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Source1

{
  "resourceType": "Questionnaire",
  "id": "SecondaryProphylaxisHealthAssessmentQuestionnaire",
  "url": "https://fhir-ig.digital.health.nz/rheumatic-fever/Questionnaire/SecondaryProphylaxisHealthAssessmentQuestionnaire",
  "identifier": [
    {
      "use": "official",
      "value": "SecondaryProphylaxisHealthAssessmentQuestionnaire",
      "period": {
        "start": "2023-10-16"
      }
    }
  ],
  "version": "1.0.0",
  "name": "SecondaryProphylaxisHealthAssessmentQuestionnaire",
  "title": "Secondary Prophylaxis Health Assessment Questionnaire",
  "status": "draft",
  "experimental": false,
  "subjectType": [
    "Patient"
  ],
  "date": "2023-11-10",
  "publisher": "Te Whatu Ora",
  "contact": [
    {
      "name": "Te Whatu Ora",
      "telecom": [
        {
          "system": "url",
          "value": "https://www.tewhatuora.govt.nz/"
        },
        {
          "system": "email",
          "value": "integration@tewhatuora.govt.nz"
        }
      ]
    },
    {
      "name": "HNZ Integration Team",
      "telecom": [
        {
          "system": "email",
          "value": "integration@tewhatuora.govt.nz",
          "use": "work"
        }
      ]
    }
  ],
  "description": "Gathers information about patient health at a secondary prophylaxis medication appointment",
  "purpose": "Gathers information about patient health at a secondary prophylaxis medication appointment",
  "item": [
    {
      "linkId": "page1",
      "prefix": "page1",
      "text": "Please complete this questionnaire at the secondary prophylaxis appointment to assess a rheumatic fever patient's health.",
      "type": "display"
    },
    {
      "linkId": "ReasonsInjectionOverdue",
      "prefix": "2)",
      "text": "Reason(s) injection was give late? (multiple choice)",
      "type": "choice",
      "required": true,
      "repeats": true,
      "answerOption": [
        {
          "valueString": "Previously Care On-Hold"
        },
        {
          "valueString": "Unable to Contact Patient"
        },
        {
          "valueString": "Patient Not Available on the Day"
        },
        {
          "valueString": "Patient Declined Treatment"
        },
        {
          "valueString": "INR Too High"
        },
        {
          "valueString": "Patient Lost to Follow-Up"
        },
        {
          "valueString": "Service Delayed To Follow-Up"
        },
        {
          "valueString": "Service Unavailable on the Day"
        },
        {
          "valueString": "Service Error"
        },
        {
          "valueString": "Other"
        }
      ]
    },
    {
      "linkId": "OverdueInjectionOtherDetail",
      "prefix": "3)",
      "text": "Other details for late injection (enter text)",
      "type": "text",
      "required": true
    },
    {
      "linkId": "OtherPainManagementToolsUsed",
      "prefix": "11)",
      "text": "Pain management tools used? (multiple choice)",
      "type": "choice",
      "required": true,
      "repeats": true,
      "answerOption": [
        {
          "valueString": "Ice pack"
        },
        {
          "valueString": "Buzzy bee"
        },
        {
          "valueString": "Numbing cream (Emla)"
        },
        {
          "valueString": "Numbing spray"
        },
        {
          "valueString": "Distraction"
        },
        {
          "valueString": "Very slow injection"
        },
        {
          "valueString": "Other"
        }
      ]
    },
    {
      "linkId": "PainManagementOtherDetails",
      "prefix": "11.1)",
      "text": "Details of other pain management (enter text)",
      "type": "text",
      "enableWhen": [
        {
          "question": "OtherPainManagementToolsUsed",
          "operator": "=",
          "answerString": "Other"
        }
      ],
      "required": true
    },
    {
      "linkId": "PostInjectionConcern",
      "prefix": "12)",
      "text": "Post injection concern or possible reaction identified?",
      "type": "boolean",
      "required": true,
      "initial": [
        {
          "valueBoolean": false
        }
      ]
    },
    {
      "linkId": "PostInjectionConcernDetails",
      "prefix": "12.1)",
      "text": "If Yes, Record Details, Symptoms, Actions Taken and Follow-Up Plan (enter text)",
      "type": "text",
      "enableWhen": [
        {
          "question": "PostInjectionConcern",
          "operator": "=",
          "answerBoolean": true
        }
      ],
      "required": true
    },
    {
      "linkId": "AnyOtherConcerns",
      "prefix": "13)",
      "text": "Were There Any Other Concerns or Issues Identified During the Visit?",
      "type": "boolean",
      "required": true,
      "initial": [
        {
          "valueBoolean": false
        }
      ]
    },
    {
      "linkId": "OtherConcernsDetail",
      "prefix": "13.1)",
      "text": "If yes, describe details, actions taken, and follow-up planned (enter text)",
      "type": "text",
      "enableWhen": [
        {
          "question": "AnyOtherConcerns",
          "operator": "=",
          "answerBoolean": true
        }
      ],
      "required": true
    },
    {
      "linkId": "HealthEducationTopicsDiscussed",
      "prefix": "14)",
      "text": "Health education topics discussed? (multiple choice)",
      "type": "choice",
      "required": true,
      "repeats": true,
      "answerOption": [
        {
          "valueString": "Secondary prophylaxis"
        },
        {
          "valueString": "Sore Throat Management"
        },
        {
          "valueString": "Skin Infection Management"
        },
        {
          "valueString": "Dental Health"
        },
        {
          "valueString": "Endocarditis Prophylaxis"
        },
        {
          "valueString": "Nutrition"
        },
        {
          "valueString": "Physical Activity"
        },
        {
          "valueString": "Healthy Home Environments"
        },
        {
          "valueString": "Sexual Health"
        },
        {
          "valueString": "Other"
        }
      ]
    },
    {
      "linkId": "HealthEducationOtherDetail",
      "prefix": "14.1)",
      "text": "Enter details of other health education topic discussed (enter text)",
      "type": "text",
      "enableWhen": [
        {
          "question": "HealthEducationTopicsDiscussed",
          "operator": "=",
          "answerString": "Other"
        }
      ],
      "required": true
    },
    {
      "linkId": "RecentOrUpcomingAppointments",
      "prefix": "15)",
      "text": "Any recent or upcoming follow-up appointments?",
      "type": "boolean",
      "required": true
    },
    {
      "linkId": "RecentOrUpcomingAppointmentsDetails",
      "prefix": "15.1)",
      "text": "Enter details and dates of any recent or upcoming follow-up appointments (enter text)",
      "type": "text",
      "enableWhen": [
        {
          "question": "RecentOrUpcomingAppointments",
          "operator": "=",
          "answerBoolean": true
        }
      ],
      "required": true
    },
    {
      "linkId": "PlanForNextMedicationAppointment",
      "prefix": "16)",
      "text": "Comments for the next appointment (enter text)",
      "type": "text",
      "required": true
    }
  ]
}