Structured Data Capture
4.0.0-ci-build - STU 4 CI-build International flag

Structured Data Capture, published by HL7 International / FHIR Infrastructure. This guide is not an authorized publication; it is the continuous build for version 4.0.0-ci-build built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/sdc/ and changes regularly. See the Directory of published versions

Questionnaire: Cardiology Form

Official URL: http://hl7.org/fhir/uv/sdc/Questionnaire/CardiologyForm Version: 4.0.0-ci-build
Standards status: Trial-use Maturity Level: 4 Computable Name:
Other Identifiers: OID:2.16.840.1.113883.4.642.40.17.35.43

This example contains custom embedded extensions that define the appearance of a form that are used to drive the creation of the rendering Liquid. These include extensions that override the text, manage whitespace, change color and formatting, grouping, etc. None of these extensions are 'standard'. They are included here only as examples of the sort of additional metadata an author could potentially include in their Questionnaire to help drive the rendering process.

To find the extensions, look at one of the computable views (XML, JSON, or TTL) and search for note-info, which is part of the name of the example extensions used on groups, questions, display items, and answer options within this example.

Language: en

Structure
LinkIDTextCardinalityTypeFlagsDescription & Constraintsdoco
.. Questionnaire http://hl7.org/fhir/uv/sdc/Questionnaire/CardiologyForm#4.0.0-ci-build
... patient_header Patient Information 0..1 group Value Set:
.... patient_surname Surname: 1..1 string Value Set:
.... patient_firstname First Name: 1..1 string Value Set:
.... patient_date_of_birth DOB: 1..1 date Value Set:
.... patient_gender Gender: 1..1 choice Value Set:
Options: 3 options
.... patient_hc_pc HN PC: 0..1 string Max Length: 2
Value Set:
..... patient_hc_number HN: 0..1 string Max Length: 10
Value Set:
..... patient_hc_vc HN VC: 0..1 string Value Set:
.... patient_address_line1 Address (Line 1): 1..1 string Value Set:
..... patient_address_line2 Address (Line 2): 0..1 string Value Set:
..... patient_address_city City: 1..1 string Value Set:
..... patient_address_province Province: 1..1 string Max Length: 2
Value Set:
..... patient_address_postalcode Postal Code: 1..1 string Value Set:
.... patient_phone_mobile Mobile #: 0..1 string Value Set:
.... patient_phone_home Home #: 0..1 string Value Set:
.... patient_phone_business Business #: 0..1 string Value Set:
.... patient_email Email: 0..1 string Value Set:
... additionalinfo_header [Optional] Additional Patient Information 0..1 group Value Set:
.... additionalinfo_sexassignedatbirth Sex assigned at birth: 0..1 choice iconicon Value Set:
Options: 4 options
.... additionalinfo_pronouns Pronouns: 0..1 choice Value Set:
Options: 4 options
..... additionalinfo_pronouns_other Other pronouns: 1..1 string Enable When: additionalinfo_pronouns = other (NullFlavor#OTH)
Value Set:
.... additionalinfo_preferredlanguage Preferred language: 0..1 choice iconicon Value Set:
Options: 3 options
..... additionalinfo_preferredlanguage_specify Specify: 1..1 string Enable When: additionalinfo_preferredlanguage = other (NullFlavor#OTH)
Value Set:
..... additionalinfo_preferredlanguage_translatorrequired Translator required 0..* string Enable When: additionalinfo_preferredlanguage = other (NullFlavor#OTH)
Value Set:
Options: 1 option
.... additionalinfo_bestmethodofcontact Best method of contact: 0..1 choice Value Set:
Options: 4 options
..... additionalinfo_bestmethodofcontact_voicemails Voicemails acceptable 0..* string Enable When: additionalinfo_bestmethodofcontact = Mobile (ContactPointUse#mobile)
Value Set:
Options: 1 option
.... additionalinfo_preferredname_select Preferred name 0..* string Value Set:
Options: 1 option
.... additionalinfo_preferredname Prefered name String 0..1 string Enable When: additionalinfo_preferredname_select = Preferred Name
Value Set:
.... additionalinfo_alternatecontact_select Alternate contact 0..* string Value Set:
Options: 1 option
