Generated Narrative: Questionnaire CardiologyForm Language: en Structure LinkID Text Cardinality Type Flags Description & Constraints Questionnaire urn:uuid:d7176d16-5fd4-48a7-b7e6-b488e8df763d#4.0.0-ci-build #xD; patient_header Patient Information 0..1 group #xD; patient_surname Surname: 1..1 string #xD; patient_firstname First Name: 1..1 string #xD; patient_date_of_birth DOB: 1..1 date #xD; patient_gender Gender: 1..1 choice Options: 3 options #xD; patient_hc_pc HN PC: 0..1 string Max Length: 2 #xD; patient_hc_number HN: 0..1 string Max Length: 10 #xD; patient_hc_vc HN VC: 0..1 string #xD; patient_address_line1 Address (Line 1): 1..1 string #xD; patient_address_line2 Address (Line 2): 0..1 string #xD; patient_address_city City: 1..1 string #xD; patient_address_province Province: 1..1 string Max Length: 2 #xD; patient_address_postalcode Postal Code: 1..1 string #xD; patient_phone_mobile Mobile #: 0..1 string #xD; patient_phone_home Home #: 0..1 string #xD; patient_phone_business Business #: 0..1 string #xD; patient_email Email: 0..1 string #xD; additionalinfo_header [Optional] Additional Patient Information 0..1 group #xD; additionalinfo_sexassignedatbirth Sex assigned at birth: 0..1 choice Options: 4 options #xD; additionalinfo_pronouns Pronouns: 0..1 choice Options: 4 options #xD; additionalinfo_pronouns_other Other pronouns: 1..1 string Enable When: additionalinfo_pronouns = other (v3 Code System NullFlavor#OTH) #xD; additionalinfo_preferredlanguage Preferred language: 0..1 choice Options: 3 options #xD; additionalinfo_preferredlanguage_specify Specify: 1..1 string Enable When: additionalinfo_preferredlanguage = other (v3 Code System NullFlavor#OTH) #xD; additionalinfo_preferredlanguage_translatorrequired Translator required 0..* string Enable When: additionalinfo_preferredlanguage = other (v3 Code System NullFlavor#OTH) Options: 1 option #xD; additionalinfo_bestmethodofcontact Best method of contact: 0..1 choice Options: 4 options #xD; additionalinfo_bestmethodofcontact_voicemails Voicemails acceptable 0..* string Enable When: additionalinfo_bestmethodofcontact = Mobile (ContactPointUse#mobile) Options: 1 option #xD; additionalinfo_preferredname_select Preferred name 0..* string Options: 1 option #xD; additionalinfo_preferredname Prefered name String 0..1 string Enable When: additionalinfo_preferredname_select = Preferred Name #xD; additionalinfo_alternatecontact_select Alternate contact 0..* string Options: 1 option #xD; additionalinfo_alternatecontact_name Name: 1..1 string Enable When: additionalinfo_alternatecontact_select = Alternate contact #xD; additionalinfo_alternatecontact_phone Alternate contact phone #: 0..1 string Enable When: additionalinfo_alternatecontact_select = Alternate contact #xD; additionalinfo_alternatecontact_relationship Relationship: 0..1 string Enable When: additionalinfo_alternatecontact_select = Alternate contact #xD; additionalinfo_alternatecontact_bookingcontact Is Alternate contact the appointment booking contact?: 0..1 choice Enable When: additionalinfo_alternatecontact_select = Alternate contact Options: 2 options #xD; additionalinfo_unsafecontacts_select Unsafe contact persons (do not speak with) 0..* string Options: 1 option #xD; additionalinfo_unsafecontacts_speakwithpatientdirectly Only speak with patient directly 0..* string Enable When: additionalinfo_unsafecontacts_select = Unsafe contact persons (do not speak with) Options: 1 option #xD; additionalinfo_unsafecontacts_donotspeakwith Do not speak with: 0..1 string Enable When: additionalinfo_unsafecontacts_select = Unsafe contact persons (do not speak with) #xD; additionalinfo_accessibilityconcernsordisability_selectt Accessibility concerns or disability 0..* string Options: 1 option #xD; additionalinfo_accessibilityconcernsordisability Accessibility concerns Options 0..* choice Enable When: additionalinfo_accessibilityconcernsordisability_selectt = Accessibility concerns or disability Options: 4 options #xD; additionalinfo_specialconsiderations_select Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues) 0..