<status value="active"/> <experimental value="false"/> <subjectType value="Patient"/> <date value="2026-01-20T15:05:51.993+00:00"/> <publisher value="HL7 International / FHIR Infrastructure"/> <contact> <name value="HL7 International / FHIR Infrastructure"/> <telecom> <system value="url"/> <value value="http://www.hl7.org/Special/committees/fiwg"/> </telecom> </contact> <contact> <telecom> <system value="url"/> <value value="http://www.hl7.org/Special/committees/fiwg"/> </telecom> </contact> <jurisdiction> <coding> <system value="http://unstats.un.org/unsd/methods/m49/m49.htm"/> <code value="001"/> <display value="World"/> </coding> </jurisdiction> <effectivePeriod> <start value="2025-02-03"/> </effectivePeriod> <code> <system value="http://snomed.info/sct"/> <code value="789718008"/> <display value="Cardiology service"/> </code> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="list"/> <display value="List"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;"/> </extension> <linkId value="patient_header"/> <text value="Patient Information"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;"/> </extension> </text> <type value="group"/> <item> <linkId value="patient_surname"/> <text value="Surname:"/> <type value="string"/> <required value="true"/> </item> <item> <linkId value="patient_firstname"/> <text value="First Name:"/> <type value="string"/> <required value="true"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/entryFormat"> <valueString value="yyyy/MM/dd"/> </extension> <linkId value="patient_date_of_birth"/> <text value="DOB:"/> <type value="date"/> <required value="true"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="radio-button"/> <display value="Radio Button"/> </coding> </valueCodeableConcept> </extension> <linkId value="patient_gender"/> <text value="Gender:"/> <type value="choice"/> <required value="true"/> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/administrative-gender"/> <code value="male"/> <display value="Male"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/administrative-gender"/> <code value="female"/> <display value="Female"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/administrative-gender"/> <code value="other"/> <display value="Other"/> </valueCoding> </answerOption> </item> <item> <linkId value="patient_hc_pc"/> <text value="HN PC:"/> <type value="string"/> <maxLength value="2"/> <item> <linkId value="patient_hc_number"/> <text value="HN:"/> <type value="string"/> <maxLength value="10"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/minLength"> <valueInteger value="2"/> </extension> <linkId value="patient_hc_vc"/> <text value="HN VC:"/> <type value="string"/> </item> </item> <item> <linkId value="patient_address_line1"/> <text value="Address (Line 1):"/> <type value="string"/> <required value="true"/> <item> <linkId value="patient_address_line2"/> <text value="Address (Line 2):"/> <type value="string"/> </item> <item> <linkId value="patient_address_city"/> <text value="City:"/> <type value="string"/> <required value="true"/> </item> <item> <linkId value="patient_address_province"/> <text value="Province:"/> <type value="string"/> <required value="true"/> <maxLength value="2"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="pat-pcode"/> </extension> <extension url="severity"> <valueCode value="error"/> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath"/> <expression value="%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]$'))"/> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid Canadian postal-code"/> </extension> </extension> <linkId value="patient_address_postalcode"/> <text value="Postal Code:"/> <type value="string"/> <required value="true"/> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="mobilephone"/> </extension> <extension url="severity"> <valueCode value="error"/> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath"/> <expression value="%resource.repeat(item).where(linkId='patient_phone_mobile').answer.all(value.matches('^(\+\d{1,2}\s?)?$?\d{3}$?[\s.-]?\d{3}[\s.-]?\d{4}$'))"/> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid phone number"/> </extension> </extension> <linkId value="patient_phone_mobile"/> <text value="Mobile #:"/> <type value="string"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="homephone"/> </extension> <extension url="severity"> <valueCode value="error"/> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath"/> <expression value="%resource.repeat(item).where(linkId='patient_phone_home').answer.all(value.matches('^(\+\d{1,2}\s?)?$?\d{3}$?[\s.-]?\d{3}[\s.-]?\d{4}$'))"/> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid phone number"/> </extension> </extension> <linkId value="patient_phone_home"/> <text value="Home #:"/> <type value="string"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="busphone"/> </extension> <extension url="severity"> <valueCode value="error"/> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath"/> <expression value="%resource.repeat(item).where(linkId='patient_phone_business').answer.all(value.matches('^(\+\d{1,2}\s?)?$?\d{3}$?[\s.-]?\d{3}[\s.-]?\d{4}$'))"/> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid phone number"/> </extension> </extension> <linkId value="patient_phone_business"/> <text value="Business #:"/> <type value="string"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="patemail"/> </extension> <extension url="severity"> <valueCode value="error"/> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath"/> <expression value="%resource.repeat(item).where(linkId='patient_email').answer.all(value.matches('(?:[a-z0-9!#$%&'*+/=?^_`{|}~-]+(?:\.[a-z0-9!#$%&'*+/=?^_`{|}~-]+)*|"(?:[\x01-\x08\x0b\x0c\x0e-\x1f\x21\x23-\x5b\x5d-\x7f]|\\[\x01-\x09\x0b\x0c\x0e-\x7f])*")@(?:(?:[a-z0-9](?:[a-z0-9-]*[a-z0-9])?\.)+[a-z0-9](?:[a-z0-9-]*[a-z0-9])?|\[(?:(?:(2(5[0-5]|[0-4][0-9])|1[0-9][0-9]|[1-9]?[0-9]))\.){3}(?:(2(5[0-5]|[0-4][0-9])|1[0-9][0-9]|[1-9]?[0-9])|[a-z0-9-]*[a-z0-9]:(?:[\x01-\x08\x0b\x0c\x0e-\x1f\x21-\x5a\x53-\x7f]|\\[\x01-\x09\x0b\x0c\x0e-\x7f])+)\])'))"/> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid email address"/> </extension> </extension> <linkId value="patient_email"/> <text value="Email:"/> <type value="string"/> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;"/> </extension> <linkId value="additionalinfo_header"/> <text value="[Optional] Additional Patient Information"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="[Optional] Additional Patient Information "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;"/> </extension> </text> <type value="group"/> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://example.com/CodeSystem/item-controls"/> <code value="push-button"/> <display value="Push Button"/> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_sexassignedatbirth"/> <text value="Sex assigned at birth:"/> <type value="choice"/> <answerOption> <valueCoding> <system value="http://loinc.org"/> <code value="LA3-6"/> <display value="Female"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://loinc.org"/> <code value="LA2-8"/> <display value="Male"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/exampleCS"/> <code value="Intersex"/> <display value="Intersex"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://loinc.org"/> <code value="LA4489-6"/> <display value="Unknown"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://example.com/CodeSystem/item-controls"/> <code value="push-button"/> <display value="Push Button"/> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_pronouns"/> <text value="Pronouns:"/> <type value="choice"/> <answerOption> <valueCoding> <system value="http://loinc.org"/> <code value="LA29519-8"/> <display value="She/Her"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://loinc.org"/> <code value="LA29518-0"/> <display value="He/Him"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://loinc.org"/> <code value="LA29519-8"/> <display