<status value="active"/> <experimental value="true"/> <subjectType value="Patient"/> <date value="2015"/> <publisher value="HL7 International / FHIR Infrastructure"/> <contact> <telecom> <system value="url"/> <value value="http://www.hl7.org/Special/committees/fiwg"/> </telecom> </contact> <description value="This represents an implementation of the "US Surgeon General family health portrait" form found at https://lforms-demo.nlm.nih.gov"/> <useContext> <code> <system value="http://terminology.hl7.org/CodeSystem/usage-context-type"/> <code value="species"/> </code> <valueCodeableConcept> <coding> <system value="http://snomed.info/sct"/> <code value="337915000"/> <display value="Homo sapiens"/> </coding> </valueCodeableConcept> </useContext> <jurisdiction> <coding> <system value="urn:iso:std:iso:3166"/> <code value="US"/> </coding> </jurisdiction> <purpose value="Captures basic family history information"/> <copyright value="(c) 2015 Regenstrief Institute"/> <approvalDate value="2015-10-31"/> <lastReviewDate value="2017-03-15"/> <code> <system value="http://loinc.org"/> <code value="54127-6"/> <display value="US Surgeon General family health portrait [USSG-FHT]"/> </code> <item> <linkId value="0"/> <type value="group"/> <item> <linkId value="0.1"/> <text value="Date Done"/> <type value="date"/> </item> <item> <linkId value="0.2"/> <text value="Time Done"/> <type value="time"/> </item> <item> <linkId value="0.3"/> <text value="Where Done"/> <type value="string"/> </item> <item> <linkId value="0.4"/> <text value="Comment"/> <type value="string"/> </item> </item> <item> <linkId value="1"/> <definition value="http://loinc.org/rdf#54126-8"/> <text value="Your health information"/> <type value="group"/> <required value="true"/> <item> <linkId value="1.1"/> <type value="group"/> <item> <linkId value="1.1.1"/> <definition value="http://loinc.org/rdf#54125-0"/> <text value="Name"/> <type value="string"/> <maxLength value="200"/> </item> <item> <linkId value="1.1.2"/> <definition value="http://loinc.org/rdf#54131-8"/> <text value="Gender"/> <type value="coding"/> <required value="true"/> <answerValueSet value="http://loinc.org/vs/LL1-9"/> <item> <linkId value="1.1.2.1.1"/> <text value="Please specify"/> <type value="string"/> <required value="true"/> </item> </item> <item> <linkId value="1.1.3"/> <definition value="http://loinc.org/rdf#21112-8"/> <text value="Date of Birth"/> <type value="date"/> </item> <item> <linkId value="1.1.4"/> <definition value="http://loinc.org/rdf#54132-6"/> <text value="Were you born a twin?"/> <type value="coding"/> <answerValueSet value="http://loinc.org/vs/LL623-0"/> <initial> <valueCoding> <system value="http://loinc.org"/> <code value="LA32-8"/> <display value="No"/> </valueCoding> </initial> </item> <item> <linkId value="1.1.5"/> <definition value="http://loinc.org/rdf#54128-4"/> <text value="Were you adopted?"/> <type value="coding"/> <answerValueSet value="http://loinc.org/vs/LL361-7"/> </item> <item> <linkId value="1.1.6"/> <definition value="http://loinc.org/rdf#54135-9"/> <text value="Are your parents related to each other in any way other than marriage?"/> <type value="coding"/> <answerValueSet value="http://loinc.org/vs/LL361-7"/> </item> <item> <linkId value="1.1.7"/> <definition value="http://loinc.org/rdf#8302-2"/> <text value="Height"/> <type value="decimal"/> <required value="true"/> <item> <linkId value="1.1.7.1.1"/> <text value="Units"/> <type value="coding"/> <answerValueSet value="#length"/> </item> </item> <item> <linkId value="1.1.8"/> <definition value="http://loinc.org/rdf#29463-7"/> <text value="Weight"/> <type value="decimal"/> <item> <linkId value="1.1.8.1.1"/> <text value="Units"/> <type value="coding"/> <answerValueSet value="#weight"/> </item> </item> <item> <linkId value="1.1.9"/> <definition value="http://loinc.org/rdf#39156-5"/> <text value="Body mass index (BMI) [Ratio]"/> <type value="decimal"/>  <readOnly value="true"/> </item> <item> <linkId value="1.1.10"/> <definition value="http://loinc.org/rdf#54134-2"/> <text value="Race"/> <type value="coding"/> <required value="true"/> <answerValueSet value="http://loinc.org/vs/LL629-7"/> </item> <item> <linkId value="1.1.11"/> <definition value="http://loinc.org/rdf#54133-4"/> <text value="Ethnicity"/> <type value="coding"/> <repeats value="true"/> <answerValueSet value="http://loinc.org/vs/LL628-9"/> </item> </item> <item> <linkId value="1.2"/> <definition value="http://loinc.org/rdf#54137-5"/> <text value="Your diseases history"/> <type value="group"/> <repeats value="true"/> <item> <linkId