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Packageihe.qrph.bfdr
Resource TypeQuestionnaireResponse
IdQuestionnaireResponse-QuestionnaireResponse-mothers-live-birth-jada-quinn.json
FHIR VersionR4

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Narrative

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Generated Narrative: QuestionnaireResponse QuestionnaireResponse-mothers-live-birth-jada-quinn

version: versionId: id (PrimitiveType/QuestionnaireResponse.meta.versionId): element = id -> versionId=id[11]; Last updated: 2023-06-21 21:34:58+0000

LinkIDTextDefinitionAnswerdoco
.. QuestionnaireResponse-mothers-live-birth-jada-quinnQuestionnaire:Questionnaire - Mother's Worksheet for Child's Birth Certificate
... mother-current-legal-nameWhat is your current legal name?
.... mother-first-nameFirstJada
.... mother-middle-nameMiddleAnn
.... mother-last-nameLastQuinn
... child-nameWhat will be your baby's legal name (as it should appear on the birth certificate)?
.... child-first-nameFirstBaby
.... child-middle-nameMiddleG
.... child-last-nameLastQuinn
... mother-addressWhere do you usually live - that is - where is your household/residence located?
.... mother-nbr-streetComplete number and street (do not enter rural route numbers)1875 West Morton Avenue
.... mother-cityCity, Town, or LocationSalt Lake City
.... mother-countyCountySalt Lake
.... mother-stateState (or U.S. Territory, Canadian Province)UT
.... mother-zipZip Code84116
... inside-city-limitsIs this household inside city limits (inside the incorporated limits of the city, town, or location where you live)?expandedYes-NoIndicator Y: Yes
... mother-mailWhat is your mailing address
.... mother-mail-sameSame as residence [Go to next question]false
.... mother-mail-nbr-streetComplete number and street1848 South 1300 East
.... mother-mail-cityCity, Town, or LocationSalt Lake City
.... mother-mail-stateState (or U.S. Territory, Canadian Province)UT
.... mother-mail-zipZip Code84401
... mother-dobWhat is your date of birth?1985-01-15
... mother-birthplaceIn what State, U.S. territory, or foreign country were you born? Please specify one of the following:
.... mother-birthplace-stateStateUT
... mother-educationWhat is the highest level of schooling that you have completed at the time of delivery? (Check the box that best describes your education. If you are currently enrolled, check the box that indicates the previous grade or highest degree received).unknown PHC1455: Doctorate Degree or Professional Degree
... mother-ethnicityAre you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.
.... mother-shlAre you Spanish/Hispanic/LatinaRace & Ethnicity - CDC 2186-5: Not Hispanic or Latino
... mother-raceWhat is your race? (Please check one or more races to indicate what you consider yourself to be).
.... mother-race-categoryRace categoriesRace & Ethnicity - CDC 2106-3: White
.... mother-detailed-raceExtended race codesRace & Ethnicity - CDC 1004-1: American Indian
... receive-wicDid you receive WIC (Women, Infants and Children) food for yourself during this pregnancy?expandedYes-NoIndicator Y: Yes
... infertility-treatmentDid this pregnancy result from infertility treatment? (If yes, please answer 12a and 12b)true
.... drugs-ai-iiIf yes, did this pregnancy result from fertility-enhancing drugs, artificial insemination, or intrauterine insemination?false
.... art-ivf-giftIf yes, did this pregnancy result from assisted reproductive technology (e.g., in-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT))?true
... mothers-heightWhat is your height?
.... mothers-height-feetFeet5 ft (Details: UCUM codeft = 'ft')
.... mothers-height-inchesInches7 [in_i] (Details: UCUM code[in_i] = '[in_i]')
... mothers-prepregnancy-weightlbs145 [lb_av] (Details: UCUM code[lb_av] = '[lb_av]')
... mothers-smokingHow many cigarettes OR packs of cigarettes did you smoke on an average day during each of the following time periods? If you NEVER smoked, enter zero for each time period.
.... mothers-smoking-3-months-priorThree months before pregnancy
..... mothers-smoking-3-months-prior-cig# of cigarettes*0
..... mothers-smoking-3-months-prior-pck# of packs1
.... mothers-smoking-trimester-1First three months of pregnancy
..... mothers-smoking-trimester-1-cig# of cigarettes*3
..... mothers-smoking-trimester-1-pck# of packs0
.... mothers-smoking-trimester-2Second three months of pregnancy
..... mothers-smoking-trimester-2-cig# of cigarettes*1
..... mothers-smoking-trimester-2-pck# of packs0
.... mothers-smoking-trimester-3Third trimester of pregnancy
..... mothers-smoking-trimester-3-cig# of cigarettes*0
..... mothers-smoking-trimester-3-pck# of packs0
... mother-prior-nameWhat name did you use prior to your first marriage?
