Structured Data Capture
4.0.0 - International flag

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

Questionnaire: US Surgeon General - Family Health Portrait (Experimental)

Official URL: http://hl7.org/fhir/uv/sdc/Questionnaire/questionnaire-sdc-profile-example-ussg-fht Version: 4.0.0
Standards status: Informative Active as of 1970-01-01 Computable Name: USSurgeonGeneralFamilyHealthPortrait
Other Identifiers: http://example.org/panel-id#54127-6, OID:2.16.840.1.113883.4.642.40.17.35.17

Usage: Species: Homo sapiens

Copyright/Legal: (c) 2015 Regenstrief Institute

This represents an implementation of the "US Surgeon General family health portrait" form found at https://lforms-demo.nlm.nih.gov

LinkIDTextCardinalityTypeFlagsDescription & Constraintsdoco
.. USSurgeonGeneralFamilyHealthPortrait This represents an implementation of the "US Surgeon General family health portrait" form found at https://lforms-demo.nlm.nih.gov Questionnaire http://hl7.org/fhir/uv/sdc/Questionnaire/questionnaire-sdc-profile-example-ussg-fht#4.0.0
... 0 null 0..1 group
.... 0.1 Date Done 0..1 date
.... 0.2 Time Done 0..1 time
.... 0.3 Where Done 0..1 string
.... 0.4 Comment 0..1 string
... 1 Your health information 1..1 group
.... 1.1 null 0..1 group
..... 1.1.1 Name 0..1 string Max Length: 200
..... 1.1.2 Gender 1..1 choice Value Set: LOINC Answer Codes for LL1-9
...... 1.1.2.1.1 Please specify 1..1 string Enable When: 1.1.2 =
..... 1.1.3 Date of Birth 0..1 date
..... 1.1.4 Were you born a twin? 0..1 choice Value Set: LOINC Answer Codes for LL623-0
Initial Value: Coding = LOINC#LA32-8 "No"
..... 1.1.5 Were you adopted? 0..1 choice Value Set: LOINC Answer Codes for LL361-7
..... 1.1.6 Are your parents related to each other in any way other than marriage? 0..1 choice Value Set: LOINC Answer Codes for LL361-7
..... 1.1.7 Height 1..1 decimal
...... 1.1.7.1.1 Units 0..1 choice Value Set: Length Units
..... 1.1.8 Weight 0..1 decimal
...... 1.1.8.1.1 Units 0..1 choice Value Set: Weight Units
..... 1.1.9 Body mass index (BMI) [Ratio] 0..1 decimal iconicon
..... 1.1.10 Race 1..1 choice Value Set: LOINC Answer Codes for LL629-7
..... 1.1.11 Ethnicity 0..* choice Value Set: LOINC Answer Codes for LL628-9
.... 1.2 Your diseases history 0..* group
..... 1.2.1 Disease or Condition 0..1 choice Value Set: LOINC Answer Codes for LL626-3
..... 1.2.2 Age at Diagnosis 0..1 choice Value Set: LOINC Answer Codes for LL619-8
... 2 Family member health information 0..* group
.... 2.1.1 null 0..1 group
..... 2.1.1.1 Relationship to you 0..1 choice Value Set: LOINC Answer Codes for LL621-4
..... 2.1.1.2 Name 0..1 string
..... 2.1.1.3 Gender 0..1 choice Value Set: LOINC Answer Codes for LL1-9
...... 2.1.1.3.1.1 Please specify 1..1 string Enable When: 2.1.1.3 =
..... 2.1.1.4 Living? 0..1 choice Value Set: LOINC Answer Codes for LL361-7
...... 2.1.1.4.1 null 0..1 group
....... 2.1.1.4.1.1 Cause of Death 0..1 choice Value Set: LOINC Answer Codes for LL627-1
........ 2.1.1.4.1.1.1 Please specify 0..1 string Enable When: 2.1.1.4.1.1 =
....... 2.1.1.4.1.2 Age at Death 0..1 choice Value Set: LOINC Answer Codes for LL619-8
...... 2.1.1.4.2 null 0..1 group
....... 2.1.1.4.2.1 Date of Birth 0..1 date
....... 2.1.1.4.2.2 Age 0..1 decimal
..... 2.1.1.5 Was this person born a twin? 0..1 choice Value Set: LOINC Answer Codes for LL623-0
..... 2.1.1.6 Was this person adopted? 0..1 choice Value Set: LOINC Answer Codes for LL623-0
..... 2.1.1.7 Race 0..* choice Value Set: LOINC Answer Codes for LL629-7
..... 2.1.1.8 Ethnicity 0..* choice Value Set: LOINC Answer Codes for LL628-9
.... 2.1.2 This family member's history of disease 0..* group
..... 2.1.2.1 Disease or Condition 1..1 choice Value Set: LOINC Answer Codes for LL626-3
..... 2.1.2.2 Age at Diagnosis 0..1 choice Value Set: LOINC Answer Codes for LL619-8
..... 2.1.2.3 Mock-up item: Height 0..1 decimal
..... 2.1.2.4 Mock-up item: Weight 0..1 decimal
..... 2.1.2.5 Mock-up item: BMI 0..1 decimal

doco Documentation for this format

Contained Resources

  • Include these codes as defined in http://unitsofmeasure.org version Not Stated (use latest from terminology server)
    CodeDisplay
    [in_i]inch (international)
    cmcentimeters

  • Include these codes as defined in http://unitsofmeasure.org version Not Stated (use latest from terminology server)
    CodeDisplay
    [lb_av]pound (US and British)
    kgkilograms

  • linkId: 0

Date Done

  • linkId: 0.1

Time Done

  • linkId: 0.2

Where Done

  • linkId: 0.3

Comment

  • linkId: 0.4

Your health information*

  • linkId: 1

  • linkId: 1.1

Name

  • linkId: 1.1.1
  • Max Length:: 200

Gender*

Please specify*

  • linkId: 1.1.2.1.1
  • Enable When: todo

Date of Birth

  • linkId: 1.1.3

Were you born a twin?

