QuestionnaireResponse-patients-fetal-death-carmen-lee
type: QuestionnaireResponse
node role: treeRoot
id:
  v: QuestionnaireResponse-patients-fetal-death-carmen-lee
text:
  status:
    v: generated
  div: Generated Narrative: QuestionnaireResponse QuestionnaireResponse-patients-fetal-death-carmen-lee LinkID Text Definition Answer<img src="[binary]" alt="doco" style="background-color: inherit"/> QuestionnaireResponse-patients-fetal-death-carmen-lee Questionnaire:Questionnaire - Patient's Worksheet for the Report of Fetal Death #xD; mother-current-legal-name What is your current legal name? #xD; mother-first-name First Carmen #xD; mother-middle-name Middle Teresa #xD; mother-last-name Last Lee #xD; mother-address Where do you usually live - that is - where is your household/residence located? #xD; mother-nbr-street Complete number and street (do not enter rural route numbers) 3670 Miller Road #xD; mother-city City, Town, or Location #xD; mother-state State (or U.S. Territory, Canadian Province) MI #xD; mother-zip Zip Code 48103 #xD; inside-city-limits Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)? v2 Y/N Indicator N: No #xD; mother-mail What is your mailing address #xD; mother-mail-same Same as residence [Go to next question] true #xD; mother-dob What is your date of birth? 1986-02-15 #xD; mother-birthplace In what State, U.S. territory, or foreign country were you born? Please specify one of the following: #xD; mother-birthplace-territory or U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas PR #xD; mother-education 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). Education Level SEC: Some secondary or high school education #xD; mother-ethnicity true #xD; mother-ethnicity-mexican true #xD; mother-ethnicity-puerto-rican true #xD; mother-ethnicity-cuban true #xD; mother-ethnicity-other false #xD; mother-race #xD; mother-race-black-or-aa true #xD; father-current-…
questionnaire:
  v: http://hl7.org/fhir/us/bfdr/Questionnaire/Questionnaire-patients-fetal-death
  link: http://hl7.org/fhir/us/bfdr/Questionnaire/Questionnaire-patients-fetal-death
status:
  v: completed
subject:
  link: http://hl7.org/fhir/us/bfdr/Patient/patient-decedent-fetus-not-named
  reference:
    v: Patient/patient-decedent-fetus-not-named
  display:
    v: Patient - Decedent Fetus (Fetus Not Named)
source:
  link: http://hl7.org/fhir/us/bfdr/Patient/patient-mother-carmen-teresa-lee
  reference:
    v: Patient/patient-mother-carmen-teresa-lee
  display:
    v: Patient - Mother (Carmen Teresa Lee)
item:
  link id:
    v: mother-current-legal-name
  text:
    v: What is your current legal name?
  item:
    link id:
      v: mother-first-name
    text:
      v: First
    answer:
      value: string
        v: Carmen
  item:
    link id:
      v: mother-middle-name
    text:
      v: Middle
    answer:
      value: string
        v: Teresa
  item:
    link id:
      v: mother-last-name
    text:
      v: Last
    answer:
      value: string
        v: Lee
item:
  link id:
    v: mother-address
  text:
    v: Where do you usually live - that is - where is your household/residence located?
  item:
    link id:
      v: mother-nbr-street
    text:
      v: Complete number and street (do not enter rural route numbers)
    answer:
      value: string
        v: 3670 Miller Road
  item:
    link id:
      v: mother-city
    text:
      v: City, Town, or Location
  item:
    link id:
      v: mother-state
    text:
      v: State (or U.S. Territory, Canadian Province)
    answer:
      value: string
        v: MI
  item:
    link id:
      v: mother-zip
    text:
      v: Zip Code
    answer:
      value: string
        v: 48103
item:
  link id:
    v: inside-city-limits
  text:
    v: Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)?
  answer:
    value: Coding
      system:
        v: http://terminology.hl7.org/CodeSystem/v2-0136
      code:
        v: N
      display:
        v: No
item:
  link id:
    v: mother-mail
  text:
    v: What is your mailing address
  item:
    link id:
      v: mother-mail-same
    text:
      v: Same as residence [Go to next question]
    answer:
      value: boolean
        v: true
item:
  link id:
    v: mother-dob
  text:
    v: What is your date of birth?
  answer:
    value: date
      v: 1986-02-15
item:
  link id:
    v: mother-birthplace
  text:
    v: In what State, U.S. territory, or foreign country were you born? Please specify one of the following:
  item:
    link id:
      v: mother-birthplace-territory
    text:
      v: or U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas
    answer:
      value: string
        v: PR
item:
  link id:
    v: mother-education
  text:
    v: 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:
    value: Coding
      system:
        v: http://terminology.hl7.org/CodeSystem/v3-EducationLevel
      code:
        v: SEC
      display:
        v: Some secondary or high school education
item:
  link id:
    v: mother-ethnicity
  answer:
    value: boolean
      v: true
item:
  link id:
    v: mother-ethnicity-mexican
  answer:
    value: boolean
      v: true
item:
  link id:
    v: mother-ethnicity-puerto-rican
  answer:
    value: boolean
      v: true
item:
  link id:
    v: mother-ethnicity-cuban
  answer:
    value: boolean
      v: true
item:
  link id:
    v: mother-ethnicity-other
  answer:
    value: boolean
      v: false
item:
  link id:
    v: mother-race
  item:
    link id:
      v: mother-race-black-or-aa
    answer:
      value: boolean
        v: true
item:
  link id:
    v: father-current-legal-name
  text:
    v: What is the current legal name of your baby's father?
  item:
    link id:
      v: father-first-name
    text:
      v: First
    answer:
      value: string
        v: Tom
  item:
    link id:
      v: father-middle-name