.... mother-prior-first-nameFirstJada
.... mother-prior-middle-nameMiddleAnn
.... mother-prior-last-nameLastKing
... married-conceptionWere you married at the time you conceived this child, at the time of birth, or at any time between conception and giving birth? [If yes, please go to question 19; If no, please see below]true
... father-current-legal-nameWhat is the current legal name of your baby's father?
.... father-first-nameFirstJames
.... father-middle-nameMiddleBrandon
.... father-last-nameLastQuinn
... father-dobWhat the father's date of birth?1983-09-27
... father-birthplaceIn what State, U.S. territory, or foreign country was the father born? Please specify one of the following:
.... father-birthplace-stateStateNY
... father-educationWhat is the highest level of schooling that the father will have completed at the time of delivery? (Check the box that best describes his education. If he is currently enrolled, check the box that indicates the previous grade or highest degree received).unknown PHC1455: Doctorate Degree or Professional Degree
... father-ethnicityIs the father Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.
.... father-shlIs the father Spanish/Hispanic/LatinaRace & Ethnicity - CDC 2186-5: Not Hispanic or Latino
... father-raceWhat is the father's race? (Please check one or more races to indicate what he considers himself to be).
.... father-race-categoryRace categoriesRace & Ethnicity - CDC 2106-3: White
... parents-ssnFurnishing parent(s) Social Security Number(s) (SSNs) is required by Federal Law, 42 USC 405(c) (section 205(c) of the Social Security Act). The number(s) will be made available to the (State Social Services Agency) to assist with child support enforcement activities and to the Internal Revenue Service for the purpose of determining Earned Income Tax Credit compliance.
.... mother-ssnWhat is your Social Security Number?132-22-5986
.... father-ssnWhat is the father’s Social Security Number? If you are not married, and if a paternity acknowledgment has not been completed, leave this item blank.132-22-5987
... baby-ssnDo you want a Social Security Number issued for your baby? [If yes, please sign request belowfalse
... informant-nameIf other than the mother, what is the name of the person providing information for this worksheet?
.... informant-first-nameFirstJane
.... informant-last-nameLastKing
... informant-relationshipWhat is your relationship to the baby's mother?unknown PHC1497: Other relative

doco Documentation for this format

Source1

{
  "resourceType": "QuestionnaireResponse",
  "id": "QuestionnaireResponse-mothers-live-birth-jada-quinn",
  "meta": {
    "versionId": "11",
    "lastUpdated": "2023-06-21T21:34:58.869Z"
  },
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "questionnaire": "https://profiles.ihe.net/QRPH/bfdr/Questionnaire/Questionnaire-mothers-live-birth",
  "status": "completed",
  "subject": {
    "reference": "Patient/patient-child-babyg-quinn",
    "display": "BabyG Quinn"
  },
  "source": {
    "reference": "Patient/patient-mother-jada-ann-quinn",
    "display": "Patient - Mother (Jada Ann Quinn)"
  },
  "item": [
    {
      "linkId": "mother-current-legal-name",
      "text": "What is your current legal name?",
      "item": [
        {
          "linkId": "mother-first-name",
          "text": "First",
          "answer": [
            {
              "valueString": "Jada"
            }
          ]
        },
        {
          "linkId": "mother-middle-name",
          "text": "Middle",
          "answer": [
            {
              "valueString": "Ann"
            }
          ]
        },
        {
          "linkId": "mother-last-name",
          "text": "Last",
          "answer": [
            {
              "valueString": "Quinn"
            }
          ]
        }
      ]
    },
    {
      "linkId": "child-name",
      "text": "What will be your baby's legal name (as it should appear on the birth certificate)?",
      "item": [
        {
          "linkId": "child-first-name",
          "text": "First",
          "answer": [
            {
              "valueString": "Baby"
            }
          ]
        },
        {
          "linkId": "child-middle-name",
          "text": "Middle",
          "answer": [
            {
              "valueString": "G"
            }
          ]
        },
        {
          "linkId": "child-last-name",
          "text": "Last",
          "answer": [
            {
              "valueString": "Quinn"
            }
          ]
        }
      ]
    },
    {
      "linkId": "mother-address",
      "text": "Where do you usually live - that is - where is your household/residence located?",
      "item": [
        {
          "linkId": "mother-nbr-street",
          "text": "Complete number and street (do not enter rural route numbers)",
          "answer": [
            {
              "valueString": "1875 West Morton Avenue"
            }
          ]
        },
        {
          "linkId": "mother-city",
          "text": "City, Town, or Location",
          "answer": [
            {
              "valueString": "Salt Lake City"
            }
          ]
        },
        {