value="1.2.1"/> <definition value="http://loinc.org/rdf#54140-9"/> <text value="Disease or Condition"/> <type value="coding"/> <answerValueSet value="http://loinc.org/vs/LL626-3"/> </item> <item> <linkId value="1.2.2"/> <definition value="http://loinc.org/rdf#54130-0"/> <text value="Age at Diagnosis"/> <type value="coding"/> <answerValueSet value="http://loinc.org/vs/LL619-8"/> </item> </item> </item> <item> <linkId value="2"/> <definition value="http://loinc.org/rdf#54114-4"/> <text value="Family member health information"/> <type value="group"/> <item> <linkId value="2.1"/> <type value="group"/> <repeats value="true"/>  <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-referenceResource"> <valueCode value="Patient"/> </extension> <linkId value="2.1.1.0"/> <text value="Family Member identity"/> <type value="reference"/> </item> <item> <linkId value="2.1.1.1"/> <definition value="http://loinc.org/rdf#54136-7"/> <text value="Relationship to you"/> <type value="coding"/> <answerValueSet value="http://loinc.org/vs/LL621-4"/> </item> <item> <linkId value="2.1.1.2"/> <definition value="http://loinc.org/rdf#54138-3"/> <text value="Name"/> <type value="string"/> </item> <item> <linkId value="2.1.1.3"/> <definition value="http://loinc.org/rdf#54123-5"/> <text value="Gender"/> <type value="coding"/> <answerValueSet value="http://loinc.org/vs/LL1-9"/> <item> <linkId value="2.1.1.3.1.1"/> <text value="Please specify"/> <type value="string"/> <required value="true"/> </item> </item> <item> <linkId value="2.1.1.4"/> <definition value="http://loinc.org/rdf#54139-1"/> <text value="Living?"/> <type value="coding"/> <answerValueSet value="http://loinc.org/vs/LL361-7"/> <item> <linkId value="2.1.1.4.1"/> <type value="group"/> <item> <linkId value="2.1.1.4.1.1"/> <definition value="http://loinc.org/rdf#54112-8"/> <text value="Cause of Death"/> <type value="coding"/> <answerValueSet value="http://loinc.org/vs/LL627-1"/> <item> <linkId value="2.1.1.4.1.1.1"/> <text value="Please specify"/> <type value="string"/> </item> </item> <item> <linkId value="2.1.1.4.1.2"/> <definition value="http://loinc.org/rdf#54113-6"/> <text value="Age at Death"/> <type value="coding"/> <answerValueSet value="http://loinc.org/vs/LL619-8"/> </item> </item> <item> <linkId value="2.1.1.4.2"/> <type value="group"/> <item> <linkId value="2.1.1.4.2.1"/> <definition value="http://loinc.org/rdf#54124-3"/> <text value="Date of Birth"/> <type value="date"/> </item> <item> <linkId value="2.1.1.4.2.2"/> <definition value="http://loinc.org/rdf#54141-7"/> <text value="Age"/> <type value="decimal"/> </item> </item> </item> <item> <linkId value="2.1.1.5"/> <definition value="http://loinc.org/rdf#54121-9"/> <text value="Was this person born a twin?"/> <type value="coding"/> <answerValueSet value="http://loinc.org/vs/LL623-0"/> </item> <item> <linkId value="2.1.1.6"/> <definition value="http://loinc.org/rdf#54122-7"/> <text value="Was this person adopted?"/> <type value="coding"/> <answerValueSet value="http://loinc.org/vs/LL623-0"/> </item> <item> <linkId value="2.1.1.7"/> <definition value="http://loinc.org/rdf#54119-3"/> <text value="Race"/> <type value="coding"/> <repeats value="true"/> <answerValueSet value="http://loinc.org/vs/LL629-7"/> </item> <item> <linkId value="2.1.1.8"/> <definition value="http://loinc.org/rdf#54120-1"/> <text value="Ethnicity"/> <type value="coding"/> <repeats value="true"/> <answerValueSet value="http://loinc.org/vs/LL628-9"/> </item>  <item> <linkId value="2.1.2"/> <definition value="http://loinc.org/rdf#54117-7"/> <text value="This family member's history of disease"/> <type value="group"/> <repeats value="true"/> <item> <linkId value="2.1.2.1"/> <definition value="http://loinc.org/rdf#54116-9"/> <text value="Disease or Condition"/> <type value="coding"/> <required value="true"/> <answerValueSet value="http://loinc.org/vs/LL626-3"/> </item> <item> <linkId value="2.1.2.2"/> <definition value="http://loinc.org/rdf#54115-1"/> <text value="Age at Diagnosis"/> <type value="coding"/> <answerValueSet value="http://loinc.org/vs/LL619-8"/> </item> <item> <linkId value="2.1.2.3"/> <text value="Mock-up item: Height"/> <type value="decimal"/> </item> <item> <linkId value="2.1.2.4"/> <text value="Mock-up item: Weight"/> <type value="decimal"/> </item> <item> <linkId value="2.1.2.5"/> <text value="Mock-up item: BMI"/> <type value="decimal"/> </item> </item> </item> </item> </Questionnaire> </resource> <request> <method value="PUT"/> <url value="http://hl7.org/fhir/us/sdc/Questionnaire/54127-6"/> </request> </entry> </Bundle>

