Birth And Fetal Death (BFDR) - STU2-ballot
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Birth And Fetal Death (BFDR) - STU2-ballot, published by HL7 International / Public Health. This guide is not an authorized publication; it is the continuous build for version 2.0.0-Preview1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of and changes regularly. See the Directory of published versions

Questionnaire: Questionnaire - Patient's Fetal Death Worksheet

Official URL: Version: 2.0.0-Preview1
Draft as of 2024-07-17 Computable Name: QuestionnairePatientsFetalDeathWorksheet
Other Identifiers: OID:2.16.840.1.113883.4.642.

This Questionnaire represents the Patient’s Worksheet for the Report of Fetal Death.

Generated Narrative: Questionnaire Questionnaire-patients-fetal-death

LinkIDTextCardinalityTypeDescription & Constraintsdoco
.. QuestionnairePatientsFetalDeathWorksheetThis Questionnaire represents the [Patient's Worksheet for the Report of Fetal Death](
... introWe are truly sorry about the loss you have experienced. We understand that this is a difficult time for you and your loved ones. We need to ask you a few questions to assist in the completion of the official report of fetal death. State laws provide protection against the unauthorized release of identifying information from the report of fetal death to ensure confidentiality of the parents. This information may also help researchers understand some of the factors that are related to miscarriage and stillbirth. Your assistance in providing complete and accurate information is very important. We appreciate your help, especially during this very difficult time.0..1display
... child-name1. Would you like to name the child? This is entirely optional.0..1group
.... child-first-nameFirst0..1string
.... child-middle-nameMiddle0..1string
.... child-last-nameLast0..1string
.... child-suffixSuffix (Jr., III, etc.)0..1string
2. What is your current legal name?0..1group
.... mother-first-nameFirst0..1string
.... mother-middle-nameMiddle0..1string
.... mother-last-nameLast0..1string
.... mother-suffixSuffix (Jr., III, etc.)0..1string
... mother-address3. Where do you usually live - that is - where is your household/residence located?0..1group
.... mother-nbr-streetComplete number and street (do not enter rural route numbers)0..1string
.... mother-apt-nbrApartment Number0..1string
.... mother-cityCity, Town, or Location0..1string
.... mother-countyCounty0..1string
.... mother-stateState (or U.S. Territory, Canadian Province)0..1choiceValue Set: States, Territories and Provinces Vital Records
.... mother-zipZip Code0..1string
.... mother-countryIf not in the United States, country0..1choiceValue Set: Residence Country Vital Records
... inside-city-limits4. Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)?0..1choiceValue Set: Yes No Unknown Vital Records
... mother-mail5. What is your mailing address0..1group
.... mother-mail-sameSame as residence [Go to next question]0..1boolean
.... mother-mail-nbr-streetComplete number and street0..1stringEnable When: mother-mail-same =
.... mother-mail-apt-nbrApartment Number0..1stringEnable When: mother-mail-same =
.... mother-mail-po-boxP.O. Box0..1stringEnable When: mother-mail-same =
.... mother-mail-cityCity, Town, or Location0..1stringEnable When: mother-mail-same =
.... mother-mail-stateState (or U.S. Territory, Canadian Province)0..1choiceEnable When: mother-mail-same =
Value Set: States, Territories and Provinces Vital Records
.... mother-mail-zipZip Code0..1stringEnable When: mother-mail-same =
.... mother-mail-countryIf not in the United States, country0..1choiceEnable When: mother-mail-same =
Value Set: Residence Country Vital Records
... mother-dob6. What is your date of birth?0..1date
... mother-birthplace7. In what State, U.S. territory, or foreign country were you born? Please specify one of the following:0..1group
.... mother-birthplace-stateState0..1choiceValue Set: US States Vital Records
.... mother-birthplace-territoryor U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas0..1choiceValue Set: US Territories Vital Records
.... mother-birthplace-countryor Foreign country0..1choiceValue Set: Birthplace Country Vital Records
... mother-education8. 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).0..1choiceValue Set: Education Level Vital Records