value="They/Them"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor"/> <code value="OTH"/> <display value="other"/> </valueCoding> </answerOption> <item> <linkId value="additionalinfo_pronouns_other"/> <text value="Other pronouns:"/> <type value="string"/> <enableWhen> <question value="additionalinfo_pronouns"/> <operator value="="/> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor"/> <code value="OTH"/> <display value="other"/> </answerCoding> </enableWhen> <enableBehavior value="all"/> <required value="true"/> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://example.com/CodeSystem/item-controls"/> <code value="push-button"/> <display value="Push Button"/> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_preferredlanguage"/> <text value="Preferred language:"/> <type value="choice"/> <required value="false"/> <answerOption> <valueCoding> <system value="urn:ietf:bcp:47"/> <code value="en"/> <display value="English"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="urn:ietf:bcp:47"/> <code value="fr"/> <display value="French"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor"/> <code value="OTH"/> <display value="other"/> </valueCoding> </answerOption> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="additionalinfo_preferredlanguage_specify"/> <text value="Specify:"/> <type value="string"/> <enableWhen> <question value="additionalinfo_preferredlanguage"/> <operator value="="/> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor"/> <code value="OTH"/> <display value="other"/> </answerCoding> </enableWhen> <enableBehavior value="all"/> <required value="true"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="additionalinfo_preferredlanguage_translatorrequired"/> <text value="Translator required"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="string"/> <enableWhen> <question value="additionalinfo_preferredlanguage"/> <operator value="="/> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor"/> <code value="OTH"/> <display value="other"/> </answerCoding> </enableWhen> <repeats value="true"/> <answerOption> <valueString value="Translator Required"/> </answerOption> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://example.com/CodeSystem/item-controls"/> <code value="push-button"/> <display value="Push Button"/> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_bestmethodofcontact"/> <text value="Best method of contact:"/> <type value="choice"/> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/contact-point-use"/> <code value="mobile"/> <display value="Mobile"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/contact-point-use"/> <code value="home"/> <display value="Home"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/contact-point-use"/> <code value="work"/> <display value="Work"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/contact-point-system"/> <code value="email"/> <display value="Email"/> </valueCoding> </answerOption> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="additionalinfo_bestmethodofcontact_voicemails"/> <text value="Voicemails acceptable"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="string"/> <enableWhen> <question value="additionalinfo_bestmethodofcontact"/> <operator value="="/> <answerCoding> <system value="http://hl7.org/fhir/contact-point-use"/> <code value="mobile"/> <display value="Mobile"/> </answerCoding> </enableWhen> <enableBehavior value="any"/> <repeats value="true"/> <answerOption> <valueString value=" Voicemails acceptable"/> </answerOption> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="additionalinfo_preferredname_select"/> <text value="Preferred name"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="string"/> <repeats value="true"/> <answerOption> <valueString value="Preferred Name"/> </answerOption> </item> <item> <linkId value="additionalinfo_preferredname"/> <text value="Prefered name String"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="string"/> <enableWhen> <question value="additionalinfo_preferredname_select"/> <operator value="="/> <answerString value="Preferred Name"/> </enableWhen> <enableBehavior value="all"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_alternatecontact_select"/> <text value="Alternate contact"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="string"/> <repeats value="true"/> <answerOption> <valueString value="Alternate contact"/> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="additionalinfo_alternatecontact_name"/> <text value="Name:"/> <type value="string"/> <enableWhen> <question value="additionalinfo_alternatecontact_select"/> <operator value="="/> <answerString value="Alternate contact"/> </enableWhen> <enableBehavior value="all"/> <required value="true"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="altphone"/> </extension> <extension url="severity"> <valueCode value="error"/> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath"/> <expression value="%resource.repeat(item).where(linkId='additionalinfo_alternatecontact_phone').answer.all(value.matches('^(\+\d{1,2}\s?)?$?\d{3}$?[\s.-]?\d{3}[\s.-]?\d{4}$'))"/> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid phone number"/> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="additionalinfo_alternatecontact_phone"/> <text value="Alternate contact phone #:"/> <type value="string"/> <enableWhen> <question value="additionalinfo_alternatecontact_select"/> <operator value="="/> <answerString value="Alternate contact"/> </enableWhen> <enableBehavior value="all"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="additionalinfo_alternatecontact_relationship"/> <text value="Relationship:"/> <type value="string"/> <enableWhen> <question value="additionalinfo_alternatecontact_select"/> <operator value="="/> <answerString value="Alternate contact"/> </enableWhen> <enableBehavior value="all"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="radio-button"/> <display value="Radio Button"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="additionalinfo_alternatecontact_bookingcontact"/> <text value="Is Alternate contact the appointment booking contact?:"/> <type value="choice"/> <enableWhen> <question value="additionalinfo_alternatecontact_select"/> <operator value="="/> <answerString value="Alternate contact"/> </enableWhen> <enableBehavior value="all"/> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532"/> <code value="Y"/> <display value="Yes"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532"/> <code value="N"/> <display value="No"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_unsafecontacts_select"/> <text value="Unsafe contact persons (do not speak with)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="string"/> <repeats value="true"/> <answerOption> <valueString value="Unsafe contact persons (do not speak with)"/> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="additionalinfo_unsafecontacts_speakwithpatientdirectly"/> <text value="Only speak with patient directly"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="string"/> <enableWhen> <question value="additionalinfo_unsafecontacts_select"/> <operator value="="/> <answerString value="Unsafe contact persons (do not speak with)"/> </enableWhen> <enableBehavior value="all"/> <repeats value="true"/> <answerOption> <valueString value="Only speak with patient directly"/> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="additionalinfo_unsafecontacts_donotspeakwith"/> <text value="Do not speak with:"/> <type value="string"/> <enableWhen> <question value="additionalinfo_unsafecontacts_select"/> <operator value="="/> <answerString value="Unsafe contact persons (do not speak with)"/> </enableWhen> <enableBehavior value="all"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_accessibilityconcernsordisability_selectt"/> <text value="Accessibility concerns or disability"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="string"/> <repeats value="true"/> <answerOption> <valueString value="Accessibility concerns or