Structured Data Capture
4.0.0-ci-build - STU 4 CI-build
Structured Data Capture
4.0.0-ci-build - STU 4 CI-build
Structured Data Capture, published by HL7 International / FHIR Infrastructure. This guide is not an authorized publication; it is the continuous build for version 4.0.0-ci-build built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/sdc/ and changes regularly. See the Directory of published versions
| Page standards status: Informative |
<QuestionnaireResponse xmlns="http://hl7.org/fhir">
<id value="Cardiology-MariaSantos"/>
<language value="en"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">Patient Information<br/> Surname: Santos<br/>First Name: Maria<br/>DOB: 1948-05-19<br/>Gender: Female<br/>HN PC: ON<br/>Address (Line 1): 85 King St S<br/>Mobile #: 519-555-0362<br/>Home #: 519-555-0198<br/>Email: maria.santos@example.com<br/>[Optional] Additional Patient Information<br/><br/> Sex assigned at birth: Female<br/>Pronouns: She/HerThey/Them<br/>Preferred language: English<br/>Best method of contact: Home<br/><span style="display:none;"><br/></span> Accessibility concerns or disability<br/><br/>Wheelchair; Hearing impaired<br/><br/>Referral Details<br/> Triage Considerations Requested Priority: <br/><span style="font-weight:bold;color:#EE6B00;">Routine<br/></span><br/>Service(s) Requested <span style="display:none;"><br/></span> Cardiology Consultation<br/><b>Concern(s) / Indication(s) Triggering Referral</b><br/><i>Select all that apply:</i><br/><br/> <span style="display:none;"><br/></span> Congestive Heart Failure<br/><span style="font-weight:bold;">Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations<br/></span> 77F, progressive exertional dyspnea and bilateral ankle edema x 2 months. BNP elevated at 480. CXR shows mild cardiomegaly. On furosemide 20mg with partial response. Please assess and advise on HF management.<br/>Cumulative Patient Profile<br/><br/><i>Please delete any sensitive information you do not intend to share from the CPP</i><br/> Current Problem List: Suspected CHF (onset Jan 2026)
Hypertension
Type 2 diabetes<br/>Past Medical History: Left hip replacement (2020)
Type 2 diabetes (2012)<br/>Current Medications : Furosemide 20 mg PO daily
Perindopril 4 mg PO daily
Metformin 500 mg PO BID
Empagliflozin 10 mg PO daily<br/>Family History: Mother: CHF, deceased age 80<br/>Allergies: NKDA<br/>Referrer's Information<br/> Site Name: Amplify Primary Care<br/>Address (Line 1): 10248 Yonge St<br/>Phone #: 416-555-5555<br/>Fax #: 416-555-5555<br/>Billing Number: 55554<br/>Professional ID: 55555<br/>Signed: Dr. Sean Sender<br/>Role: Family Physician</div>
</text>
<questionnaire
value="http://hl7.org/fhir/uv/sdc/Questionnaire/CardiologyForm"/>
<status value="completed"/>
<subject>
<reference value="Patient/pat-53234"/>
<display value="MOMO ABBAS"/>
</subject>
<authored value="2026-03-12T22:51:31.735Z"/>
<author>
<reference value="Practitioner/smart-Practitioner-71482713"/>
<type value="Practitioner"/>
<display value="Susan Clark"/>
</author>
<item>
<linkId value="patient_header"/>
<text value="Patient Information"/>
<item>
<linkId value="patient_surname"/>
<text value="Surname:"/>
<answer>
<valueString value="Santos"/>
</answer>
</item>
<item>
<linkId value="patient_firstname"/>
<text value="First Name:"/>
<answer>
<valueString value="Maria"/>
</answer>
</item>
<item>
<linkId value="patient_date_of_birth"/>
<text value="DOB:"/>
<answer>
<valueDate value="1948-05-19"/>
</answer>
</item>
<item>
<linkId value="patient_gender"/>
<text value="Gender:"/>
<answer>
<valueCoding>
<system value="http://hl7.org/fhir/administrative-gender"/>
<code value="female"/>
<display value="Female"/>
</valueCoding>
</answer>
</item>
<item>
<linkId value="patient_hc_pc"/>
<text value="HN PC:"/>
<answer>
<valueString value="ON"/>
<item>
<linkId value="patient_hc_number"/>
<text value="HN:"/>
<answer>
<valueString value="7413582609"/>
</answer>
</item>
<item>
<linkId value="patient_hc_vc"/>
<text value="HN VC:"/>
<answer>
<valueString value="TC"/>