          "linkId": "mother-county",
          "text": "County",
          "answer": [
            {
              "valueString": "Salt Lake"
            }
          ]
        },
        {
          "linkId": "mother-state",
          "text": "State (or U.S. Territory, Canadian Province)",
          "answer": [
            {
              "valueString": "UT"
            }
          ]
        },
        {
          "linkId": "mother-zip",
          "text": "Zip Code",
          "answer": [
            {
              "valueString": "84116"
            }
          ]
        }
      ]
    },
    {
      "linkId": "inside-city-limits",
      "text": "Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)?",
      "answer": [
        {
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/v2-0532",
            "code": "Y",
            "display": "Yes"
          }
        }
      ]
    },
    {
      "linkId": "mother-mail",
      "text": "What is your mailing address",
      "item": [
        {
          "linkId": "mother-mail-same",
          "text": "Same as residence [Go to next question]",
          "answer": [
            {
              "valueBoolean": false
            }
          ]
        },
        {
          "linkId": "mother-mail-nbr-street",
          "text": "Complete number and street",
          "answer": [
            {
              "valueString": "1848 South 1300 East"
            }
          ]
        },
        {
          "linkId": "mother-mail-city",
          "text": "City, Town, or Location",
          "answer": [
            {
              "valueString": "Salt Lake City"
            }
          ]
        },
        {
          "linkId": "mother-mail-state",
          "text": "State (or U.S. Territory, Canadian Province)",
          "answer": [
            {
              "valueString": "UT"
            }
          ]
        },
        {
          "linkId": "mother-mail-zip",
          "text": "Zip Code",
          "answer": [
            {
              "valueString": "84401"
            }
          ]
        }
      ]
    },
    {
      "linkId": "mother-dob",
      "text": "What is your date of birth?",
      "answer": [
        {
          "valueDate": "1985-01-15"
        }
      ]
    },
    {
      "linkId": "mother-birthplace",
      "text": "In what State, U.S. territory, or foreign country were you born? Please specify one of the following:",
      "item": [
        {
          "linkId": "mother-birthplace-state",
          "text": "State",
          "answer": [
            {
              "valueString": "UT"
            }
          ]
        }
      ]
    },
    {
      "linkId": "mother-education",
      "text": "What is the highest level of schooling that you have completed at the time of delivery? (Check the box that best describes your education. If you are currently enrolled, check the box that indicates the previous grade or highest degree received).",
      "answer": [
        {
          "valueCoding": {
            "system": "urn:oid:2.16.840.1.114222.4.5.274",
            "code": "PHC1455",
            "display": "Doctorate Degree or Professional Degree"
          }
        }
      ]
    },
    {
      "linkId": "mother-ethnicity",
      "text": "Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.",
      "item": [
        {
          "linkId": "mother-shl",
          "text": "Are you Spanish/Hispanic/Latina",
          "answer": [
            {
              "valueCoding": {
                "system": "urn:oid:2.16.840.1.113883.6.238",
                "code": "2186-5",
                "display": "Not Hispanic or Latino"
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "mother-race",
      "text": "What is your race? (Please check one or more races to indicate what you consider yourself to be).",
      "item": [
        {
          "linkId": "mother-race-category",
          "text": "Race categories",
          "answer": [
            {
              "valueCoding": {
                "system": "urn:oid:2.16.840.1.113883.6.238",
                "code": "2106-3",
                "display": "White"
              }
            }
          ]
        },
        {
          "linkId": "mother-detailed-race",
          "text": "Extended race codes",
          "answer": [
            {
              "valueCoding": {
                "system": "urn:oid:2.16.840.1.113883.6.238",
                "code": "1004-1",
                "display": "American Indian"
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "receive-wic",
      "text": "Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy?",
      "answer": [
        {
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/v2-0532",
            "code": "Y",
            "display": "Yes"
          }
        }
      ]
    },
    {
      "linkId": "infertility-treatment",
      "text": "Did this pregnancy result from infertility treatment? (If yes, please answer 12a and 12b)",
      "answer": [
        {
          "valueBoolean": true,
          "item": [
            {
              "linkId": "drugs-ai-ii",
              "text": "If yes, did this pregnancy result from fertility-enhancing drugs, artificial insemination, or intrauterine insemination?",