.... additionalinfo_alternatecontact_name Name: 1..1 string Enable When: additionalinfo_alternatecontact_select = Alternate contact
Value Set:
.... additionalinfo_alternatecontact_phone Alternate contact phone #: 0..1 string Enable When: additionalinfo_alternatecontact_select = Alternate contact
Value Set:
.... additionalinfo_alternatecontact_relationship Relationship: 0..1 string Enable When: additionalinfo_alternatecontact_select = Alternate contact
Value Set:
.... additionalinfo_alternatecontact_bookingcontact Is Alternate contact the appointment booking contact?: 0..1 choice iconicon Enable When: additionalinfo_alternatecontact_select = Alternate contact
Value Set:
Options: 2 options
.... additionalinfo_unsafecontacts_select Unsafe contact persons (do not speak with) 0..* string Value Set:
Options: 1 option
.... additionalinfo_unsafecontacts_speakwithpatientdirectly Only speak with patient directly 0..* string Enable When: additionalinfo_unsafecontacts_select = Unsafe contact persons (do not speak with)
Value Set:
Options: 1 option
.... additionalinfo_unsafecontacts_donotspeakwith Do not speak with: 0..1 string Enable When: additionalinfo_unsafecontacts_select = Unsafe contact persons (do not speak with)
Value Set:
.... additionalinfo_accessibilityconcernsordisability_selectt Accessibility concerns or disability 0..* string Value Set:
Options: 1 option
.... additionalinfo_accessibilityconcernsordisability Accessibility concerns Options 0..* choice iconicon Enable When: additionalinfo_accessibilityconcernsordisability_selectt = Accessibility concerns or disability
Value Set:
Options: 4 options
.... additionalinfo_specialconsiderations_select Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues) 0..* string Value Set:
Options: 1 option
.... 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)
Value Set:
.... additionalinfo_sendcopiestoadditionalproviders Send copies of reports to additional providers 0..* string Value Set:
Options: 1 option
.... additionalinfo_sendcopiestoadditionalproviders_names Name(s): 1..1 string Enable When: additionalinfo_sendcopiestoadditionalproviders = Send copies of reports to additional providers
Value Set:
..... additionalinfo_sendcopiestoadditionalproviders_contactinfo Contact information: 1..1 string Enable When: additionalinfo_sendcopiestoadditionalproviders = Send copies of reports to additional providers
Value Set:
..... additionalinfo_sendcopiestoadditionalproviders_ispcp This is the Primary Care Provider 0..* string Enable When: additionalinfo_sendcopiestoadditionalproviders = Send copies of reports to additional providers
Value Set:
Options: 1 option
... 102173268919 Referral Details 0..1 group Value Set:
.... cardio_triagecons Triage Considerations 0..1 group Value Set:
..... referral_requestedpriority Requested Priority: 1..1 choice iconicon Value Set:
Options: 2 options
...... referral_requestedpriority_urgentreason Reason for urgent triage 1..1 string Enable When: referral_requestedpriority = Urgent (RequestPriority#urgent)
Value Set:
..... referral_secondopinion Second Opinion 0..* choice iconicon Value Set:
Options: 1 option
..... referral_secondopinion_reason Reason for second opinion: 0..1 text Enable When: referral_secondopinion = Second or third medical opinion (SNOMED CT#77406008)
Value Set:
.... 695991571585 Service(s) Requested Select all that apply: 1..1 group Value Set:
..... referralService HSCs Assigned: 0..1 string iconiconiconicon Value Set:
..... 223886162384 Cardiac Testing 0..* choice iconicon Value Set:
Options: 1 option
..... 660331267409 Exam(s) Requested 0..1 group Enable When: 223886162384 = Cardiac Testing (standardized-referral-form-codes#20001)
Value Set:
...... 720409326878 24 Hour Ambulatory Blood Pressure Monitoring 0..* choice iconicon Value Set:
Options: 1 option
...... 960455115596 Coronary Angiogram 0..* choice iconicon Value Set:
Options: 1 option
...... 297634898828 Echocardiogram - Resting 0..* choice iconicon Value Set:
Options: 1 option
...... 443484577720 sub Echocardiogram - Resting 0..1 group Enable When: 297634898828 = Echocardiogram - Resting (standardized-referral-form-codes#20005)