Were you adopted?

Are your parents related to each other in any way other than marriage?

Height*

  • linkId: 1.1.7

Units

Weight

  • linkId: 1.1.8

Units

Body mass index (BMI) [Ratio]

  • linkId: 1.1.9

Race*

Ethnicity

Your diseases history

  • linkId: 1.2

Disease or Condition

Age at Diagnosis

Family member health information

  • linkId: 2

  • linkId: 2.1.1

Relationship to you

Name

  • linkId: 2.1.1.2

Gender

Please specify*

  • linkId: 2.1.1.3.1.1
  • Enable When: todo

Living?

  • linkId: 2.1.1.4.1

Cause of Death

Please specify

  • linkId: 2.1.1.4.1.1.1
  • Enable When: todo

Age at Death

  • linkId: 2.1.1.4.2

Date of Birth

  • linkId: 2.1.1.4.2.1

Age

  • linkId: 2.1.1.4.2.2

Was this person born a twin?

Was this person adopted?

Race

Ethnicity

This family member's history of disease

  • linkId: 2.1.2

Disease or Condition*

Age at Diagnosis

Mock-up item: Height

  • linkId: 2.1.2.3

Mock-up item: Weight

  • linkId: 2.1.2.4

Mock-up item: BMI

  • linkId: 2.1.2.5

Contained Resources

  • Include these codes as defined in http://unitsofmeasure.org version Not Stated (use latest from terminology server)
    CodeDisplay
    [in_i]inch (international)
    cmcentimeters

  • Include these codes as defined in http://unitsofmeasure.org version Not Stated (use latest from terminology server)
    CodeDisplay
    [lb_av]pound (US and British)
    kgkilograms

LinkIDDescription & Constraintsdoco
.. 0
... 0.1
... 0.2
... 0.3
.. 1
... 1.1
.... 1.1.1 Max Length: 200
.... 1.1.2 Value Set: LOINC Answer Codes for LL1-9
..... 1.1.2.1.1 Enable When: Not done yet
.... 1.1.3
.... 1.1.4 Value Set: LOINC Answer Codes for LL623-0
Initial Value: Coding = LOINC#LA32-8 "No"
.... 1.1.5 Value Set: LOINC Answer Codes for LL361-7
.... 1.1.6 Value Set: LOINC Answer Codes for LL361-7
.... 1.1.7
..... 1.1.7.1.1 Value Set: Length Units
.... 1.1.8
..... 1.1.8.1.1 Value Set: Weight Units
.... 1.1.9
.... 1.1.10 Value Set: LOINC Answer Codes for LL629-7
.... 1.1.11 Value Set: LOINC Answer Codes for LL628-9
... 1.2
.... 1.2.1 Value Set: LOINC Answer Codes for LL626-3
.... 1.2.2 Value Set: LOINC Answer Codes for LL619-8
.. 2
... 2.1.1
.... 2.1.1.1 Value Set: LOINC Answer Codes for LL621-4
.... 2.1.1.2
.... 2.1.1.3 Value Set: LOINC Answer Codes for LL1-9
..... 2.1.1.3.1.1 Enable When: Not done yet
.... 2.1.1.4 Value Set: LOINC Answer Codes for LL361-7
..... 2.1.1.4.1
...... 2.1.1.4.1.1 Value Set: LOINC Answer Codes for LL627-1
....... 2.1.1.4.1.1.1 Enable When: Not done yet
...... 2.1.1.4.1.2 Value Set: LOINC Answer Codes for LL619-8
..... 2.1.1.4.2
...... 2.1.1.4.2.1
...... 2.1.1.4.2.2
.... 2.1.1.5 Value Set: LOINC Answer Codes for LL623-0
.... 2.1.1.6 Value Set: LOINC Answer Codes for LL623-0
.... 2.1.1.7 Value Set: LOINC Answer Codes for LL629-7
.... 2.1.1.8 Value Set: LOINC Answer Codes for LL628-9
... 2.1.2
.... 2.1.2.1 Value Set: LOINC Answer Codes for LL626-3
.... 2.1.2.2 Value Set: LOINC Answer Codes for LL619-8
.... 2.1.2.3
.... 2.1.2.4
.... 2.1.2.5

doco Documentation for this format

Contained Resources

  • Include these codes as defined in http://unitsofmeasure.org version Not Stated (use latest from terminology server)
    CodeDisplay
    [in_i]inch (international)
    cmcentimeters

  • Include these codes as defined in http://unitsofmeasure.org version Not Stated (use latest from terminology server)
    CodeDisplay
    [lb_av]pound (US and British)
    kgkilograms

Test this Questionnaire

Try this questionnaire out:

    Contained Resources

    • Include these codes as defined in http://unitsofmeasure.org version Not Stated (use latest from terminology server)
      CodeDisplay
      [in_i]inch (international)
      cmcentimeters

    • Include these codes as defined in http://unitsofmeasure.org version Not Stated (use latest from terminology server)
      CodeDisplay
      [lb_av]pound (US and British)
      kgkilograms

    Responses for this Questionnaire

    Contained resources