* string Options: 1 option #xD; additionalinfo_specialconsiderations Details of special considerations: 1..1 text Enable When: additionalinfo_specialconsiderations_select = Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues) #xD; additionalinfo_sendcopiestoadditionalproviders Send copies of reports to additional providers 0..* string Options: 1 option #xD; additionalinfo_sendcopiestoadditionalproviders_names Name(s): 1..1 string Enable When: additionalinfo_sendcopiestoadditionalproviders = Send copies of reports to additional providers #xD; additionalinfo_sendcopiestoadditionalproviders_contactinfo Contact information: 1..1 string Enable When: additionalinfo_sendcopiestoadditionalproviders = Send copies of reports to additional providers #xD; additionalinfo_sendcopiestoadditionalproviders_ispcp This is the Primary Care Provider 0..* string Enable When: additionalinfo_sendcopiestoadditionalproviders = Send copies of reports to additional providers Options: 1 option #xD; 102173268919 Referral Details 0..1 group #xD; cardio_triagecons Triage Considerations 0..1 group #xD; referral_requestedpriority Requested Priority: 1..1 choice Options: 2 options #xD; referral_requestedpriority_urgentreason Reason for urgent triage 1..1 string Enable When: referral_requestedpriority = Urgent (RequestPriority#urgent) #xD; referral_secondopinion Second Opinion 0..* choice Options: 1 option #xD; referral_secondopinion_reason Reason for second opinion: 0..1 text Enable When: referral_secondopinion = Second or third medical opinion (SNOMED CT#77406008) #xD; 695991571585 Service(s) Requested Select all that apply: 1..1 group #xD; referralService HSCs Assigned: 0..1 string #xD; 223886162384 Cardiac Testing 0..* choice Options: 1 option #xD; 660331267409 Exam(s) Requested 0..1 group Enable When: 223886162384 = Cardiac Testing (standardized-referral-form-codes#20001) #xD; 720409326878 24 Hour Ambulatory Blood Pressure Monitoring 0..* choice Options: 1 option #xD; 960455115596 Coronary Angiogram 0..* choice Options: 1 option #xD; 297634898828 Echocardiogram - Resting 0..* choice Options: 1 option #xD; 443484577720 sub Echocardiogram - Resting 0..1 group Enable When: 297634898828 = Echocardiogram - Resting (standardized-referral-form-codes#20005) #xD; 165530569567 Echocardiogram (2D) 0..* choice Options: 1 option #xD; 286552421895 Echocardiogram with Contrast 0..* choice Options: 1 option #xD; 910527687300 Echocardiogram with Saline (Bubble) 0..* choice Options: 1 option #xD; 657824763133 Pediatric Echocardiogram 0..* choice Options: 1 option #xD; 992743200182 Transesophageal Echocardiogram (TEE) 0..* choice Options: 1 option #xD; 894277763438 Electrocardiogram (ECG) 0..* choice Options: 1 option #xD; 279226023495 Holter Monitoring 0..* choice Options: 1 option #xD; 440449731882 sub holter monitoring 0..1 group Enable When: 279226023495 = Holter Monitoring (standardized-referral-form-codes#20007) #xD; 671328703851 24 Hours 0..* choice Options: 1 option #xD; 423992261841 48 Hours 0..* choice Options: 1 option #xD; 419924239187 72 Hours 0..* choice Options: 1 option #xD; 731054417270 7 Days 0..* choice Options: 1 option #xD; 235876421044 14 Days 0..* choice Options: 1 option #xD; 374742834400 Loop / Event Monitor 0..* choice Options: 1 option #xD; 159161544747 Cardiovascular stress testing 0..* choice Options: 1 option #xD; 370275060390 Sub Stress Testing 0..1 group Enable When: 159161544747 = Stress Testing (standardized-referral-form-codes#20009) #xD; 814218498309 ECG - Exercise Stress Test 0..* choice Options: 1 option #xD; 307107493993 ECG - Dobutamine/Persantine Stress Test 0..* choice Options: 1 option #xD; 805303414102 Echocardiogram - Exercise Stress Test 0..* choice Options: 1 option #xD; 193586908489 Echocardiogram - Dobutamine/Persantine Stress Test 0..* choice Options: 1 option #xD; 918517139023 Nuclear Medicine 0..* choice Options: 1 option #xD; 222686221935 sub Nuclear Medicine 0..1 group Enable When: 918517139023 = Nuclear Medicine (standardized-referral-form-codes#20010) #xD; 924189648184 MUGA - Resting 0..* choice Options: 1 option #xD; 857163514910 Cardiac Pyrophosphate 0..* choice Options: 1 option #xD; 892165959617 Myocardial perfusion scan 0..