Value Set:
....... 165530569567 Echocardiogram (2D) 0..* choice Value Set:
Options: 1 option
....... 286552421895 Echocardiogram with Contrast 0..* choice iconicon Value Set:
Options: 1 option
....... 910527687300 Echocardiogram with Saline (Bubble) 0..* choice iconicon Value Set:
Options: 1 option
....... 657824763133 Pediatric Echocardiogram 0..* choice iconicon Value Set:
Options: 1 option
....... 992743200182 Transesophageal Echocardiogram (TEE) 0..* choice iconicon Value Set:
Options: 1 option
...... 894277763438 Electrocardiogram (ECG) 0..* choice iconicon Value Set:
Options: 1 option
...... 279226023495 Holter Monitoring 0..* choice iconicon Value Set:
Options: 1 option
...... 440449731882 sub holter monitoring 0..1 group Enable When: 279226023495 = Holter Monitoring (standardized-referral-form-codes#20007)
Value Set:
....... 671328703851 24 Hours 0..* choice iconicon Value Set:
Options: 1 option
....... 423992261841 48 Hours 0..* choice iconicon Value Set:
Options: 1 option
....... 419924239187 72 Hours 0..* choice iconicon Value Set:
Options: 1 option
....... 731054417270 7 Days 0..* choice iconicon Value Set:
Options: 1 option
....... 235876421044 14 Days 0..* choice iconicon Value Set:
Options: 1 option
...... 374742834400 Loop / Event Monitor 0..* choice iconicon Value Set:
Options: 1 option
...... 159161544747 Cardiovascular stress testing 0..* choice iconicon Value Set:
Options: 1 option
...... 370275060390 Sub Stress Testing 0..1 group Enable When: 159161544747 = Stress Testing (standardized-referral-form-codes#20009)
Value Set:
....... 814218498309 ECG - Exercise Stress Test 0..* choice iconicon Value Set:
Options: 1 option
....... 307107493993 ECG - Dobutamine/Persantine Stress Test 0..* choice iconicon Value Set:
Options: 1 option
....... 805303414102 Echocardiogram - Exercise Stress Test 0..* choice iconicon Value Set:
Options: 1 option
....... 193586908489 Echocardiogram - Dobutamine/Persantine Stress Test 0..* choice iconicon Value Set:
Options: 1 option
...... 918517139023 Nuclear Medicine 0..* choice iconicon Value Set:
Options: 1 option
...... 222686221935 sub Nuclear Medicine 0..1 group Enable When: 918517139023 = Nuclear Medicine (standardized-referral-form-codes#20010)
Value Set:
....... 924189648184 MUGA - Resting 0..* choice iconicon Value Set:
Options: 1 option
....... 857163514910 Cardiac Pyrophosphate 0..* choice iconicon Value Set:
Options: 1 option
....... 892165959617 Myocardial perfusion scan 0..* choice iconicon Value Set:
Options: 1 option
....... 538288549138 sub MIBI 0..1 group Enable When: 892165959617 = MIBI Scans / Myocardial Perfusion Imaging (MPI): (standardized-referral-form-codes#20028)
Value Set:
........ 373435981917 MIBI Scan - Exercise Stress Test 0..* string Value Set:
Options: 1 option
........ 434394942688 MIBI Scan - Dobutamine/Persantine Stress Test 0..* string Value Set:
Options: 1 option
........ 913594478162 Thallium Viability Test 0..* string Value Set:
Options: 1 option
...... 992682216482 Tilt Table Testing 0..* choice iconicon Value Set:
Options: 1 option
...... cardiology_referral_services_cardiactesting_other Other 0..* choice iconicon Value Set:
Options: 1 option
...... cardiology_referral_services_cardiactesting_other_specify Specify 1..1 text Enable When: cardiology_referral_services_cardiactesting_other = other (NullFlavor#OTH)
Value Set:
..... 785727177547 Cardiology Consultation 0..* choice iconicon Value Set:
Options: 1 option
.... 186952778859 Concern(s) / Indication(s) Triggering Referral Select all that apply: 1..1 group Value Set:
..... 219569805461 Arrhythmias or Palpitations 0..* choice iconicon Value Set:
Options: 1 option
..... 571934328499 Cardiovascular Risk Assessment 0..* choice iconicon Value Set:
Options: 1 option
..... 459737733395 Chest Pain or Angina 0..* choice iconicon Value Set:
Options: 1 option
..... 929919815516 Congenital Heart Disease 0..* choice iconicon Value Set:
Options: 1 option
..... 832263816528 Congestive Heart Failure 0..* choice iconicon Value Set:
Options: 1 option
..... 803760213460 Coronary Artery Disease 0..* choice iconicon Value Set:
Options: 1 option
..... 129767162379 Dyspnea 0..* choice iconicon Value Set:
Options: 1 option
..... 116150628533 Hypertension 0..* choice iconicon Value Set:
Options: 1 option
..... 513825527027 Murmur 0..* choice iconicon Value Set:
Options: 1 option
..... 975075898688 Pericardial Disease 0..* choice iconicon Value Set:
Options: 1 option
..... 704148928571 Peripheral Edema 0..* choice iconicon Value Set:
Options: 1 option
..... 886489617115 Post-Myocardial Infarction 0..* choice iconicon Value Set:
Options: 1 option
..... 621745958993 Pre-operative Consultation 0..* choice iconicon Value Set:
Options: 1 option
..... 873024527134 Procedure Date (if known) 0..1 date Enable When: 621745958993 = Pre-operative Consultation (standardized-referral-form-codes#20044)
Value Set:
..... 197975129599 Syncope 0..* choice iconicon Value Set:
Options: 1 option
..... 675849150752 Valvular Heart Disease or Prosthetic Heart Valve 0..* choice iconicon Value Set:
Options: 1 option
..... 721982740516 Other 0..* choice iconicon Value Set:
Options: 1 option
..... 720594942482 Specify 1..1 text Enable When: 721982740516 = other (NullFlavor#OTH)
Value Set:
.... Descriptionofclinicalquestion Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations 1..1 text Value Set:
.... cpp_separate CPP attached separately (if not entered below) 0..* string Value Set:
Options: 1 option
.... cpp_currentprob Current Problem List: 0..1 text Enable When: cpp_separate exists false
Value Set:
.... cpp_pastmedicalhistory Past Medical History: 0..1 text Enable When: cpp_separate exists false
Value Set:
.... cpp_currentmedications Current Medications : 0..1 text Enable When: cpp_separate exists false
Value Set:
.... cpp_familyhistory Family History: 0..1 text Enable When: cpp_separate exists false
Value Set:
.... cpp_allergies Allergies: 0..1 text Enable When: cpp_separate exists false
Value Set:
... 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 Value Set:
.... preferredconsultlocation_selector Preferred consultant or location 0..* string Value Set:
Options: 1 option
.... preferredconsultlocation_specify Please specify either a preferred consultant or location 0..1 group Enable When: preferredconsultlocation_selector = Preferred consultant or location
Value Set:
..... preferredconsultlocation_consultant Consultant: 0..1 string Value Set:
..... preferredconsultlocation_location Location: 0..1 string Value Set:
.... preferredconsultlocation_willingtotravel Patient willing to travel for shorter wait time 0..* string Value Set:
Options: 1 option
.... preferredconsultlocation_otherconsiderations Other considerations: 0..1 string Value Set:
... supportingdocumentation_header Supporting Documentation Please attach all relevant laboratory and diagnostic investigations. 0..1 group Value Set:
.... supportingdocumentation_details Personal Health Information that is medically relevant has not been disclosed at the request of the patient. 0..* string Value Set:
Options: 1 option
... supportingdocumentation_attachment Add Attachments 0..1 attachment Value Set:
... feedbacksurvey_cardiology Click here to provide feedback on this form 0..1 display Value Set:
... referrer_header Referrer's Information 0..1 group Value Set:
.... referrer_sitename Site Name: 0..1 string Value Set:
.... referrer_address_line1 Address (Line 1): 1..1 string Value Set:
..... referrer_address_line2 Address (Line 2): 0..1 string Value Set:
..... referrer_address_city City: 1..1 string Value Set:
..... referrer_address_province Province: 1..1 string Max Length: 2
Value Set:
..... referrer_address_postalcode Postal Code: 1..1 string Value Set:
.... referrer_phone Phone #: 0..1 string Value Set:
.... referrer_fax Fax #: 0..1 string Value Set:
.... referrer_billing Billing Number: 0..1 integer Value Set:
.... referrer_professionalid Professional ID: 0..1 integer Value Set:
.... referrer_signature Signed: 1..1 text Value Set:
.... referrer_role Role: 0..1 choice Value Set:
Options: 9 options