Generated Narrative: Questionnaire 54127-6

Profile: http://hl7.org/fhir/us/sdc/StructureDefinition/sdc-questionnaire

LinkID	Text	Cardinality	Type	Description & Constraints
	This represents an implementation of the "US Surgeon General family health portrait" form found at https://lforms-demo.nlm.nih.gov		Questionnaire	http://hl7.org/fhir/us/sdc/Questionnaire/54127-6
0	null	0..1	group
0.1	Date Done	0..1	date
0.2	Time Done	0..1	time
0.3	Where Done	0..1	string
0.4	Comment	0..1	string
1	Your health information	1..1	group	Definition: http://loinc.org/rdf#54126-8
1.1	null	0..1	group
1.1.1	Name	0..1	string	Max Length: 200 Definition: http://loinc.org/rdf#54125-0
1.1.2	Gender	1..1	coding	Definition: http://loinc.org/rdf#54131-8 Value Set: LOINC Answer Codes for LL1-9
1.1.2.1.1	Please specify	1..1	string
1.1.3	Date of Birth	0..1	date	Definition: http://loinc.org/rdf#21112-8
1.1.4	Were you born a twin?	0..1	coding	Definition: http://loinc.org/rdf#54132-6 Value Set: LOINC Answer Codes for LL623-0 Initial Value: Coding = LOINC#LA32-8 "No"
1.1.5	Were you adopted?	0..1	coding	Definition: http://loinc.org/rdf#54128-4 Value Set: LOINC Answer Codes for LL361-7
1.1.6	Are your parents related to each other in any way other than marriage?	0..1	coding	Definition: http://loinc.org/rdf#54135-9 Value Set: LOINC Answer Codes for LL361-7
1.1.7	Height	1..1	decimal	Definition: http://loinc.org/rdf#8302-2
1.1.7.1.1	Units	0..1	coding	Value Set: ValueSet Length Units
1.1.8	Weight	0..1	decimal	Definition: http://loinc.org/rdf#29463-7
1.1.8.1.1	Units	0..1	coding	Value Set: ValueSet Weight Units
1.1.9	Body mass index (BMI) [Ratio]	0..1	decimal	Definition: http://loinc.org/rdf#39156-5
1.1.10	Race	1..1	coding	Definition: http://loinc.org/rdf#54134-2 Value Set: LOINC Answer Codes for LL629-7
1.1.11	Ethnicity	0..*	coding	Definition: http://loinc.org/rdf#54133-4 Value Set: LOINC Answer Codes for LL628-9
1.2	Your diseases history	0..*	group	Definition: http://loinc.org/rdf#54137-5
1.2.1	Disease or Condition	0..1	coding	Definition: http://loinc.org/rdf#54140-9 Value Set: LOINC Answer Codes for LL626-3
1.2.2	Age at Diagnosis	0..1	coding	Definition: http://loinc.org/rdf#54130-0 Value Set: LOINC Answer Codes for LL619-8
2	Family member health information	0..1	group	Definition: http://loinc.org/rdf#54114-4
2.1	null	0..*	group
2.1.1.0	Family Member identity	0..1	reference
2.1.1.1	Relationship to you	0..1	coding	Definition: http://loinc.org/rdf#54136-7 Value Set: LOINC Answer Codes for LL621-4