disability"/> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://example.com/CodeSystem/item-controls"/> <code value="push-button"/> <display value="Push Button"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="additionalinfo_accessibilityconcernsordisability"/> <text value="Accessibility concerns Options"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> </text> <type value="choice"/> <enableWhen> <question value="additionalinfo_accessibilityconcernsordisability_selectt"/> <operator value="="/> <answerString value="Accessibility concerns or disability"/> </enableWhen> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://snomed.info/sct"/> <code value="129839007"/> <display value="Falls risk"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct"/> <code value="301621006"/> <display value="Patient requires lift"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct"/> <code value="105503008"/> <display value="Wheelchair"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct"/> <code value="15188001"/> <display value="Hearing impaired"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_specialconsiderations_select"/> <text value="Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="string"/> <repeats value="true"/> <answerOption> <valueString value="Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)"/> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="additionalinfo_specialconsiderations"/> <text value="Details of special considerations:"/> <type value="text"/> <enableWhen> <question value="additionalinfo_specialconsiderations_select"/> <operator value="="/> <answerString value="Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)"/> </enableWhen> <required value="true"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_sendcopiestoadditionalproviders"/> <text value="Send copies of reports to additional providers"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="string"/> <repeats value="true"/> <answerOption> <valueString value="Send copies of reports to additional providers"/> </answerOption> </item> <item> <linkId value="additionalinfo_sendcopiestoadditionalproviders_names"/> <text value="Name(s):"/> <type value="string"/> <enableWhen> <question value="additionalinfo_sendcopiestoadditionalproviders"/> <operator value="="/> <answerString value="Send copies of reports to additional providers"/> </enableWhen> <enableBehavior value="all"/> <required value="true"/> <item> <linkId value="additionalinfo_sendcopiestoadditionalproviders_contactinfo"/> <text value="Contact information:"/> <type value="string"/> <enableWhen> <question value="additionalinfo_sendcopiestoadditionalproviders"/> <operator value="="/> <answerString value="Send copies of reports to additional providers"/> </enableWhen> <enableBehavior value="all"/> <required value="true"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_sendcopiestoadditionalproviders_ispcp"/> <text value="This is the Primary Care Provider"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="string"/> <enableWhen> <question value="additionalinfo_sendcopiestoadditionalproviders"/> <operator value="="/> <answerString value="Send copies of reports to additional providers"/> </enableWhen> <enableBehavior value="all"/> <repeats value="true"/> <answerOption> <valueString value="This is the Primary Care Provider"/> </answerOption> </item> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;"/> </extension> <extension url="http://example.com/StructureDefinition/group-note-info"> <extension url="sortIndex"> <valuePositiveInt value="1"/> </extension> <extension url="text"> <valueString value="Referral Details"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" Referral Details "/> </extension> </valueString> </extension> <extension url="style"> <valueString value="font-weight:bold;text-decoration:underline;"/> </extension> <extension url="groupItems"> <valueBoolean value="false"/> </extension> </extension> <linkId value="102173268919"/> <text value="Referral Details"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Referral Details "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;color:#202035;"/> </extension> </text> <type value="group"/> <item> <extension url="http://example.com/StructureDefinition/group-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath"/> <expression value="true"/> </valueExpression> </extension> <extension url="sortIndex"> <valuePositiveInt value="1"/> </extension> <extension url="text"> <valueString value="Triage Considerations"/> </extension> <extension url="style"> <valueString value="font-weight:bold;"/> </extension> </extension> <linkId value="cardio_triagecons"/> <text value="Triage Considerations"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Triage Considerations "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;"/> </extension> </text> <type value="group"/> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://example.com/CodeSystem/item-controls"/> <code value="push-button"/> <display value="Push Button"/> </coding> </valueCodeableConcept> </extension> <extension url="http://example.com/StructureDefinition/question-note-info"> <extension url="sortIndex"> <valuePositiveInt value="1"/> </extension> <extension url="text"> <valueString value="Requested Priority:"/> </extension> <extension url="sameLine"> <valueBoolean value="true"/> </extension> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#EE6B00;"/> </extension> </extension> <linkId value="referral_requestedpriority"/> <text value="Requested Priority:"/> <type value="choice"/> <required value="true"/> <answerOption> <extension url="http://example.com/StructureDefinition/option-note-info"> <extension url="text"> <valueString value="Routine"/> </extension> <extension url="style"> <valueString value="font-weight:bold;color:#EE6B00;"/> </extension> </extension> <valueCoding> <system value="http://hl7.org/fhir/request-priority"/> <code value="routine"/> <display value="Routine"/> </valueCoding> <initialSelected value="true"/> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/request-priority"/> <code value="urgent"/> <display value="Urgent"/> </valueCoding> </answerOption> <item> <linkId value="referral_requestedpriority_urgentreason"/> <text value="Reason for urgent triage"/> <type value="string"/> <enableWhen> <question value="referral_requestedpriority"/> <operator value="="/> <answerCoding> <system value="http://hl7.org/fhir/request-priority"/> <code value="urgent"/> <display value="Urgent"/> </answerCoding> </enableWhen> <required value="true"/> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <extension url="http://example.com/StructureDefinition/question-note-info"> <extension url="sortIndex"> <valuePositiveInt value="2"/> </extension> <extension url="text"> <valueString value="Second Opinion"/> </extension> </extension> <linkId value="referral_secondopinion"/> <text value="Second Opinion"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://snomed.info/sct"/> <code value="77406008"/> <display value="Second or third medical opinion"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="referral_secondopinion_reason"/> <text value="Reason for second opinion:"/> <type value="text"/> <enableWhen> <question value="referral_secondopinion"/> <operator value="="/> <answerCoding> <system value="http://snomed.info/sct"/> <code value="77406008"/> <display value="Second or third medical opinion"/> </answerCoding> </enableWhen> </item> </item> <item> <extension url="http://example.com/StructureDefinition/group-note-info"> <extension url="sortIndex"> <valuePositiveInt value="2"/> </extension> <extension url="text"> <valueString value="Service(s) Requested"/> </extension> <extension url="style"> <valueString value="font-weight:bold;"/> </extension> </extension> <linkId value="695991571585"/> <text value="Service(s) Requested Select all that apply:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Service(s) Requested Select all that apply: "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="color:Gray20;"/> </extension> </text> <type value="group"/> <required value="true"/> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression"> <valueExpression> <description value="Calculates HSC services based on selected checkboxes for cardiac testing and cardiology consult"/> <language value="text/fhirpath"/> <expression value="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', '')"/> </valueExpression> </extension> <extension url="http://example.com/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="HSCs Assigned:"/> </extension> <extension url="style"> <valueString value="font-weight:bold;"/> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true"/> </extension> <linkId value="referralService"/> <text value="HSCs Assigned:"/> <type value="string"/> <readOnly value="true"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="223886162384"/> <text value="Cardiac Testing"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20001"/> <display value="Cardiac Testing"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="660331267409"/> <text value="Exam(s) Requested"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Exam(s) Requested "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="color:Gray20;font-weight:bold;"/> </extension> </text> <type value="group"/> <enableWhen> <question value="223886162384"/> <operator value="="/> <answerCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20001"/> <display value="Cardiac Testing"/> </answerCoding> </enableWhen> <enableBehavior value="all"/> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="720409326878"/> <text value="24 Hour Ambulatory Blood Pressure Monitoring"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20003"/> <display value="24 Hour Ambulatory Blood Pressure Monitoring"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="960455115596"/> <text value="Coronary Angiogram"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20004"/> <display value="Coronary Angiogram"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="297634898828"/> <text value="Echocardiogram - Resting"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20005"/> <display value="Echocardiogram - Resting"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;"/> </extension> <linkId value="443484577720"/> <text value="sub Echocardiogram - Resting"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="group"/> <enableWhen> <question value="297634898828"/> <operator value="="/> <answerCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20005"/> <display value="Echocardiogram - Resting"/> </answerCoding> </enableWhen> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="165530569567"/> <text value="Echocardiogram (2D)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20012"/> <display value="Echocardiogram (2D)"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="286552421895"/> <text value="Echocardiogram with Contrast"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20013"/> <display value="Echocardiogram with Contrast"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <linkId value="910527687300"/> <text value="Echocardiogram with Saline (Bubble)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20014"/> <display value="Echocardiogram with Saline (Bubble)"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <linkId value="657824763133"/> <text value="Pediatric Echocardiogram"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20015"/> <display value="Pediatric Echocardiogram"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="992743200182"/> <text value="Transesophageal Echocardiogram (TEE)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20016"/> <display value="Transesophageal Echocardiogram (TEE)"/> </valueCoding> </answerOption> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="894277763438"/> <text value="Electrocardiogram (ECG)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20006"/> <display value="Electrocardiogram (ECG)"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="279226023495"/> <text value="Holter Monitoring"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20007"/> <display value="Holter Monitoring"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;"/> </extension> <linkId value="440449731882"/> <text value="sub holter monitoring"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="group"/> <enableWhen> <question value="279226023495"/> <operator value="="/> <answerCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20007"/> <display value="Holter Monitoring"/> </answerCoding> </enableWhen> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <linkId value="671328703851"/> <text value="24 Hours"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20017"/> <display value="24 Hours"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <linkId value="423992261841"/> <text value="48 Hours"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20018"/> <display value="48 Hours"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <linkId value="419924239187"/> <text value="72 Hours"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20019"/> <display value="72 Hours"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <linkId value="731054417270"/> <text value="7 Days"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20020"/> <display value="7 Days"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <linkId value="235876421044"/> <text value="14 Days"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20021"/> <display value="14 Days"/> </valueCoding> </answerOption> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="374742834400"/> <text value="Loop / Event Monitor"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20008"/> <display value="Loop / Event Monitor"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <linkId value="159161544747"/> <text value="Cardiovascular stress testing"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20009"/> <display value="Stress Testing"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;"/> </extension> <linkId value="370275060390"/> <text value="Sub Stress Testing"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="group"/> <enableWhen> <question value="159161544747"/> <operator value="="/> <answerCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20009"/> <display value="Stress Testing"/> </answerCoding> </enableWhen> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="814218498309"/> <text value="ECG - Exercise Stress Test"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20022"/> <display value="ECG - Exercise Stress Test"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="307107493993"/> <text value="ECG - Dobutamine/Persantine Stress Test"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20023"/> <display value="ECG - Dobutamine/Persantine Stress Test"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <linkId value="805303414102"/> <text value="Echocardiogram - Exercise Stress Test"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20024"/> <display value="Echocardiogram - Exercise Stress Test"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <linkId value="193586908489"/> <text value="Echocardiogram - Dobutamine/Persantine Stress Test"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20025"/> <display value="Echocardiogram - Dobutamine/Persantine Stress Test"/> </valueCoding> </answerOption> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <linkId value="918517139023"/> <text value="Nuclear Medicine"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20010"/> <display value="Nuclear Medicine"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;"/> </extension> <linkId value="222686221935"/> <text value="sub Nuclear Medicine"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="group"/> <enableWhen> <question value="918517139023"/> <operator value="="/> <answerCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20010"/> <display value="Nuclear