doco 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")

Language: en

Patient Information

  • linkId: patient_header
  • Answers:

Surname:*

  • linkId: patient_surname
  • Answers:

First Name:*

  • linkId: patient_firstname
  • Answers:

DOB:*

  • linkId: patient_date_of_birth
  • Answers:

Gender:*

HN PC:

  • linkId: patient_hc_pc
  • Max Length:: 2
  • Answers:

HN:

  • linkId: patient_hc_number
  • Max Length:: 10
  • Answers:

HN VC:

  • linkId: patient_hc_vc
  • Answers:

Address (Line 1):*

  • linkId: patient_address_line1
  • Answers:

Address (Line 2):

  • linkId: patient_address_line2
  • Answers:

City:*

  • linkId: patient_address_city
  • Answers:

Province:*

  • linkId: patient_address_province
  • Max Length:: 2
  • Answers:

Postal Code:*

  • linkId: patient_address_postalcode
  • Answers:

Mobile #:

  • linkId: patient_phone_mobile
  • Answers:

Home #:

  • linkId: patient_phone_home
  • Answers:

Business #:

  • linkId: patient_phone_business
  • Answers:

Email:

  • linkId: patient_email
  • Answers:

[Optional] Additional Patient Information

  • linkId: additionalinfo_header
  • Answers:

Sex assigned at birth:

Pronouns:

Other pronouns:*

  • linkId: additionalinfo_pronouns_other
  • Enable When: todo
  • Answers:

Preferred language:

Specify:*

  • linkId: additionalinfo_preferredlanguage_specify
  • Enable When: todo
  • Answers:

Translator required

  • linkId: additionalinfo_preferredlanguage_translatorrequired
  • Enable When: todo
  • Answers:
  • Answers: 1 option

Best method of contact:

Voicemails acceptable

  • linkId: additionalinfo_bestmethodofcontact_voicemails
  • Enable When: todo
  • Answers:
  • Answers: 1 option

Preferred name

Prefered name String

  • linkId: additionalinfo_preferredname
  • Enable When: todo
  • Answers:

Alternate contact

Name:*

  • linkId: additionalinfo_alternatecontact_name
  • Enable When: todo
  • Answers:

Alternate contact phone #:

  • linkId: additionalinfo_alternatecontact_phone
  • Enable When: todo
  • Answers:

Relationship:

  • linkId: additionalinfo_alternatecontact_relationship
  • Enable When: todo
  • Answers:

Is Alternate contact the appointment booking contact?:

  • linkId: additionalinfo_alternatecontact_bookingcontact
  • Enable When: todo
  • Answers:
  • Answers: 2 options

Unsafe contact persons (do not speak with)

Only speak with patient directly

  • linkId: additionalinfo_unsafecontacts_speakwithpatientdirectly
  • Enable When: todo
  • Answers:
  • Answers: 1 option

Do not speak with:

  • linkId: additionalinfo_unsafecontacts_donotspeakwith
  • Enable When: todo
  • Answers:

Accessibility concerns or disability

  • linkId: additionalinfo_accessibilityconcernsordisability_selectt
  • Answers:
  • Answers: 1 option

Accessibility concerns Options

  • linkId: additionalinfo_accessibilityconcernsordisability
  • Enable When: todo
  • Answers:
  • Answers: 4 options

Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)

Details of special considerations:*

  • linkId: additionalinfo_specialconsiderations
  • Enable When: todo
  • Answers:

Send copies of reports to additional providers

Name(s):*

  • linkId: additionalinfo_sendcopiestoadditionalproviders_names
  • Enable When: todo
  • Answers:

Contact information:*

  • linkId: additionalinfo_sendcopiestoadditionalproviders_contactinfo
  • Enable When: todo
  • Answers:

This is the Primary Care Provider

  • linkId: additionalinfo_sendcopiestoadditionalproviders_ispcp
  • Enable When: todo
  • Answers:
  • Answers: 1 option

Referral Details

  • linkId: 102173268919
  • Answers:

Triage Considerations

  • linkId: cardio_triagecons
  • Answers:

Requested Priority:*

Reason for urgent triage*

  • linkId: referral_requestedpriority_urgentreason
  • Enable When: todo
  • Answers:

Second Opinion

Reason for second opinion:

  • linkId: referral_secondopinion_reason
  • Enable When: todo
  • Answers:

Service(s) Requested Select all that apply:*

  • linkId: 695991571585
  • Answers:

HSCs Assigned:

  • Flags: icon
  • linkId: referralService
  • Answers:

Cardiac Testing

Exam(s) Requested

  • linkId: 660331267409
  • Enable When: todo
  • Answers:

24 Hour Ambulatory Blood Pressure Monitoring

Coronary Angiogram

Echocardiogram - Resting

sub Echocardiogram - Resting

  • linkId: 443484577720
  • Enable When: todo
  • Answers:

Echocardiogram (2D)

Echocardiogram with Contrast

Echocardiogram with Saline (Bubble)