* choice Options: 1 option #xD; 538288549138 sub MIBI 0..1 group Enable When: 892165959617 = MIBI Scans / Myocardial Perfusion Imaging (MPI): (standardized-referral-form-codes#20028) #xD; 373435981917 MIBI Scan - Exercise Stress Test 0..* string Options: 1 option #xD; 434394942688 MIBI Scan - Dobutamine/Persantine Stress Test 0..* string Options: 1 option #xD; 913594478162 Thallium Viability Test 0..* string Options: 1 option #xD; 992682216482 Tilt Table Testing 0..* choice Options: 1 option #xD; cardiology_referral_services_cardiactesting_other Other 0..* choice Options: 1 option #xD; cardiology_referral_services_cardiactesting_other_specify Specify 1..1 text Enable When: cardiology_referral_services_cardiactesting_other = other (v3 Code System NullFlavor#OTH) #xD; 785727177547 Cardiology Consultation 0..* choice Options: 1 option #xD; 186952778859 Concern(s) / Indication(s) Triggering Referral Select all that apply: 1..1 group #xD; 219569805461 Arrhythmias or Palpitations 0..* choice Options: 1 option #xD; 571934328499 Cardiovascular Risk Assessment 0..* choice Options: 1 option #xD; 459737733395 Chest Pain or Angina 0..* choice Options: 1 option #xD; 929919815516 Congenital Heart Disease 0..* choice Options: 1 option #xD; 832263816528 Congestive Heart Failure 0..* choice Options: 1 option #xD; 803760213460 Coronary Artery Disease 0..* choice Options: 1 option #xD; 129767162379 Dyspnea 0..* choice Options: 1 option #xD; 116150628533 Hypertension 0..* choice Options: 1 option #xD; 513825527027 Murmur 0..* choice Options: 1 option #xD; 975075898688 Pericardial Disease 0..* choice Options: 1 option #xD; 704148928571 Peripheral Edema 0..* choice Options: 1 option #xD; 886489617115 Post-Myocardial Infarction 0..* choice Options: 1 option #xD; 621745958993 Pre-operative Consultation 0..* choice Options: 1 option #xD; 873024527134 Procedure Date (if known) 0..1 date Enable When: 621745958993 = Pre-operative Consultation (standardized-referral-form-codes#20044) #xD; 197975129599 Syncope 0..* choice Options: 1 option #xD; 675849150752 Valvular Heart Disease or Prosthetic Heart Valve 0..* choice Options: 1 option #xD; 721982740516 Other 0..* choice Options: 1 option #xD; 720594942482 Specify 1..1 text Enable When: 721982740516 = other (v3 Code System NullFlavor#OTH) #xD; Descriptionofclinicalquestion Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations 1..1 text #xD; cpp_header Cumulative Patient Profile Please delete any sensitive information you do not intend to share from the CPP 0..1 group #xD; cpp_separate CPP attached separately (if not entered below) 0..* string Options: 1 option #xD; cpp_currentprob Current Problem List: 0..1 text Enable When: cpp_separate exists false #xD; cpp_pastmedicalhistory Past Medical History: 0..1 text Enable When: cpp_separate exists false #xD; cpp_currentmedications Current Medications : 0..1 text Enable When: cpp_separate exists false #xD; cpp_familyhistory Family History: 0..1 text Enable When: cpp_separate exists false #xD; cpp_allergies Allergies: 0..1 text Enable When: cpp_separate exists false #xD; preferredconsultlocation_header Preferred Consultant or Location All patients will be triaged to the shortest wait time unless a preferred consultant or location is entered. 0..1 group #xD; preferredconsultlocation_selector Preferred consultant or location 0..* string Options: 1 option #xD; preferredconsultlocation_specify Please specify either a preferred consultant or location 0..1 group Enable When: preferredconsultlocation_selector = Preferred consultant or location #xD; preferredconsultlocation_consultant Consultant: 0..1 string #xD; preferredconsultlocation_location Location: 0..1 string #xD; preferredconsultlocation_willingtotravel Patient willing to travel for shorter wait time 0..* string Options: 1 option #xD; preferredconsultlocation_otherconsiderations Other considerations: 0..1 string #xD; supportingdocumentation_header Supporting Documentation Please attach all relevant laboratory and diagnostic investigations. 0..1 group #xD; supportingdocumentation_details Personal Health Information that is medically relevant has not been disclosed at the request of the patient. 0..