Structured Data Capture
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Structured Data Capture, published by HL7 International - FHIR Infrastructure Work Group. This is not an authorized publication; it is the continuous build for version 3.0.0). This version is based on the current content of https://github.com/HL7/sdc/ and changes regularly. See the Directory of published versions

Example QuestionnaireResponse: SDC-Response to LOINC USSG Family History

Page standards status: Informative
LinkIdTextDefinitionAnswerdoco
.. questionnaireresponse-sdc-example-ussg-fht-answersQuestionnaireResponse
... 0
.... 0.1Date Done2008-01-17
... 1Your health information
.... 1.1
..... 1.1.1NameAnnie Proband
..... 1.1.2GenderLOINC LA3-6: Female
..... 1.1.3Date of Birth1966-04-04
..... 1.1.4Were you born a twin?LOINC LA32-8: No
..... 1.1.5Were you adopted?LOINC LA32-8: No
..... 1.1.6Are your parents related to each other in any way other than marriage?LOINC LA32-8: No
..... 1.1.7Height63
...... 1.1.7.1.1UnitsUCUM [in_i]: inch (international)
..... 1.1.8Weight127
...... 1.1.8.1.1UnitsUCUM [lb_av]: pound (US and British)
..... 1.1.9Body mass index (BMI) [Ratio]22.5
..... 1.1.10RaceLOINC LA4457-3: White
..... 1.1.11Ethnicity
... 2Family member health information
.... 2.1.1
..... 2.1.1.1Relationship to youLOINC LA10405-1: Daughter
..... 2.1.1.2NameSusan
..... 2.1.1.3GenderLOINC LA3-6: Female
..... 2.1.1.4Living?LOINC LA33-6: Yes
...... 2.1.1.4.2
....... 2.1.1.4.2.2Age17
..... 2.1.1.5Was this person born a twin?LOINC LA32-8: No
..... 2.1.1.6Was this person adopted?LOINC LA32-8: No
... 2Family member health information
.... 2.1.1
..... 2.1.1.1Relationship to youLOINC LA10415-0: Brother
..... 2.1.1.2NameBrian
..... 2.1.1.3GenderLOINC LA2-8: Male
..... 2.1.1.4Living?LOINC LA33-6: Yes
...... 2.1.1.4.2
....... 2.1.1.4.2.2Age32
..... 2.1.1.5Was this person born a twin?LOINC LA32-8: No
..... 2.1.1.6Was this person adopted?LOINC LA32-8: No
.... 2.1.2This family member's history of disease
..... 2.1.2.1Disease or ConditionLOINC LA14284-6: Other Cancer
..... 2.1.2.2Age at DiagnosisLOINC LA10397-0: 30-39
... 2Family member health information
.... 2.1.1
..... 2.1.1.1Relationship to youLOINC LA10418-4: Sister
..... 2.1.1.2NameJanet
..... 2.1.1.3GenderLOINC LA3-6: Female
..... 2.1.1.4Living?LOINC LA33-6: Yes
...... 2.1.1.4.2
....... 2.1.1.4.2.2Age36
..... 2.1.1.5Was this person born a twin?LOINC LA32-8: No
..... 2.1.1.6Was this person adopted?LOINC LA32-8: No
.... 2.1.2This family member's history of disease
..... 2.1.2.1Disease or ConditionLOINC LA14283-8: Breast Cancer
..... 2.1.2.2Age at DiagnosisLOINC LA10397-0: 30-39
... 2Family member health information
.... 2.1.1
..... 2.1.1.1Relationship to youLOINC LA10419-2: Nephew
..... 2.1.1.2NameIan
..... 2.1.1.3GenderLOINC LA2-8: Male
..... 2.1.1.4Living?LOINC LA33-6: Yes
...... 2.1.1.4.2
....... 2.1.1.4.2.2Age16
..... 2.1.1.5Was this person born a twin?LOINC LA32-8: No
..... 2.1.1.6Was this person adopted?LOINC LA32-8: No
... 2Family member health information
.... 2.1.1
..... 2.1.1.1Relationship to youLOINC LA10420-0: Niece