              "answer": [
                {
                  "valueBoolean": false
                }
              ]
            },
            {
              "linkId": "art-ivf-gift",
              "text": "If yes, did this pregnancy result from assisted reproductive technology (e.g., in-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT))?",
              "answer": [
                {
                  "valueBoolean": true
                }
              ]
            }
          ]
        }
      ]
    },
    {
      "linkId": "mothers-height",
      "text": "What is your height?",
      "item": [
        {
          "linkId": "mothers-height-feet",
          "text": "Feet",
          "answer": [
            {
              "valueQuantity": {
                "value": 5,
                "unit": "ft",
                "system": "http://unitsofmeasure.org",
                "code": "ft"
              }
            }
          ]
        },
        {
          "linkId": "mothers-height-inches",
          "text": "Inches",
          "answer": [
            {
              "valueQuantity": {
                "value": 7,
                "unit": "[in_i]",
                "system": "http://unitsofmeasure.org",
                "code": "[in_i]"
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "mothers-prepregnancy-weight",
      "text": "lbs",
      "answer": [
        {
          "valueQuantity": {
            "value": 145,
            "unit": "[lb_av]",
            "system": "http://unitsofmeasure.org",
            "code": "[lb_av]"
          }
        }
      ]
    },
    {
      "linkId": "mothers-smoking",
      "text": "How many cigarettes OR packs of cigarettes did you smoke on an average day during each of the following time periods? If you NEVER smoked, enter zero for each time period.",
      "item": [
        {
          "linkId": "mothers-smoking-3-months-prior",
          "text": "Three months before pregnancy",
          "item": [
            {
              "linkId": "mothers-smoking-3-months-prior-cig",
              "text": "# of cigarettes*",
              "answer": [
                {
                  "valueInteger": 0
                }
              ]
            },
            {
              "linkId": "mothers-smoking-3-months-prior-pck",
              "text": "# of packs",
              "answer": [
                {
                  "valueInteger": 1
                }
              ]
            }
          ]
        },
        {
          "linkId": "mothers-smoking-trimester-1",
          "text": "First three months of pregnancy",
          "item": [
            {
              "linkId": "mothers-smoking-trimester-1-cig",
              "text": "# of cigarettes*",
              "answer": [
                {
                  "valueInteger": 3
                }
              ]
            },
            {
              "linkId": "mothers-smoking-trimester-1-pck",
              "text": "# of packs",
              "answer": [
                {
                  "valueInteger": 0
                }
              ]
            }
          ]
        },
        {
          "linkId": "mothers-smoking-trimester-2",
          "text": "Second three months of pregnancy",
          "item": [
            {
              "linkId": "mothers-smoking-trimester-2-cig",
              "text": "# of cigarettes*",
              "answer": [
                {
                  "valueInteger": 1
                }
              ]
            },
            {
              "linkId": "mothers-smoking-trimester-2-pck",
              "text": "# of packs",
              "answer": [
                {
                  "valueInteger": 0
                }
              ]
            }
          ]
        },
        {
          "linkId": "mothers-smoking-trimester-3",
          "text": "Third trimester of pregnancy",
          "item": [
            {
              "linkId": "mothers-smoking-trimester-3-cig",
              "text": "# of cigarettes*",
              "answer": [
                {
                  "valueInteger": 0
                }
              ]
            },
            {
              "linkId": "mothers-smoking-trimester-3-pck",
              "text": "# of packs",
              "answer": [
                {
                  "valueInteger": 0
                }
              ]
            }
          ]
        }
      ]
    },
    {
      "linkId": "mother-prior-name",
      "text": "What name did you use prior to your first marriage?",
      "item": [
        {
          "linkId": "mother-prior-first-name",
          "text": "First",
          "answer": [
            {
              "valueString": "Jada"
            }
          ]
        },
        {
          "linkId": "mother-prior-middle-name",
          "text": "Middle",
          "answer": [
            {
              "valueString": "Ann"
            }
          ]
        },
        {
          "linkId": "mother-prior-last-name",
          "text": "Last",
          "answer": [
            {
              "valueString": "King"
            }
          ]
        }
      ]
    },
    {
      "linkId": "married-conception",