* string Options: 1 option #xD; supportingdocumentation_attachment Add Attachments 0..1 attachment #xD; feedbacksurvey_cardiology Click here to provide feedback on this form 0..1 display #xD; referrer_header Referrer's Information 0..1 group #xD; referrer_sitename Site Name: 0..1 string #xD; referrer_address_line1 Address (Line 1): 1..1 string #xD; referrer_address_line2 Address (Line 2): 0..1 string #xD; referrer_address_city City: 1..1 string #xD; referrer_address_province Province: 1..1 string Max Length: 2 #xD; referrer_address_postalcode Postal Code: 1..1 string #xD; referrer_phone Phone #: 0..1 string #xD; referrer_fax Fax #: 0..1 string #xD; referrer_billing Billing Number: 0..1 integer #xD; referrer_professionalid Professional ID: 0..1 integer #xD; referrer_signature Signed: 1..1 text #xD; referrer_role Role: 0..1 choice Options: 9 options #xD; Documentation for this format Options Sets Answer options for patient_gender http://hl7.org/fhir/administrative-gender#male ("Male") http://hl7.org/fhir/administrative-gender#female ("Female") http://hl7.org/fhir/administrative-gender#other ("Other") Answer options for additionalinfo_sexassignedatbirth http://loinc.org#LA3-6 ("Female") http://loinc.org#LA2-8 ("Male") http://example.com/CodeSystem/exampleCS#Intersex ("Intersex") http://loinc.org#LA4489-6 ("Unknown") Answer options for additionalinfo_pronouns http://loinc.org#LA29519-8 ("She/Her") http://loinc.org#LA29518-0 ("He/Him") http://loinc.org#LA29519-8 ("They/Them") http://terminology.hl7.org/CodeSystem/v3-NullFlavor#OTH ("other") Answer options for additionalinfo_preferredlanguage urn:ietf:bcp:47#en ("English") urn:ietf:bcp:47#fr ("French") http://terminology.hl7.org/CodeSystem/v3-NullFlavor#OTH ("other") Answer options for additionalinfo_preferredlanguage_translatorrequired Translator Required Answer options for additionalinfo_bestmethodofcontact http://hl7.org/fhir/contact-point-use#mobile ("Mobile") http://hl7.org/fhir/contact-point-use#home ("Home") http://hl7.org/fhir/contact-point-use#work ("Work") http://hl7.org/fhir/contact-point-system#email ("Email") Answer options for additionalinfo_bestmethodofcontact_voicemails Voicemails acceptable Answer options for additionalinfo_preferredname_select Preferred Name Answer options for additionalinfo_alternatecontact_select Alternate contact Answer options for additionalinfo_alternatecontact_bookingcontact http://terminology.hl7.org/CodeSystem/v2-0532#Y ("Yes") http://terminology.hl7.org/CodeSystem/v2-0532#N ("No") Answer options for additionalinfo_unsafecontacts_select Unsafe contact persons (do not speak with) Answer options for additionalinfo_unsafecontacts_speakwithpatientdirectly Only speak with patient directly Answer options for additionalinfo_accessibilityconcernsordisability_selectt Accessibility concerns or disability Answer options for additionalinfo_accessibilityconcernsordisability http://snomed.info/sct#129839007 ("Falls risk") http://snomed.info/sct#301621006 ("Patient requires lift") http://snomed.info/sct#105503008 ("Wheelchair") http://snomed.info/sct#15188001 ("Hearing impaired") Answer options for additionalinfo_specialconsiderations_select Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues) Answer options for additionalinfo_sendcopiestoadditionalproviders Send copies of reports to additional providers Answer options for additionalinfo_sendcopiestoadditionalproviders_ispcp This is the Primary Care Provider Answer options for referral_requestedpriority http://hl7.org/fhir/request-priority#routine ("Routine") http://hl7.org/fhir/request-priority#urgent ("Urgent") Answer options for referral_secondopinion http://snomed.info/sct#77406008 ("Second or third medical opinion") Answer options for 223886162384 http://example.com/CodeSystem/standardized-referral-form-codes#20001 ("Cardiac Testing") Answer options for 720409326878 http://example.com/CodeSystem/standardized-referral-form-codes#20003 ("24 Hour Ambulatory Blood Pressure Monitoring") Answer options for 960455115596 http://example.com/CodeSystem/standardized-referral-form-codes#20004 ("Coronary Angiogram") Answer options for 297634898828 http://example.com/CodeSystem/standardized-referral-form-codes#20005 ("Echocardiogram - Resting") Answer options for 165530569567 http://example.com/CodeSystem/standardized-referral-form-codes#20012 ("Echocardiogram (2D)") Answer options for 286552421895 http://example.com/CodeSystem/standardized-referral-form-codes#20013 ("Echocardiogram with Contrast") Answer options for 910527687300 http://example.com/CodeSystem/standardized-referral-form-codes#20014 ("Echocardiogram with Saline (Bubble)") Answer options for 657824763133 http://example.com/CodeSystem/standardized-referral-form-codes#20015 ("Pediatric Echocardiogram") Answer options for 992743200182 http://example.com/CodeSystem/standardized-referral-form-codes#20016 ("Transesophageal Echocardiogram (TEE)") Answer options for 894277763438 http://example.com/CodeSystem/standardized-referral-form-codes#20006 ("Electrocardiogram (ECG)") Answer options for 279226023495 http://example.com/CodeSystem/standardized-referral-form-codes#20007 ("Holter Monitoring") Answer options for 671328703851 http://example.com/CodeSystem/standardized-referral-form-codes#20017 ("24 Hours") Answer options for 423992261841 http://example.com/CodeSystem/standardized-referral-form-codes#20018 ("48 Hours") Answer options for 419924239187 http://example.com/CodeSystem/standardized-referral-form-codes#20019 ("72 Hours") Answer options for 731054417270 http://example.com/CodeSystem/standardized-referral-form-codes#20020 ("7 Days") Answer options for 235876421044 http://example.com/CodeSystem/standardized-referral-form-codes#20021 ("14 Days") Answer options for 374742834400 http://example.com/CodeSystem/standardized-referral-form-codes#20008 ("Loop / Event Monitor") Answer options for 159161544747 http://example.com/CodeSystem/standardized-referral-form-codes#20009 ("Stress Testing") Answer options for 814218498309 http://example.com/CodeSystem/standardized-referral-form-codes#20022 ("ECG - Exercise Stress Test") Answer options for 307107493993 http://example.com/CodeSystem/standardized-referral-form-codes#20023 ("ECG - Dobutamine/Persantine Stress Test") Answer options for 805303414102 http://example.com/CodeSystem/standardized-referral-form-codes#20024 ("Echocardiogram - Exercise Stress Test") Answer options for 193586908489 http://example.com/CodeSystem/standardized-referral-form-codes#20025 ("Echocardiogram - Dobutamine/Persantine Stress Test") Answer options for 918517139023 http://example.com/CodeSystem/standardized-referral-form-codes#20010 ("Nuclear Medicine") Answer options for 924189648184 http://example.com/CodeSystem/standardized-referral-form-codes#20026 ("MUGA - Resting") Answer options for 857163514910 http://example.com/CodeSystem/standardized-referral-form-codes#20027 ("Cardiac Pyrophosphate") Answer options for 892165959617 http://example.com/CodeSystem/standardized-referral-form-codes#20028 ("MIBI Scans / Myocardial Perfusion Imaging (MPI):") Answer options for 373435981917 MIBI Scan - Exercise Stress Test Answer options for 434394942688 MIBI Scan - Dobutamine/Persantine Stress Test Answer options for 913594478162 Thallium Viability Test Answer options for 992682216482 http://example.com/CodeSystem/standardized-referral-form-codes#20011 ("Tilt Table Testing") Answer options for cardiology_referral_services_cardiactesting_other http://terminology.hl7.org/CodeSystem/v3-NullFlavor#OTH ("other") Answer options for 785727177547 http://example.com/CodeSystem/standardized-referral-form-codes#20002 ("Cardiology Consultation") Answer options for 219569805461 http://snomed.info/sct#698247007 ("Arrhythmias or Palpitations") Answer options for 571934328499 http://example.com/CodeSystem/standardized-referral-form-codes#20033 ("Cardiovascular Risk Assessment") Answer options for 459737733395 http://example.com/CodeSystem/standardized-referral-form-codes#20034 ("Chest Pain or Angina") Answer options for 929919815516 http://example.com/CodeSystem/standardized-referral-form-codes#20035 ("Congenital Heart Disease") Answer options for 832263816528 http://example.com/CodeSystem/standardized-referral-form-codes#20036 ("Congestive Heart Failure") Answer options for 803760213460 http://example.com/CodeSystem/standardized-referral-form-codes#20037 ("Coronary