..... 2.1.1.2NameHelen
..... 2.1.1.3GenderLOINC LA3-6: Female
..... 2.1.1.4Living?LOINC LA33-6: Yes
...... 2.1.1.4.2
....... 2.1.1.4.2.2Age15
..... 2.1.1.5Was this person born a twin?LOINC LA32-8: No
..... 2.1.1.6Was this person adopted?LOINC LA32-8: No
... 2Family member health information
.... 2.1.1
..... 2.1.1.1Relationship to youLOINC LA10416-8: Father
..... 2.1.1.2NameDonald
..... 2.1.1.3GenderLOINC LA2-8: Male
..... 2.1.1.4Living?LOINC LA33-6: Yes
...... 2.1.1.4.2
....... 2.1.1.4.2.2Age52
..... 2.1.1.5Was this person born a twin?LOINC LA32-8: No
..... 2.1.1.6Was this person adopted?LOINC LA32-8: No
... 2Family member health information
.... 2.1.1
..... 2.1.1.1Relationship to youLOINC LA10425-9: Paternal Uncle
..... 2.1.1.2NameEric
..... 2.1.1.3GenderLOINC LA2-8: Male
..... 2.1.1.4Living?LOINC LA33-6: Yes
...... 2.1.1.4.2
....... 2.1.1.4.2.2Age56
..... 2.1.1.5Was this person born a twin?LOINC LA32-8: No
..... 2.1.1.6Was this person adopted?LOINC LA32-8: No
... 2Family member health information
.... 2.1.1
..... 2.1.1.1Relationship to youLOINC LA10421-8: Paternal Aunt
..... 2.1.1.2NameFiona
..... 2.1.1.3GenderLOINC LA3-6: Female
..... 2.1.1.4Living?LOINC LA33-6: Yes
...... 2.1.1.4.2
....... 2.1.1.4.2.2Age57
..... 2.1.1.5Was this person born a twin?LOINC LA32-8: No
..... 2.1.1.6Was this person adopted?LOINC LA32-8: No
.... 2.1.2This family member's history of disease
..... 2.1.2.1Disease or ConditionLOINC LA10543-9: Skin Cancer
... 2Family member health information
.... 2.1.1
..... 2.1.1.1Relationship to youLOINC LA10423-4: Paternal Grandfather
..... 2.1.1.2NameBob
..... 2.1.1.3GenderLOINC LA2-8: Male
..... 2.1.1.4Living?LOINC LA32-8: No
...... 2.1.1.4.1
....... 2.1.1.4.1.1Cause of DeathLOINC LA10537-1: Colon Cancer
....... 2.1.1.4.1.2Age at DeathLOINC LA10400-2: OVER 60
..... 2.1.1.5Was this person born a twin?LOINC LA32-8: No
..... 2.1.1.6Was this person adopted?LOINC LA32-8: No
.... 2.1.2This family member's history of disease
..... 2.1.2.1Disease or ConditionLOINC LA10537-1: Colon Cancer
..... 2.1.2.2Age at DiagnosisLOINC LA10400-2: OVER 60
... 2Family member health information
.... 2.1.1
..... 2.1.1.1Relationship to youLOINC LA10424-2: Paternal Grandmother
..... 2.1.1.2NameClaire
..... 2.1.1.3GenderLOINC LA3-6: Female
..... 2.1.1.4Living?LOINC LA32-8: No
...... 2.1.1.4.1
....... 2.1.1.4.1.1Cause of DeathLOINC LA10589-2: Other/Unexpected
........ 2.1.1.4.1.1.1Please specifyLou Gehrigs
....... 2.1.1.4.1.2Age at DeathLOINC LA10400-2: OVER 60
..... 2.1.1.5Was this person born a twin?LOINC LA32-8: No
..... 2.1.1.6Was this person adopted?LOINC LA32-8: No
... 2Family member health information
.... 2.1.1
..... 2.1.1.1Relationship to youLOINC LA10417-6: Mother
..... 2.1.1.2NameHarriet
..... 2.1.1.3GenderLOINC LA3-6: Female
..... 2.1.1.4Living?LOINC LA32-8: No
...... 2.1.1.4.1
....... 2.1.1.4.1.1Cause of DeathLOINC LA15682-0: Ovarian Cancer
....... 2.1.1.4.1.2Age at DeathLOINC LA10399-6: 50-59
..... 2.1.1.5Was this person born a twin?LOINC LA32-8: No
..... 2.1.1.6Was this person adopted?LOINC LA32-8: No