Pediatric Echocardiogram

Transesophageal Echocardiogram (TEE)

Electrocardiogram (ECG)

Holter Monitoring

sub holter monitoring

  • linkId: 440449731882
  • Enable When: todo
  • Answers:

24 Hours

48 Hours

72 Hours

7 Days

14 Days

Loop / Event Monitor

Cardiovascular stress testing

Sub Stress Testing

  • linkId: 370275060390
  • Enable When: todo
  • Answers:

ECG - Exercise Stress Test

ECG - Dobutamine/Persantine Stress Test

Echocardiogram - Exercise Stress Test

Echocardiogram - Dobutamine/Persantine Stress Test

Nuclear Medicine

sub Nuclear Medicine

  • linkId: 222686221935
  • Enable When: todo
  • Answers:

MUGA - Resting

Cardiac Pyrophosphate

Myocardial perfusion scan

sub MIBI

  • linkId: 538288549138
  • Enable When: todo
  • Answers:

MIBI Scan - Exercise Stress Test

MIBI Scan - Dobutamine/Persantine Stress Test

Thallium Viability Test

Tilt Table Testing

Other

Specify*

  • linkId: cardiology_referral_services_cardiactesting_other_specify
  • Enable When: todo
  • Answers:

Cardiology Consultation

Concern(s) / Indication(s) Triggering Referral Select all that apply:*

  • linkId: 186952778859
  • Answers:

Arrhythmias or Palpitations

Cardiovascular Risk Assessment

Chest Pain or Angina

Congenital Heart Disease

Congestive Heart Failure

Coronary Artery Disease

Dyspnea

Hypertension

Murmur

Pericardial Disease

Peripheral Edema

Post-Myocardial Infarction

Pre-operative Consultation

Procedure Date (if known)

  • linkId: 873024527134
  • Enable When: todo
  • Answers:

Syncope

Valvular Heart Disease or Prosthetic Heart Valve

Other

Specify*

  • linkId: 720594942482
  • Enable When: todo
  • Answers:

Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations*

  • linkId: Descriptionofclinicalquestion
  • Answers:

Cumulative Patient Profile Please delete any sensitive information you do not intend to share from the CPP

  • linkId: cpp_header
  • Answers:

CPP attached separately (if not entered below)

Current Problem List:

  • linkId: cpp_currentprob
  • Enable When: todo
  • Answers:

Past Medical History:

  • linkId: cpp_pastmedicalhistory
  • Enable When: todo
  • Answers:

Current Medications :

  • linkId: cpp_currentmedications
  • Enable When: todo
  • Answers:

Family History:

  • linkId: cpp_familyhistory
  • Enable When: todo
  • Answers:

Allergies:

  • linkId: cpp_allergies
  • Enable When: todo
  • Answers:

Preferred Consultant or Location All patients will be triaged to the shortest wait time unless a preferred consultant or location is entered.

  • linkId: preferredconsultlocation_header
  • Answers:

Preferred consultant or location

Please specify either a preferred consultant or location

  • linkId: preferredconsultlocation_specify
  • Enable When: todo
  • Answers:

Consultant:

  • linkId: preferredconsultlocation_consultant
  • Answers:

Location:

  • linkId: preferredconsultlocation_location
  • Answers:

Patient willing to travel for shorter wait time

Other considerations:

  • linkId: preferredconsultlocation_otherconsiderations
  • Answers:

Supporting Documentation Please attach all relevant laboratory and diagnostic investigations.

  • linkId: supportingdocumentation_header
  • Answers:

Personal Health Information that is medically relevant has not been disclosed at the request of the patient.

Add Attachments

  • linkId: supportingdocumentation_attachment
  • Answers:

Click here to provide feedback on this form

  • linkId: feedbacksurvey_cardiology
  • Answers:

Referrer's Information

  • linkId: referrer_header
  • Answers:

Site Name:

  • linkId: referrer_sitename
  • Answers:

Address (Line 1):*

  • linkId: referrer_address_line1
  • Answers:

Address (Line 2):

  • linkId: referrer_address_line2
  • Answers:

City:*

  • linkId: referrer_address_city
  • Answers:

Province:*

  • linkId: referrer_address_province
  • Max Length:: 2
  • Answers:

Postal Code:*

  • linkId: referrer_address_postalcode
  • Answers:

Phone #:

  • linkId: referrer_phone
  • Answers:

Fax #:

  • linkId: referrer_fax
  • Answers:

Billing Number:

  • linkId: referrer_billing
  • Answers:

Professional ID:

  • linkId: referrer_professionalid
  • Answers:

Signed:*

  • linkId: referrer_signature
  • Answers:

Role:

Language: en

LinkIDDescription & Constraintsdoco
.. patient_header Value Set:
... patient_surname Value Set:
... patient_firstname Value Set:
... patient_date_of_birth Value Set:
... patient_hc_pc Max Length: 2
Value Set:
.... patient_hc_number Max Length: 10
Value Set:
.... patient_hc_vc Value Set:
... patient_address_line1 Value Set:
.... patient_address_line2 Value Set:
.... patient_address_city Value Set:
.... patient_address_province Max Length: 2
Value Set:
.... patient_address_postalcode Value Set:
... patient_phone_mobile Value Set:
... patient_phone_home Value Set:
... patient_phone_business Value Set:
... patient_email Value Set:
.. additionalinfo_header Value Set:
... additionalinfo_sexassignedatbirth Value Set:
Options: 4 options
... additionalinfo_pronouns Value Set:
Options: 4 options
.... additionalinfo_pronouns_other Enable When: Not done yet
Value Set:
... additionalinfo_preferredlanguage Value Set:
Options: 3 options
.... additionalinfo_preferredlanguage_specify Enable When: Not done yet
Value Set:
.... additionalinfo_preferredlanguage_translatorrequired Enable When: Not done yet
Value Set:
Options: 1 option
... additionalinfo_bestmethodofcontact Value Set:
Options: 4 options
.... additionalinfo_bestmethodofcontact_voicemails Enable When: Not done yet
Value Set:
Options: 1 option
... additionalinfo_preferredname_select Value Set:
Options: 1 option
... additionalinfo_preferredname Enable When: Not done yet
Value Set:
... additionalinfo_alternatecontact_select Value Set:
Options: 1 option
... additionalinfo_alternatecontact_name Enable When: Not done yet
Value Set:
... additionalinfo_alternatecontact_phone Enable When: Not done yet
Value Set:
... additionalinfo_alternatecontact_relationship Enable When: Not done yet
Value Set:
... additionalinfo_alternatecontact_bookingcontact Enable When: Not done yet
Value Set:
Options: 2 options
... additionalinfo_unsafecontacts_select Value Set:
Options: 1 option
... additionalinfo_unsafecontacts_speakwithpatientdirectly Enable When: Not done yet
Value Set:
Options: 1 option
... additionalinfo_unsafecontacts_donotspeakwith Enable When: Not done yet
Value Set:
... additionalinfo_accessibilityconcernsordisability_selectt Value Set:
Options: 1 option
... additionalinfo_accessibilityconcernsordisability Enable When: Not done yet
Value Set:
Options: 4 options
... additionalinfo_specialconsiderations_select Value Set:
Options: 1 option
... additionalinfo_specialconsiderations Enable When: Not done yet
Value Set:
... additionalinfo_sendcopiestoadditionalproviders Value Set:
Options: 1 option
... additionalinfo_sendcopiestoadditionalproviders_names Enable When: Not done yet
Value Set:
.... additionalinfo_sendcopiestoadditionalproviders_contactinfo Enable When: Not done yet
Value Set:
.... additionalinfo_sendcopiestoadditionalproviders_ispcp Enable When: Not done yet
Value Set:
Options: 1 option
.. 102173268919 Value Set:
... cardio_triagecons Value Set:
.... referral_requestedpriority Value Set:
Options: 2 options
..... referral_requestedpriority_urgentreason Enable When: Not done yet
Value Set:
.... referral_secondopinion Value Set:
Options: 1 option
.... referral_secondopinion_reason Enable When: Not done yet
Value Set:
... 695991571585 Value Set:
.... referralService Value Set:
.... 223886162384 Value Set:
Options: 1 option
.... 660331267409 Enable When: Not done yet
Value Set:
..... 720409326878 Value Set:
Options: 1 option
..... 960455115596 Value Set:
Options: 1 option
..... 297634898828 Value Set:
Options: 1 option
..... 443484577720 Enable When: Not done yet
Value Set:
...... 165530569567 Value Set:
Options: 1 option
...... 286552421895 Value Set:
Options: 1 option
...... 910527687300 Value Set:
Options: 1 option
...... 657824763133 Value Set:
Options: 1 option
...... 992743200182 Value Set:
Options: 1 option