Medicine"/> </answerCoding> </enableWhen> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="924189648184"/> <text value="MUGA - Resting"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20026"/> <display value="MUGA - Resting"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="857163514910"/> <text value="Cardiac Pyrophosphate"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20027"/> <display value="Cardiac Pyrophosphate"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="892165959617"/> <text value="Myocardial perfusion scan"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20028"/> <display value="MIBI Scans / Myocardial Perfusion Imaging (MPI):"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="radio-button"/> <display value="Radio Button"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="538288549138"/> <text value="sub MIBI"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="group"/> <enableWhen> <question value="892165959617"/> <operator value="="/> <answerCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20028"/> <display value="MIBI Scans / Myocardial Perfusion Imaging (MPI):"/> </answerCoding> </enableWhen> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="373435981917"/> <text value="MIBI Scan - Exercise Stress Test"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="string"/> <repeats value="true"/> <answerOption> <valueString value="MIBI Scan - Exercise Stress Test"/> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="434394942688"/> <text value="MIBI Scan - Dobutamine/Persantine Stress Test"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="string"/> <repeats value="true"/> <answerOption> <valueString value="MIBI Scan - Dobutamine/Persantine Stress Test"/> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="913594478162"/> <text value="Thallium Viability Test"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="string"/> <repeats value="true"/> <answerOption> <valueString value="Thallium Viability Test"/> </answerOption> </item> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="992682216482"/> <text value="Tilt Table Testing"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20011"/> <display value="Tilt Table Testing"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="cardiology_referral_services_cardiactesting_other"/> <text value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor"/> <code value="OTH"/> <display value="other"/> </valueCoding> </answerOption> </item> <item> <linkId value="cardiology_referral_services_cardiactesting_other_specify"/> <text value="Specify"/> <type value="text"/> <enableWhen> <question value="cardiology_referral_services_cardiactesting_other"/> <operator value="="/> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor"/> <code value="OTH"/> <display value="other"/> </answerCoding> </enableWhen> <enableBehavior value="all"/> <required value="true"/> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="785727177547"/> <text value="Cardiology Consultation"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20002"/> <display value="Cardiology Consultation"/> </valueCoding> </answerOption> </item> </item> <item> <linkId value="186952778859"/> <text value="Concern(s) / Indication(s) Triggering Referral Select all that apply:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Concern(s) / Indication(s) Triggering Referral Select all that apply: "/> </extension> </text> <type value="group"/> <required value="true"/> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="219569805461"/> <text value="Arrhythmias or Palpitations"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://snomed.info/sct"/> <code value="698247007"/> <display value="Arrhythmias or Palpitations"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="571934328499"/> <text value="Cardiovascular Risk Assessment"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20033"/> <display value="Cardiovascular Risk Assessment"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="459737733395"/> <text value="Chest Pain or Angina"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20034"/> <display value="Chest Pain or Angina"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <linkId value="929919815516"/> <text value="Congenital Heart Disease"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20035"/> <display value="Congenital Heart Disease"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="832263816528"/> <text value="Congestive Heart Failure"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20036"/> <display value="Congestive Heart Failure"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="803760213460"/> <text value="Coronary Artery Disease"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20037"/> <display value="Coronary Artery Disease"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <linkId value="129767162379"/> <text value="Dyspnea"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20038"/> <display value="Dyspnea"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <linkId value="116150628533"/> <text value="Hypertension"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20039"/> <display value="Hypertension"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <linkId value="513825527027"/> <text value="Murmur"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20040"/> <display value="Murmur"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <linkId value="975075898688"/> <text value="Pericardial Disease"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20041"/> <display value="Pericardial Disease"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="704148928571"/> <text value="Peripheral Edema"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20042"/> <display value="Peripheral Edema"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="886489617115"/> <text value="Post-Myocardial Infarction"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20043"/> <display value="Post-Myocardial Infarction"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="621745958993"/> <text value="Pre-operative Consultation"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20044"/> <display value="Pre-operative Consultation"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="873024527134"/> <code> <system value="http://snomed.info/sct"/> <code value="439272007"/> <display value="Date of procedure"/> </code> <text value="Procedure Date (if known)"/> <type value="date"/> <enableWhen> <question value="621745958993"/> <operator value="="/> <answerCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20044"/> <display value="Pre-operative Consultation"/> </answerCoding> </enableWhen> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <linkId value="197975129599"/> <text value="Syncope"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://example.com/CodeSystem/standardized-referral-form-codes"/> <code value="20045"/> <display value="Syncope"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="675849150752"/> <text value="Valvular Heart Disease or Prosthetic Heart Valve"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://snomed.info/sct"/> <code value="368009"/> <display value="Valvular Heart Disease or Prosthetic Heart Valve"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="721982740516"/> <text value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="choice"/> <repeats value="true"/> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor"/> <code value="OTH"/> <display value="other"/> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="720594942482"/> <text value="Specify"/> <type value="text"/> <enableWhen> <question value="721982740516"/> <operator value="="/> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor"/> <code value="OTH"/> <display value="other"/> </answerCoding> </enableWhen> <required value="true"/> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="Descriptionofclinicalquestion"/> <text