.... 2.1.2This family member's history of disease
..... 2.1.2.1Disease or ConditionLOINC LA15682-0: Ovarian Cancer
..... 2.1.2.2Age at DiagnosisLOINC LA10398-8: 40-49
... 2Family member health information
.... 2.1.1
..... 2.1.1.1Relationship to youLOINC LA10414-3: Maternal Uncle
..... 2.1.1.2NameRudy
..... 2.1.1.3GenderLOINC LA2-8: Male
..... 2.1.1.4Living?LOINC LA33-6: Yes
...... 2.1.1.4.2
....... 2.1.1.4.2.2Age60
..... 2.1.1.5Was this person born a twin?LOINC LA32-8: No
..... 2.1.1.6Was this person adopted?LOINC LA32-8: No
... 2Family member health information
.... 2.1.1
..... 2.1.1.1Relationship to youLOINC LA10410-1: Maternal Aunt
..... 2.1.1.2NameJulie
..... 2.1.1.3GenderLOINC LA3-6: Female
..... 2.1.1.4Living?LOINC LA33-6: Yes
...... 2.1.1.4.2
....... 2.1.1.4.2.2Age57
..... 2.1.1.5Was this person born a twin?LOINC LA32-8: No
..... 2.1.1.6Was this person adopted?LOINC LA32-8: No
... 2Family member health information
.... 2.1.1
..... 2.1.1.1Relationship to youLOINC LA10412-7: Maternal Grandfather
..... 2.1.1.2NameIan
..... 2.1.1.3GenderLOINC LA2-8: Male
..... 2.1.1.4Living?LOINC LA32-8: No
...... 2.1.1.4.1
....... 2.1.1.4.1.1Cause of DeathLOINC LA16286-9: Heart attack
....... 2.1.1.4.1.2Age at DeathLOINC LA10400-2: OVER 60
..... 2.1.1.5Was this person born a twin?LOINC LA32-8: No
..... 2.1.1.6Was this person adopted?LOINC LA32-8: No
... 2Family member health information
.... 2.1.1
..... 2.1.1.1Relationship to youLOINC LA10413-5: Maternal Grandmother
..... 2.1.1.2NameGladys
..... 2.1.1.3GenderLOINC LA3-6: Female
..... 2.1.1.4Living?LOINC LA32-8: No
...... 2.1.1.4.1
....... 2.1.1.4.1.1Cause of DeathLOINC LA10589-2: Other/Unexpected
....... 2.1.1.4.1.2Age at DeathLOINC LA10400-2: OVER 60
..... 2.1.1.5Was this person born a twin?LOINC LA32-8: No
..... 2.1.1.6Was this person adopted?LOINC LA32-8: No
.... 2.1.2This family member's history of disease
..... 2.1.2.1Disease or ConditionLOINC LA14283-8: Breast Cancer
..... 2.1.2.2Age at DiagnosisLOINC LA10399-6: 50-59
.... 2.1.2This family member's history of disease
..... 2.1.2.1Disease or ConditionLOINC LA16982-3: Asthma
..... 2.1.2.2Age at DiagnosisLOINC LA10395-4: Childhood
... 2Family member health information
.... 2.1.1
..... 2.1.1.1Relationship to youLOINC LA10411-9: Maternal Cousin
..... 2.1.1.2NameKarren
..... 2.1.1.3GenderLOINC LA3-6: Female
..... 2.1.1.4Living?LOINC LA33-6: Yes
...... 2.1.1.4.2
....... 2.1.1.4.2.2Age30
..... 2.1.1.5Was this person born a twin?LOINC LA32-8: No
..... 2.1.1.6Was this person adopted?LOINC LA32-8: No
.... 2.1.2This family member's history of disease
..... 2.1.2.1Disease or ConditionLOINC LA14283-8: Breast Cancer
..... 2.1.2.2Age at DiagnosisLOINC LA10397-0: 30-39
... 2Family member health information
.... 2.1.1
..... 2.1.1.1Relationship to youLOINC LA10411-9: Maternal Cousin
..... 2.1.1.2NameMary
..... 2.1.1.3GenderLOINC LA3-6: Female
..... 2.1.1.4Living?LOINC LA33-6: Yes
...... 2.1.1.4.2
....... 2.1.1.4.2.2Age31
..... 2.1.1.5Was this person born a twin?LOINC LA32-8: No
..... 2.1.1.6Was this person adopted?LOINC LA32-8: No

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