..... 894277763438 Value Set:
Options: 1 option
..... 279226023495 Value Set:
Options: 1 option
..... 440449731882 Enable When: Not done yet
Value Set:
...... 671328703851 Value Set:
Options: 1 option
...... 423992261841 Value Set:
Options: 1 option
...... 419924239187 Value Set:
Options: 1 option
...... 731054417270 Value Set:
Options: 1 option
...... 235876421044 Value Set:
Options: 1 option
..... 374742834400 Value Set:
Options: 1 option
..... 159161544747 Value Set:
Options: 1 option
..... 370275060390 Enable When: Not done yet
Value Set:
...... 814218498309 Value Set:
Options: 1 option
...... 307107493993 Value Set:
Options: 1 option
...... 805303414102 Value Set:
Options: 1 option
...... 193586908489 Value Set:
Options: 1 option
..... 918517139023 Value Set:
Options: 1 option
..... 222686221935 Enable When: Not done yet
Value Set:
...... 924189648184 Value Set:
Options: 1 option
...... 857163514910 Value Set:
Options: 1 option
...... 892165959617 Value Set:
Options: 1 option
...... 538288549138 Enable When: Not done yet
Value Set:
....... 373435981917 Value Set:
Options: 1 option
....... 434394942688 Value Set:
Options: 1 option
....... 913594478162 Value Set:
Options: 1 option
..... 992682216482 Value Set:
Options: 1 option
..... cardiology_referral_services_cardiactesting_other Value Set:
Options: 1 option
..... cardiology_referral_services_cardiactesting_other_specify Enable When: Not done yet
Value Set:
.... 785727177547 Value Set:
Options: 1 option
... 186952778859 Value Set:
.... 219569805461 Value Set:
Options: 1 option
.... 571934328499 Value Set:
Options: 1 option
.... 459737733395 Value Set:
Options: 1 option
.... 929919815516 Value Set:
Options: 1 option
.... 832263816528 Value Set:
Options: 1 option
.... 803760213460 Value Set:
Options: 1 option
.... 129767162379 Value Set:
Options: 1 option
.... 116150628533 Value Set:
Options: 1 option
.... 513825527027 Value Set:
Options: 1 option
.... 975075898688 Value Set:
Options: 1 option
.... 704148928571 Value Set:
Options: 1 option
.... 886489617115 Value Set:
Options: 1 option
.... 621745958993 Value Set:
Options: 1 option
.... 873024527134 Enable When: Not done yet
Value Set:
.... 197975129599 Value Set:
Options: 1 option
.... 675849150752 Value Set:
Options: 1 option
.... 721982740516 Value Set:
Options: 1 option
.... 720594942482 Enable When: Not done yet
Value Set:
... Descriptionofclinicalquestion Value Set:
.. cpp_header Value Set:
... cpp_separate Value Set:
Options: 1 option
... cpp_currentprob Enable When: Not done yet
Value Set:
... cpp_pastmedicalhistory Enable When: Not done yet
Value Set:
... cpp_currentmedications Enable When: Not done yet
Value Set:
... cpp_familyhistory Enable When: Not done yet
Value Set:
... cpp_allergies Enable When: Not done yet
Value Set:
.. preferredconsultlocation_header Value Set:
... preferredconsultlocation_selector Value Set:
Options: 1 option
... preferredconsultlocation_specify Enable When: Not done yet
Value Set:
.... preferredconsultlocation_consultant Value Set:
.... preferredconsultlocation_location Value Set:
... preferredconsultlocation_willingtotravel Value Set:
Options: 1 option
... preferredconsultlocation_otherconsiderations Value Set:
.. supportingdocumentation_header Value Set:
... supportingdocumentation_details Value Set:
Options: 1 option
.. supportingdocumentation_attachment Value Set:
.. feedbacksurvey_cardiology Value Set:
.. referrer_header Value Set:
... referrer_sitename Value Set:
... referrer_address_line1 Value Set:
.... referrer_address_line2 Value Set:
.... referrer_address_city Value Set:
.... referrer_address_province Max Length: 2
Value Set:
.... referrer_address_postalcode Value Set:
... referrer_phone Value Set:
... referrer_fax Value Set:
... referrer_billing Value Set:
... referrer_professionalid Value Set:
... referrer_signature Value Set:
... referrer_role Value Set:
Options: 9 options

doco Documentation for this format

Contained resources

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Try this questionnaire out:

Responses for this Questionnaire