value="Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;"/> </extension> </text> <type value="text"/> <required value="true"/> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;"/> </extension> <linkId value="cpp_header"/> <text value="Cumulative Patient Profile Please delete any sensitive information you do not intend to share from the CPP"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Cumulative Patient Profile Please delete any sensitive information you do not intend to share from the CPP"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;"/> </extension> </text> <type value="group"/> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="cpp_separate"/> <text value="CPP attached separately (if not entered below)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="string"/> <repeats value="true"/> <answerOption> <valueString value="CPP attached separately (if not entered below)"/> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="cpp_currentprob"/> <code> <system value="http://snomed.info/sct"/> <code value="55607006"/> <display value="Problem"/> </code> <text value="Current Problem List:"/> <type value="text"/> <enableWhen> <question value="cpp_separate"/> <operator value="exists"/> <answerBoolean value="false"/> </enableWhen> <enableBehavior value="all"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="cpp_pastmedicalhistory"/> <code> <system value="http://snomed.info/sct"/> <code value="417662000"/> <display value="History of clinical finding in subject"/> </code> <text value="Past Medical History:"/> <type value="text"/> <enableWhen> <question value="cpp_separate"/> <operator value="exists"/> <answerBoolean value="false"/> </enableWhen> <enableBehavior value="all"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="cpp_currentmedications"/> <code> <system value="http://snomed.info/sct"/> <code value="129019007"/> <display value="Taking medication"/> </code> <text value="Current Medications :"/> <type value="text"/> <enableWhen> <question value="cpp_separate"/> <operator value="exists"/> <answerBoolean value="false"/> </enableWhen> <enableBehavior value="all"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="cpp_familyhistory"/> <code> <system value="http://snomed.info/sct"/> <code value="57177007"/> <display value="Family history with explicit context"/> </code> <text value="Family History:"/> <type value="text"/> <enableWhen> <question value="cpp_separate"/> <operator value="exists"/> <answerBoolean value="false"/> </enableWhen> <enableBehavior value="all"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="cpp_allergies"/> <code> <system value="http://snomed.info/sct"/> <code value="609328004"/> <display value="Allergic disposition"/> </code> <text value="Allergies:"/> <type value="text"/> <enableWhen> <question value="cpp_separate"/> <operator value="exists"/> <answerBoolean value="false"/> </enableWhen> <enableBehavior value="all"/> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;"/> </extension> <linkId value="preferredconsultlocation_header"/> <text value="Preferred Consultant or Location All patients will be triaged to the shortest wait time unless a preferred consultant or location is entered."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Preferred Consultant or Location All patients will be triaged to the shortest wait time unless a preferred consultant or location is entered."/> </extension> </text> <type value="group"/> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="preferredconsultlocation_selector"/> <text value="Preferred consultant or location"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="string"/> <repeats value="true"/> <answerOption> <valueString value="Preferred consultant or location"/> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="preferredconsultlocation_specify"/> <text value="Please specify either a preferred consultant or location"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Please specify either a preferred consultant or location"/> </extension> </text> <type value="group"/> <enableWhen> <question value="preferredconsultlocation_selector"/> <operator value="="/> <answerString value="Preferred consultant or location"/> </enableWhen> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;"/> </extension> <linkId value="preferredconsultlocation_consultant"/> <text value="Consultant:"/> <type value="string"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;"/> </extension> <linkId value="preferredconsultlocation_location"/> <text value="Location:"/> <type value="string"/> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="preferredconsultlocation_willingtotravel"/> <text value="Patient willing to travel for shorter wait time"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="string"/> <repeats value="true"/> <answerOption> <valueString value="Patient willing to travel for shorter wait time"/> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;"/> </extension> <linkId value="preferredconsultlocation_otherconsiderations"/> <text value="Other considerations:"/> <type value="string"/> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;"/> </extension> <linkId value="supportingdocumentation_header"/> <text value="Supporting Documentation Please attach all relevant laboratory and diagnostic investigations."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Supporting Documentation Please attach all relevant laboratory and diagnostic investigations. "/> </extension> </text> <type value="group"/> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="check-box"/> <display value="Check-box"/> </coding> </valueCodeableConcept> </extension> <linkId value="supportingdocumentation_details"/> <text value="Personal Health Information that is medically relevant has not been disclosed at the request of the patient."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" "/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;"/> </extension> </text> <type value="string"/> <repeats value="true"/> <answerOption> <valueString value="Personal Health Information that is medically relevant has not been disclosed at the request of the patient."/> </answerOption> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="application/pdf"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="image/gif"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="image/bmp"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="application/vnd.openxmlformats-officedocument.spreadsheetml.sheet"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="video/mp4"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="text/csv"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="image/jpeg"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="application/msword"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="image/png"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="application/vnd.openxmlformats-officedocument.wordprocessingml.document"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="application/vnd.ms-excel"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="text/plain"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="audio/mp4"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="audio/mpeg"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="image/tiff"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/maxSize"> <valueDecimal value="5000000"/> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;"/> </extension> <extension url="http://example.com/StructureDefinition/question-note-info"> <extension url="positiveText"> <valueString value="Attachment Provided"/> </extension> </extension> <linkId value="supportingdocumentation_attachment"/> <text value="Add Attachments"/> <type value="attachment"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;"/> </extension> <linkId value="feedbacksurvey_cardiology"/> <text value="Click here to provide feedback on this form"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="<a href="https://www.surveymonkey.com/r/cardioSRF" rel="noopener