "Food"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30126-9",
"display": "Clothing"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30124-4",
"display": "Utilities"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30127-7",
"display": "Child care"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30128-5",
"display": "Medicine or Any Health Care (Medical, Dental, Mental Health, Vision)"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30129-3",
"display": "Phone"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA46-8",
"display": "Other"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30122-8",
"display": "I choose not to answer this question"
}
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
],
"text": "Drop down"
}
}
],
"linkId": "/93041-2/93030-5",
"code": [
{
"system": "http://loinc.org",
"code": "93030-5",
"display": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living"
}
],
"text": "Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?",
"type": "choice",
"required": false,
"repeats": true,
"answerOption": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-optionPrefix",
"valueString": "A"
}
],
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30133-5",
"display": "Yes, it has kept me from medical appointments or from getting my medications"
}
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-optionPrefix",
"valueString": "B"
}
],
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30134-3",
"display": "Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need"
}
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-optionPrefix",
"valueString": "C"
}
],
"valueCoding": {
"system": "http://loinc.org",
"code": "LA32-8",
"display": "No"
}
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-optionPrefix",
"valueString": "X"
}
],
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30257-2",
"display": "Patient unable to respond"
}
}
]
}
]
},
{
"linkId": "/93040-4",
"code": [
{
"system": "http://loinc.org",
"code": "93040-4",
"display": "Social and emotional health [PRAPARE]"
}
],
"text": "Social and emotional health",
"type": "group",
"required": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
],
"text": "Drop down"
}
}
],
"linkId": "/93040-4/93029-7",
"code": [
{
"system": "http://loinc.org",
"code": "93029-7",
"display": "How often do you see or talk to people that you care about and feel close to [PRAPARE]"
}
],
"text": "How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?",
"type": "choice",
"required": false,
"answerOption": [
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA27722-0",
"display": "Less than once a week"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30130-1",
"display": "1 or 2 times a week"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30131-9",
"display": "3 to 5 times a week"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30132-7",
"display": "5 or more times a week"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30122-8",
"display": "I choose not to answer this question"
}
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
],
"text": "Drop down"
}
}
],
"linkId": "/93040-4/93038-8",
"code": [
{
"system": "http://loinc.org",
"code": "93038-8",
"display": "Stress level"
}
],
"text": "Stress is when someone feels tense, nervous, anxious or can't sleep at night because their mind is troubled. How stressed are you?",
"type": "choice",
"required": false,
"answerOption": [
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA6568-5",
"display": "Not at all"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA13863-8",
"display": "A little bit"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA13909-9",
"display": "Somewhat"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA13902-4",
"display": "Quite a bit"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA13914-9",
"display": "Very much"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30122-8",
"display": "I choose not to answer this question"
}
}
]
}
]
},
{
"linkId": "/93039-6",
"code": [
{
"system": "http://loinc.org",
"code": "93039-6",
"display": "Optional additional questions [PRAPARE]"
}
],
"text": "Optional additional questions",
"type": "group",
"required": false,
"item": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
],
"text": "Drop down"
}
}
],
"linkId": "/93039-6/93028-9",
"code": [
{
"system": "http://loinc.org",
"code": "93028-9",
"display": "Have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility in past 1 year [PRAPARE]"
}
],
"text": "In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?",
"type": "choice",
"required": false,
"answerOption": [
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA33-6",
"display": "Yes"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA32-8",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30122-8",
"display": "I choose not to answer this question"
}
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
],
"text": "Drop down"
}
}
],
"linkId": "/93039-6/93027-1",
"code": [
{
"system": "http://loinc.org",
"code": "93027-1",
"display": "Are you a refugee"
}
],
"text": "Are you a refugee?",
"type": "choice",
"required": false,
"answerOption": [
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA33-6",
"display": "Yes"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA32-8",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30122-8",
"display": "I choose not to answer this question"
}
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
],
"text": "Drop down"
}
}
],
"linkId": "/93039-6/93026-3",
"code": [
{
"system": "http://loinc.org",
"code": "93026-3",
"display": "Do you feel physically and emotionally safe where you currently live [PRAPARE]"
}
],
"text": "Do you feel physically and emotionally safe where you currently live?",
"type": "choice",
"required": false,
"answerOption": [
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA33-6",
"display": "Yes"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA32-8",
"display": "No"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA14072-5",
"display": "Unsure"
}
},
{
"valueCoding": {
"system": "http://loinc.org",
"code": "LA30122-8",
"display": "I choose not to answer this question"
}
}
]
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
"valueCodeableConcept": {
"coding": [
{
"system": "http://hl7.org/fhir/questionnaire-item-control",
"code": "drop-down",
"display": "Drop down"
}
],
"text": "Drop down"
}
}
],
"linkId": "/93039-6/76501-6",
"code": [
{
"system": "http://loinc.org",
"code": "76501-6",
"display": "Within the last year, have you been afraid of your partner or ex-partner"
}
],
"text": "Within the last year, have you been afraid of your partner or ex-partner?",
"type": "choice",
"required": false,
"answerOption": [
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-optionPrefix",
"valueString": "1"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/itemWeight",
"valueDecimal": 1
}
],
"valueCoding": {
"system": "http://loinc.org",
"code": "LA33-6",
"display": "Yes"
}
},
{
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/questionnaire-optionPrefix",
"valueString": "0"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/itemWeight",
"valueDecimal": 0
}
],
"valueCoding": {
"system": "http://loinc.org",
"code": "LA32-8",
"display": "No"
}
}
]
}
]
}
]
}
]
}