v: Middle

value: string
  v: Yan

link id:
  v: father-last-name
text:
  v: Last
answer:
  value: string
    v: Lee

link id:
  v: father-dob
text:
  v: What is the father's date of birth?
answer:
  value: date
    v: 1984-02-27

link id:
  v: father-birthplace
text:
  v: In what State, U.S. territory, or foreign country was the father born? Please specify one of the following:
item:
  link id:
    v: father-birthplace-state
  text:
    v: State
  answer:
    value: string
      v: NY

link id:
  v: receive-wic
text:
  v: Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy?
answer:
  value: Coding
    system:
      v: http://terminology.hl7.org/CodeSystem/v2-0136
    code:
      v: N
    display:
      v: No

link id:
  v: mothers-height
text:
  v: What is your height?
item:
  link id:
    v: mothers-height-inches
  text:
    v: Inches
  answer:
    value: Quantity
      value:
        v: 65
      unit:
        v: [in_i]
      system:
        v: http://unitsofmeasure.org
      code:
        v: [in_i]

link id:
  v: mothers-prepregnancy-weight
text:
  v: lbs
answer:
  value: Quantity
    value:
      v: 180
    unit:
      v: [lb_av]
    system:
      v: http://unitsofmeasure.org
    code:
      v: [lb_av]

link id:
  v: mothers-smoking
text:
  v: 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:
  link id:
    v: mothers-smoking-3-months-prior
  text:
    v: Three months before pregnancy
  item:
    link id:
      v: mothers-smoking-3-months-prior-cig
    text:
      v: # of cigarettes*
    answer:
      value: integer
        v: 0
  item:
    link id:
      v: mothers-smoking-3-months-prior-pck
    text:
      v: # of packs
    answer:
      value: integer
        v: 0
item:
  link id:
    v: mothers-smoking-trimester-1
  text:
    v: First three months of pregnancy
  item:
    link id:
      v: mothers-smoking-trimester-1-cig
    text:
      v: # of cigarettes*
    answer:
      value: integer
        v: 0
  item:
    link id:
      v: mothers-smoking-trimester-1-pck
    text:
      v: # of packs
    answer:
      value: integer
        v: 0
item:
  link id:
    v: mothers-smoking-trimester-2
  text:
    v: Second three months of pregnancy
  item:
    link id:
      v: mothers-smoking-trimester-2-cig
    text:
      v: # of cigarettes*
    answer:
      value: integer
        v: 0
  item:
    link id:
      v: mothers-smoking-trimester-2-pck
    text:
      v: # of packs
    answer:
      value: integer
        v: 0
item:
  link id:
    v: mothers-smoking-trimester-3
  text:
    v: Third trimester of pregnancy
  item:
    link id:
      v: mothers-smoking-trimester-3-cig
    text:
      v: # of cigarettes*
    answer:
      value: integer
        v: 0
  item:
    link id:
      v: mothers-smoking-trimester-3-pck
    text:
      v: # of packs
    answer:
      value: integer
        v: 0