2.1.1.2	Name	0..1	string	Definition: http://loinc.org/rdf#54138-3
2.1.1.3	Gender	0..1	coding	Definition: http://loinc.org/rdf#54123-5 Value Set: LOINC Answer Codes for LL1-9
2.1.1.3.1.1	Please specify	1..1	string
2.1.1.4	Living?	0..1	coding	Definition: http://loinc.org/rdf#54139-1 Value Set: LOINC Answer Codes for LL361-7
2.1.1.4.1	null	0..1	group
2.1.1.4.1.1	Cause of Death	0..1	coding	Definition: http://loinc.org/rdf#54112-8 Value Set: LOINC Answer Codes for LL627-1
2.1.1.4.1.1.1	Please specify	0..1	string
2.1.1.4.1.2	Age at Death	0..1	coding	Definition: http://loinc.org/rdf#54113-6 Value Set: LOINC Answer Codes for LL619-8
2.1.1.4.2	null	0..1	group
2.1.1.4.2.1	Date of Birth	0..1	date	Definition: http://loinc.org/rdf#54124-3
2.1.1.4.2.2	Age	0..1	decimal	Definition: http://loinc.org/rdf#54141-7
2.1.1.5	Was this person born a twin?	0..1	coding	Definition: http://loinc.org/rdf#54121-9 Value Set: LOINC Answer Codes for LL623-0
2.1.1.6	Was this person adopted?	0..1	coding	Definition: http://loinc.org/rdf#54122-7 Value Set: LOINC Answer Codes for LL623-0
2.1.1.7	Race	0..*	coding	Definition: http://loinc.org/rdf#54119-3 Value Set: LOINC Answer Codes for LL629-7
2.1.1.8	Ethnicity	0..*	coding	Definition: http://loinc.org/rdf#54120-1 Value Set: LOINC Answer Codes for LL628-9
2.1.2	This family member's history of disease	0..*	group	Definition: http://loinc.org/rdf#54117-7
2.1.2.1	Disease or Condition	1..1	coding	Definition: http://loinc.org/rdf#54116-9 Value Set: LOINC Answer Codes for LL626-3
2.1.2.2	Age at Diagnosis	0..1	coding	Definition: http://loinc.org/rdf#54115-1 Value Set: LOINC Answer Codes for LL619-8
2.1.2.3	Mock-up item: Height	0..1	decimal
2.1.2.4	Mock-up item: Weight	0..1	decimal
2.1.2.5	Mock-up item: BMI	0..1	decimal
Documentation for this format

Contained Resources

ValueSet #length

Profile: http://hl7.org/fhir/us/sdc/StructureDefinition/sdc-valueset

name: Length Units

status: Active

description:

Length units

immutable: true

compose
include
system: http://unitsofmeasure.org
concept
code: [in_i]
display: inches
concept
code: cm
display: centimeters

ValueSet #weight

Profile: http://hl7.org/fhir/us/sdc/StructureDefinition/sdc-valueset

name: Weight Units

status: Active

description:

Weight units

immutable: true

compose
include
system: http://unitsofmeasure.org
concept
code: [lb_av]
display: pounds
concept
code: km
display: kilograms