      "text": "Were you married at the time you conceived this child, at the time of birth, or at any time between conception and giving birth? [If yes, please go to question 19; If no, please see below]",
      "answer": [
        {
          "valueBoolean": true
        }
      ]
    },
    {
      "linkId": "father-current-legal-name",
      "text": "What is the current legal name of your baby's father?",
      "item": [
        {
          "linkId": "father-first-name",
          "text": "First",
          "answer": [
            {
              "valueString": "James"
            }
          ]
        },
        {
          "linkId": "father-middle-name",
          "text": "Middle",
          "answer": [
            {
              "valueString": "Brandon"
            }
          ]
        },
        {
          "linkId": "father-last-name",
          "text": "Last",
          "answer": [
            {
              "valueString": "Quinn"
            }
          ]
        }
      ]
    },
    {
      "linkId": "father-dob",
      "text": "What the father's date of birth?",
      "answer": [
        {
          "valueDate": "1983-09-27"
        }
      ]
    },
    {
      "linkId": "father-birthplace",
      "text": "In what State, U.S. territory, or foreign country was the father born? Please specify one of the following:",
      "item": [
        {
          "linkId": "father-birthplace-state",
          "text": "State",
          "answer": [
            {
              "valueString": "NY"
            }
          ]
        }
      ]
    },
    {
      "linkId": "father-education",
      "text": "What is the highest level of schooling that the father will have completed at the time of delivery? (Check the box that best describes his education. If he is currently enrolled, check the box that indicates the previous grade or highest degree received).",
      "answer": [
        {
          "valueCoding": {
            "system": "urn:oid:2.16.840.1.114222.4.5.274",
            "code": "PHC1455",
            "display": "Doctorate Degree or Professional Degree"
          }
        }
      ]
    },
    {
      "linkId": "father-ethnicity",
      "text": "Is the father Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.",
      "item": [
        {
          "linkId": "father-shl",
          "text": "Is the father Spanish/Hispanic/Latina",
          "answer": [
            {
              "valueCoding": {
                "system": "urn:oid:2.16.840.1.113883.6.238",
                "code": "2186-5",
                "display": "Not Hispanic or Latino"
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "father-race",
      "text": "What is the father's race? (Please check one or more races to indicate what he considers himself to be).",
      "item": [
        {
          "linkId": "father-race-category",
          "text": "Race categories",
          "answer": [
            {
              "valueCoding": {
                "system": "urn:oid:2.16.840.1.113883.6.238",
                "code": "2106-3",
                "display": "White"
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "parents-ssn",
      "text": "Furnishing parent(s) Social Security Number(s) (SSNs) is required by Federal Law, 42 USC 405(c) (section 205(c) of the Social Security Act). The number(s) will be made available to the (State Social Services Agency) to assist with child support enforcement activities and to the Internal Revenue Service for the purpose of determining Earned Income Tax Credit compliance.",
      "item": [
        {
          "linkId": "mother-ssn",
          "text": "What is your Social Security Number?",
          "answer": [
            {
              "valueString": "132-22-5986"
            }
          ]
        },
        {
          "linkId": "father-ssn",
          "text": "What is the father’s Social Security Number? If you are not married, and if a paternity acknowledgment has not been completed, leave this item blank.",
          "answer": [
            {
              "valueString": "132-22-5987"
            }
          ]
        }
      ]
    },
    {
      "linkId": "baby-ssn",
      "text": "Do you want a Social Security Number issued for your baby? [If yes, please sign request below",
      "answer": [
        {
          "valueBoolean": false
        }
      ]
    },
    {
      "linkId": "informant-name",
      "text": "If other than the mother, what is the name of the person providing information for this worksheet?",
      "item": [
        {
          "linkId": "informant-first-name",
          "text": "First",
          "answer": [
            {
              "valueString": "Jane"
            }
          ]
        },
        {
          "linkId": "informant-last-name",
          "text": "Last",
          "answer": [
            {
              "valueString": "King"
            }
          ]
        }
      ]
    },
    {
      "linkId": "informant-relationship",
      "text": "What is your relationship to the baby's mother?",
      "answer": [
        {
          "valueCoding": {
            "system": "urn:oid:2.16.840.1.114222.4.5.274",
            "code": "PHC1497",
            "display": "Other relative"
          }
        }
      ]
    }
  ]
}