Artery Disease") Answer options for 129767162379 http://example.com/CodeSystem/standardized-referral-form-codes#20038 ("Dyspnea") Answer options for 116150628533 http://example.com/CodeSystem/standardized-referral-form-codes#20039 ("Hypertension") Answer options for 513825527027 http://example.com/CodeSystem/standardized-referral-form-codes#20040 ("Murmur") Answer options for 975075898688 http://example.com/CodeSystem/standardized-referral-form-codes#20041 ("Pericardial Disease") Answer options for 704148928571 http://example.com/CodeSystem/standardized-referral-form-codes#20042 ("Peripheral Edema") Answer options for 886489617115 http://example.com/CodeSystem/standardized-referral-form-codes#20043 ("Post-Myocardial Infarction") Answer options for 621745958993 http://example.com/CodeSystem/standardized-referral-form-codes#20044 ("Pre-operative Consultation") Answer options for 197975129599 http://example.com/CodeSystem/standardized-referral-form-codes#20045 ("Syncope") Answer options for 675849150752 http://snomed.info/sct#368009 ("Valvular Heart Disease or Prosthetic Heart Valve") Answer options for 721982740516 http://terminology.hl7.org/CodeSystem/v3-NullFlavor#OTH ("other") Answer options for cpp_separate CPP attached separately (if not entered below) Answer options for preferredconsultlocation_selector Preferred consultant or location Answer options for preferredconsultlocation_willingtotravel Patient willing to travel for shorter wait time Answer options for supportingdocumentation_details Personal Health Information that is medically relevant has not been disclosed at the request of the patient. Answer options for referrer_role http://snomed.info/sct#309398001 ("Allied Health Professional") http://snomed.info/sct#62247001 ("Family Physician") http://snomed.info/sct#449161006 ("Physician Assistant") http://snomed.info/sct#398130009 ("Medical Student") http://snomed.info/sct#106292003 ("Nurse") http://snomed.info/sct#224571005 ("Nurse Practitioner") http://snomed.info/sct#405277009 ("Resident") http://snomed.info/sct#69280009 ("Specialist") http://terminology.hl7.org/CodeSystem/v3-NullFlavor#OTH ("other")
%resource.repeat(item).where(linkId='patient_address_postalcode').answer.all(value.matches('^(?!.*[DFIOQU])[A-VXY][0-9][A-Z] ?[0-9][A-Z][0-9]$'))
[Optional] Additional Patient Information
Is Alternate contact the appointment booking contact?:
Unsafe contact persons (do not speak with)
Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)
Send copies of reports to additional providers
Service(s) Requested Select all that apply:
Calculates HSC services based on selected checkboxes for cardiac testing and cardiology consult
iif(%resource.item.where(linkId='223886162384').answer.value.exists(), 'CARDIOLOGY_SERVICES', '') + iif(%resource.item.where(linkId='223886162384').answer.value.exists() and %resource.item.where(linkId='785727177547').answer.value.exists(), '|', '') + iif(%resource.item.where(linkId='785727177547').answer.value.exists(), 'CARDIOLOGY', '')
24 Hour Ambulatory Blood Pressure Monitoring
Echocardiogram - Dobutamine/Persantine Stress Test
MIBI Scans / Myocardial Perfusion Imaging (MPI):
MIBI Scan - Dobutamine/Persantine Stress Test
Concern(s) / Indication(s) Triggering Referral Select all that apply:
Valvular Heart Disease or Prosthetic Heart Valve
Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations
Cumulative Patient Profile Please delete any sensitive information you do not intend to share from the CPP
CPP attached separately (if not entered below)
Preferred Consultant or Location All patients will be triaged to the shortest wait time unless a preferred consultant or location is entered.
Please specify either a preferred consultant or location
Patient willing to travel for shorter wait time
Supporting Documentation Please attach all relevant laboratory and diagnostic investigations.
Personal Health Information that is medically relevant has not been disclosed at the request of the patient.
Click here to provide feedback on this form
%resource.repeat(item).where(linkId='referrer_address_postalcode').answer.all(value.matches('^(?!.*[DFIOQU])[A-VXY][0-9][A-Z] ?[0-9][A-Z][0-9]$'))