... mother-ethnicity9. Are you Spanish/Hispanic/Latina? (if so, please answer 9a-9d)0..1boolean
... mother-ethnicity-mexicanAre you Mexican, Mexican-American?0..1booleanEnable When: mother-ethnicity =
... mother-ethnicity-puerto-ricanAre you Puerto Rican?0..1booleanEnable When: mother-ethnicity =
... mother-ethnicity-cubanAre you Cuban?0..1booleanEnable When: mother-ethnicity =
... mother-ethnicity-otherAre you of other Spanish/Hispanic/Latina (e.g., Spaniard, Salvadoran, Dominican, Columbian).0..1booleanEnable When: mother-ethnicity =
.... mother-ethnicity-other-literal(specify)0..1stringEnable When: mother-ethnicity-other =
... mother-race10. What is your race? (Please check one or more races to indicate what you consider yourself to be).0..1group
.... mother-race-whiteWhite0..1boolean
.... mother-race-black-or-aaBlack or African American0..1boolean
.... mother-race-aianAmerican Indian or Alaskan Native0..1boolean
..... mother-race-aian-tribe(name of enrolled or principal tribe)0..1stringEnable When: mother-race-aian =
.... mother-race-asian-indianAsian Indian0..1boolean
.... mother-race-chineseChinese0..1boolean
.... mother-race-filipinoFilipino0..1boolean
.... mother-race-japaneseJapanese0..1boolean
.... mother-race-koreanKorean0..1boolean
.... mother-race-vietnameseVietnamese0..1boolean
.... mother-race-other-asianOther Asian0..1boolean
..... mother-race-other-asian-literal(specify)0..1stringEnable When: mother-race-other-asian =
.... mother-race-native-hawaiianNative Hawaiian0..1boolean
.... mother-race-guamanian-or-chamorroGuamanian or Chamorro0..1boolean
.... mother-race-samoanSamoan0..1boolean
.... mother-race-other-pacific-islanderOther Pacific Islander0..1boolean
..... mother-race-other-pacific-islander-specify(specify)0..1stringEnable When: mother-race-other-pacific-islander =
.... mother-race-otherOther (specify)0..1boolean
..... mother-race-other-specify(specify)0..1stringEnable When: mother-race-other =
11. What is the current legal name of your baby's father?0..1group
.... father-first-nameFirst0..1string
.... father-middle-nameMiddle0..1string
.... father-last-nameLast0..1string
.... father-suffixSuffix (Jr., III, etc.)0..1string
... father-dob12. What is the father's date of birth?0..1date
... father-birthplace13. In what State, U.S. territory, or foreign country was the father born? Please specify one of the following:0..1group
.... father-birthplace-stateState0..1choiceValue Set: US States Vital Records
.... father-birthplace-territoryor U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas0..1choiceValue Set: US Territories Vital Records
.... father-birthplace-countryor Foreign country0..1choiceValue Set: Birthplace Country Vital Records
... receive-wic14. Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy?0..1choiceValue Set: Yes No Unknown Vital Records
... mothers-height15. What is your height?0..1group
.... mothers-height-feetFeet0..1quantity
.... mothers-height-inchesInches0..1quantity
... mothers-prepregnancy-weight16. lbs0..1quantity
... mothers-smoking17. 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.0..1group
.... mothers-smoking-3-months-priorThree months before pregnancy0..1group
..... mothers-smoking-3-months-prior-cig# of cigarettes*0..1integer
..... mothers-smoking-3-months-prior-pck# of packs0..1integer
.... mothers-smoking-trimester-1First three months of pregnancy0..1group
..... mothers-smoking-trimester-1-cig# of cigarettes*0..1integer
..... mothers-smoking-trimester-1-pck# of packs0..1integer
.... mothers-smoking-trimester-2Second three months of pregnancy0..1group
..... mothers-smoking-trimester-2-cig# of cigarettes*0..1integer
..... mothers-smoking-trimester-2-pck# of packs0..1integer
.... mothers-smoking-trimester-3Third trimester of pregnancy0..1group
..... mothers-smoking-trimester-3-cig# of cigarettes*0..1integer
..... mothers-smoking-trimester-3-pck# of packs0..1integer
.... cigarette-note*refers to tobacco products only, NOT e-cigarettes.0..1display
... outroThank you for completing this worksheet at this very difficult time. The information you have provided is very important; it will be used by researchers to better understand factors related to miscarriage and stillbirth and lead to improved prevention strategies for the future.0..1display

doco Documentation for this format