noreferrer" target="_blank">Click here to provide feedback on this form</a> "/> </extension> </text> <type value="display"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;"/> </extension> <linkId value="referrer_header"/> <text value="Referrer's Information"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;"/> </extension> </text> <type value="group"/> <item> <linkId value="referrer_sitename"/> <text value="Site Name:"/> <type value="string"/> </item> <item> <linkId value="referrer_address_line1"/> <text value="Address (Line 1):"/> <type value="string"/> <required value="true"/> <item> <linkId value="referrer_address_line2"/> <text value="Address (Line 2):"/> <type value="string"/> </item> <item> <linkId value="referrer_address_city"/> <text value="City:"/> <type value="string"/> <required value="true"/> </item> <item> <linkId value="referrer_address_province"/> <text value="Province:"/> <type value="string"/> <required value="true"/> <maxLength value="2"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="ref-pcode"/> </extension> <extension url="severity"> <valueCode value="error"/> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath"/> <expression value="%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]$'))"/> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid Canadian postal-code"/> </extension> </extension> <linkId value="referrer_address_postalcode"/> <text value="Postal Code:"/> <type value="string"/> <required value="true"/> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="refphone"/> </extension> <extension url="severity"> <valueCode value="error"/> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath"/> <expression value="%resource.repeat(item).where(linkId='referrer_phone').answer.all(value.matches('^(\+\d{1,2}\s?)?$?\d{3}$?[\s.-]?\d{3}[\s.-]?\d{4}$'))"/> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid phone number"/> </extension> </extension> <linkId value="referrer_phone"/> <text value="Phone #:"/> <type value="string"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="reffax"/> </extension> <extension url="severity"> <valueCode value="error"/> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath"/> <expression value="%resource.repeat(item).where(linkId='referrer_fax').answer.all(value.matches('^(\+\d{1,2}\s?)?$?\d{3}$?[\s.-]?\d{3}[\s.-]?\d{4}$'))"/> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid phone number"/> </extension> </extension> <linkId value="referrer_fax"/> <text value="Fax #:"/> <type value="string"/> </item> <item> <linkId value="referrer_billing"/> <text value="Billing Number:"/> <type value="integer"/> </item> <item> <linkId value="referrer_professionalid"/> <text value="Professional ID:"/> <type value="integer"/> </item> <item> <linkId value="referrer_signature"/> <text value="Signed:"/> <type value="text"/> <required value="true"/> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control"/> <code value="drop-down"/> <display value="Drop down"/> </coding> </valueCodeableConcept> </extension> <linkId value="referrer_role"/> <text value="Role:"/> <type value="choice"/> <answerOption> <valueCoding> <system value="http://snomed.info/sct"/> <code value="309398001"/> <display value="Allied Health Professional"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct"/> <code value="62247001"/> <display value="Family Physician"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct"/> <code value="449161006"/> <display value="Physician Assistant"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct"/> <code value="398130009"/> <display value="Medical Student"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct"/> <code value="106292003"/> <display value="Nurse"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct"/> <code value="224571005"/> <display value="Nurse Practitioner"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct"/> <code value="405277009"/> <display value="Resident"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct"/> <code value="69280009"/> <display value="Specialist"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor"/> <code value="OTH"/> <display value="other"/> </valueCoding> </answerOption> </item> </item> </Questionnaire>

Generated Narrative: Questionnaire CardiologyForm

Language: en

Structure

LinkID	Text	Cardinality	Type	Description & Constraints
			Questionnaire	urn:uuid:d7176d16-5fd4-48a7-b7e6-b488e8df763d#4.0.0-ci-build
patient_header	Patient Information	0..1	group
patient_surname	Surname:	1..1	string
patient_firstname	First Name:	1..1	string
patient_date_of_birth	DOB:	1..1	date
patient_gender	Gender:	1..1	choice	Options: 3 options
patient_hc_pc	HN PC:	0..1	string	Max Length: 2
patient_hc_number	HN:	0..1	string	Max Length: 10
patient_hc_vc	HN VC:	0..1	string
patient_address_line1	Address (Line 1):	1..1	string
patient_address_line2	Address (Line 2):	0..1	string
patient_address_city	City:	1..1	string
patient_address_province	Province:	1..1	string	Max Length: 2
patient_address_postalcode	Postal Code:	1..1	string
patient_phone_mobile	Mobile #:	0..1	string
patient_phone_home	Home #:	0..1	string
patient_phone_business	Business #:	0..1	string
patient_email	Email:	0..1	string
additionalinfo_header	[Optional] Additional Patient Information	0..1	group
additionalinfo_sexassignedatbirth	Sex assigned at birth:	0..1	choice	Options: 4 options
additionalinfo_pronouns	Pronouns:	0..1	choice	Options: 4 options
additionalinfo_pronouns_other	Other pronouns:	1..1	string	Enable When: additionalinfo_pronouns = other (v3 Code System NullFlavor#OTH)
additionalinfo_preferredlanguage	Preferred language:	0..1	choice	Options: 3 options
additionalinfo_preferredlanguage_specify	Specify:	1..1	string	Enable When: additionalinfo_preferredlanguage = other (v3 Code System NullFlavor#OTH)
additionalinfo_preferredlanguage_translatorrequired	Translator required	0..*	string	Enable When: additionalinfo_preferredlanguage = other (v3 Code System NullFlavor#OTH) Options: 1 option
additionalinfo_bestmethodofcontact	Best method of contact:	0..1	choice	Options: 4 options
additionalinfo_bestmethodofcontact_voicemails	Voicemails acceptable	0..*	string	Enable When: additionalinfo_bestmethodofcontact = Mobile (ContactPointUse#mobile) Options: 1 option
additionalinfo_preferredname_select	Preferred name	0..*	string	Options: 1 option
additionalinfo_preferredname	Prefered name String	0..1	string	Enable When: additionalinfo_preferredname_select = Preferred Name
additionalinfo_alternatecontact_select	Alternate contact	0..*	string	Options: 1 option
additionalinfo_alternatecontact_name	Name:	1..1	string	Enable When: additionalinfo_alternatecontact_select = Alternate contact
additionalinfo_alternatecontact_phone	Alternate contact phone #:	0..1	string	Enable When: additionalinfo_alternatecontact_select = Alternate contact
additionalinfo_alternatecontact_relationship	Relationship:	0..1	string	Enable When: additionalinfo_alternatecontact_select = Alternate contact
additionalinfo_alternatecontact_bookingcontact	Is Alternate contact the appointment booking contact?:	0..1	choice	Enable When: additionalinfo_alternatecontact_select = Alternate contact Options: 2 options
additionalinfo_unsafecontacts_select	Unsafe contact persons (do not speak with)	0..*	string	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) 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)
additionalinfo_accessibilityconcernsordisability_selectt	Accessibility concerns or disability	0..*	string	Options: 1 option
additionalinfo_accessibilityconcernsordisability	Accessibility concerns Options	0..*	choice	Enable When: additionalinfo_accessibilityconcernsordisability_selectt = Accessibility concerns or disability 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	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)
additionalinfo_sendcopiestoadditionalproviders	Send copies of reports to additional providers	0..*	string	Options: 1 option
additionalinfo_sendcopiestoadditionalproviders_names	Name(s):	1..1	string	Enable When: additionalinfo_sendcopiestoadditionalproviders = Send copies of reports to additional providers
additionalinfo_sendcopiestoadditionalproviders_contactinfo	Contact information:	1..1	string	Enable When: additionalinfo_sendcopiestoadditionalproviders = Send copies of reports to additional providers
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
102173268919	Referral Details	0..1	group
cardio_triagecons	Triage Considerations	0..1	group
referral_requestedpriority	Requested Priority:	1..1	choice	Options: 2 options
referral_requestedpriority_urgentreason	Reason for urgent triage	1..1	string	Enable When: referral_requestedpriority = Urgent (RequestPriority#urgent)
referral_secondopinion	Second Opinion	0..*	choice	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)
695991571585	Service(s) Requested Select all that apply:	1..1	group
referralService	HSCs Assigned:	0..1	string
223886162384	Cardiac Testing	0..*	choice	Options: 1 option
660331267409	Exam(s) Requested	0..1	group	Enable When: 223886162384 = Cardiac Testing (standardized-referral-form-codes#20001)
720409326878	24 Hour Ambulatory Blood Pressure Monitoring	0..*	choice	Options: 1 option
960455115596	Coronary Angiogram	0..*	choice	Options: 1 option
297634898828	Echocardiogram - Resting	0..*	choice	Options: 1 option
443484577720	sub Echocardiogram - Resting	0..1	group	Enable When: 297634898828 = Echocardiogram - Resting (standardized-referral-form-codes#20005)
165530569567	Echocardiogram (2D)	0..*	choice	Options: 1 option
286552421895	Echocardiogram with Contrast	0..*	choice	Options: 1 option
910527687300	Echocardiogram with Saline (Bubble)	0..*	choice	Options: 1 option
657824763133	Pediatric Echocardiogram	0..*	choice	Options: 1 option
992743200182	Transesophageal Echocardiogram (TEE)	0..*	choice	Options: 1 option
894277763438	Electrocardiogram (ECG)	0..*	choice	Options: 1 option
279226023495	Holter Monitoring	0..*	choice	Options: 1 option
440449731882	sub holter monitoring	0..1	group	Enable When: 279226023495 = Holter Monitoring (standardized-referral-form-codes#20007)
671328703851	24 Hours	0..*	choice	Options: 1 option
423992261841	48 Hours	0..*	choice	Options: 1 option
419924239187	72 Hours	0..*	choice	Options: 1 option
731054417270	7 Days	0..*	choice	Options: 1 option
235876421044	14 Days	0..*	choice	Options: 1 option
374742834400	Loop / Event Monitor	0..*	choice	Options: 1 option
159161544747	Cardiovascular stress testing	0..*	choice	Options: 1 option
370275060390	Sub Stress Testing	0..1	group	Enable When: 159161544747 = Stress Testing (standardized-referral-form-codes#20009)
814218498309	ECG - Exercise Stress Test	0..*	choice	Options: 1 option
307107493993	ECG - Dobutamine/Persantine Stress Test	0..*	choice	Options: 1 option
805303414102	Echocardiogram - Exercise Stress Test	0..*	choice	Options: 1 option
193586908489	Echocardiogram - Dobutamine/Persantine Stress Test	0..*	choice	Options: 1 option
918517139023	Nuclear Medicine	0..*	choice	Options: 1 option
222686221935	sub Nuclear Medicine	0..1	group	Enable When: 918517139023 = Nuclear Medicine (standardized-referral-form-codes#20010)
924189648184	MUGA - Resting	0..*	choice	Options: 1 option
857163514910	Cardiac Pyrophosphate	0..*	choice	Options: 1 option
892165959617	Myocardial perfusion scan	0..*	choice	Options: 1 option
538288549138	sub MIBI	0..1	group	Enable When: 892165959617 = MIBI Scans / Myocardial Perfusion Imaging (MPI): (standardized-referral-form-codes#20028)
373435981917	MIBI Scan - Exercise Stress Test	0..*	string	Options: 1 option
434394942688	MIBI Scan - Dobutamine/Persantine Stress Test	0..*	string	Options: 1 option
913594478162	Thallium Viability Test	0..*	string	Options: 1 option
992682216482	Tilt Table Testing	0..*	choice	Options: 1 option
cardiology_referral_services_cardiactesting_other	Other	0..*	choice	Options: 1 option
cardiology_referral_services_cardiactesting_other_specify	Specify	1..1	text	Enable When: cardiology_referral_services_cardiactesting_other = other (v3 Code System NullFlavor#OTH)
785727177547	Cardiology Consultation	0..*	choice	Options: 1 option
186952778859	Concern(s) / Indication(s) Triggering Referral Select all that apply:	1..1	group
219569805461	Arrhythmias or Palpitations	0..*	choice	Options: 1 option
571934328499	Cardiovascular Risk Assessment	0..*	choice	Options: 1 option
459737733395	Chest Pain or Angina	0..*	choice	Options: 1 option
929919815516	Congenital Heart Disease	0..*	choice	Options: 1 option
832263816528	Congestive Heart Failure	0..*	choice	Options: 1 option
803760213460	Coronary Artery Disease	0..*	choice	Options: 1 option
129767162379	Dyspnea	0..*	choice	Options: 1 option
116150628533	Hypertension	0..*	choice	Options: 1 option
513825527027	Murmur	0..*	choice	Options: 1 option
975075898688	Pericardial Disease	0..*	choice	Options: 1 option
704148928571	Peripheral Edema	0..*	choice	Options: 1 option
886489617115	Post-Myocardial Infarction	0..*	choice	Options: 1 option
621745958993	Pre-operative Consultation	0..*	choice	Options: 1 option
873024527134	Procedure Date (if known)	0..1	date	Enable When: 621745958993 = Pre-operative Consultation (standardized-referral-form-codes#20044)
197975129599	Syncope	0..*	choice	Options: 1 option
675849150752	Valvular Heart Disease or Prosthetic Heart Valve	0..*	choice	Options: 1 option
721982740516	Other	0..*	choice	Options: 1 option
720594942482	Specify	1..1	text	Enable When: 721982740516 = other (v3 Code System NullFlavor#OTH)
Descriptionofclinicalquestion	Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations	1..1	text
cpp_header	Cumulative Patient Profile Please delete any sensitive information you do not intend to share from the CPP	0..1	group
cpp_separate	CPP attached separately (if not entered below)	0..*	string	Options: 1 option
cpp_currentprob	Current Problem List:	0..1	text	Enable When: cpp_separate exists false
cpp_pastmedicalhistory	Past Medical History:	0..1	text	Enable When: cpp_separate exists false
cpp_currentmedications	Current Medications :	0..1	text	Enable When: cpp_separate exists false
cpp_familyhistory	Family History:	0..1	text	Enable When: cpp_separate exists false
cpp_allergies	Allergies:	0..1	text	Enable When: cpp_separate exists false
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
preferredconsultlocation_selector	Preferred consultant or location	0..*	string	Options: 1 option
preferredconsultlocation_specify	Please specify either a preferred consultant or location	0..1	group	Enable When: preferredconsultlocation_selector = Preferred consultant or location
preferredconsultlocation_consultant	Consultant:	0..1	string
preferredconsultlocation_location	Location:	0..1	string
preferredconsultlocation_willingtotravel	Patient willing to travel for shorter wait time	0..*	string	Options: 1 option
preferredconsultlocation_otherconsiderations	Other considerations:	0..1	string
supportingdocumentation_header	Supporting Documentation Please attach all relevant laboratory and diagnostic investigations.	0..1	group
supportingdocumentation_details	Personal Health Information that is medically relevant has not been disclosed at the request of the patient.	0..*	string	Options: 1 option
supportingdocumentation_attachment	Add Attachments	0..1	attachment
feedbacksurvey_cardiology	Click here to provide feedback on this form	0..1	display
referrer_header	Referrer's Information	0..1	group
referrer_sitename	Site Name:	0..1	string
referrer_address_line1	Address (Line 1):	1..1	string
referrer_address_line2	Address (Line 2):	0..1	string
referrer_address_city	City:	1..1	string
referrer_address_province	Province:	1..1	string	Max Length: 2
referrer_address_postalcode	Postal Code:	1..1	string
referrer_phone	Phone #:	0..1	string
referrer_fax	Fax #:	0..1	string
referrer_billing	Billing Number:	0..1	integer
referrer_professionalid	Professional ID:	0..1	integer
referrer_signature	Signed:	1..1	text
referrer_role	Role:	0..1	choice	Options: 9 options
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")