</answer>
</item>
</answer>
</item>
<item>
<linkId value="patient_address_line1"/>
<text value="Address (Line 1):"/>
<answer>
<valueString value="85 King St S"/>
<item>
<linkId value="patient_address_line2"/>
<text value="Address (Line 2):"/>
<answer>
<valueString value="Unit 302"/>
</answer>
</item>
<item>
<linkId value="patient_address_city"/>
<text value="City:"/>
<answer>
<valueString value="Waterloo"/>
</answer>
</item>
<item>
<linkId value="patient_address_province"/>
<text value="Province:"/>
<answer>
<valueString value="ON"/>
</answer>
</item>
<item>
<linkId value="patient_address_postalcode"/>
<text value="Postal Code:"/>
<answer>
<valueString value="N2J 1P2"/>
</answer>
</item>
</answer>
</item>
<item>
<linkId value="patient_phone_mobile"/>
<text value="Mobile #:"/>
<answer>
<valueString value="519-555-0362"/>
</answer>
</item>
<item>
<linkId value="patient_phone_home"/>
<text value="Home #:"/>
<answer>
<valueString value="519-555-0198"/>
</answer>
</item>
<item>
<linkId value="patient_email"/>
<text value="Email:"/>
<answer>
<valueString value="maria.santos@example.com"/>
</answer>
</item>
</item>
<item>
<linkId value="additionalinfo_header"/>
<text value="[Optional] Additional Patient Information"/>
<item>
<linkId value="additionalinfo_sexassignedatbirth"/>
<text value="Sex assigned at birth:"/>
<answer>
<valueCoding>
<system value="http://loinc.org"/>
<code value="LA3-6"/>
<display value="Female"/>
</valueCoding>
</answer>
</item>
<item>
<linkId value="additionalinfo_pronouns"/>
<text value="Pronouns:"/>
<answer>
<valueCoding>
<system value="http://loinc.org"/>
<code value="LA29519-8"/>
<display value="She/Her"/>
</valueCoding>
</answer>
</item>
<item>
<linkId value="additionalinfo_preferredlanguage"/>
<text value="Preferred language:"/>
<answer>
<valueCoding>
<system value="urn:ietf:bcp:47"/>
<code value="en"/>
<display value="English"/>
</valueCoding>
</answer>
</item>
<item>
<linkId value="additionalinfo_bestmethodofcontact"/>
<text value="Best method of contact:"/>
<answer>
<valueCoding>
<system value="http://hl7.org/fhir/contact-point-use"/>
<code value="home"/>
<display value="Home"/>
</valueCoding>
</answer>
</item>
<item>
<linkId
value="additionalinfo_accessibilityconcernsordisability_selectt"/>
<text value="Accessibility concerns or disability"/>
<answer>
<valueString value="Accessibility concerns or disability"/>
</answer>
</item>
<item>
<linkId value="additionalinfo_accessibilityconcernsordisability"/>
<text value="Accessibility concerns Options"/>
<answer>
<valueCoding>
<system value="http://snomed.info/sct"/>
<code value="105503008"/>
<display value="Wheelchair"/>
</valueCoding>
</answer>
<answer>
<valueCoding>
<system value="http://snomed.info/sct"/>
<code value="15188001"/>
<display value="Hearing impaired"/>
</valueCoding>
</answer>
</item>
</item>
<item>
<linkId value="102173268919"/>
<text value="Referral Details"/>
<item>
<linkId value="cardio_triagecons"/>
<text value="Triage Considerations"/>
<item>
<linkId value="referral_requestedpriority"/>
<text value="Requested Priority:"/>
<answer>
<valueCoding>
<system value="http://hl7.org/fhir/request-priority"/>
<code value="routine"/>
<display value="Routine"/>
</valueCoding>
</answer>
</item>
</item>
<item>
<linkId value="695991571585"/>
<text value="Service(s) Requested Select all that apply:"/>
<item>
<linkId value="785727177547"/>
<text value="Cardiology Consultation"/>
<answer>
<valueCoding>
<system
value="http://example.com/CodeSystem/standardized-referral-form-codes"/>
<code value="20002"/>
<display value="Cardiology Consultation"/>
</valueCoding>
</answer>
</item>
</item>
<item>
<linkId value="186952778859"/>
<text
value="Concern(s) / Indication(s) Triggering Referral Select all that apply:"/>
<item>
<linkId value="832263816528"/>
<text value="Congestive Heart Failure"/>
<answer>
<valueCoding>
<system
value="http://example.com/CodeSystem/standardized-referral-form-codes"/>
<code value="20036"/>
<display value="Congestive Heart Failure"/>
</valueCoding>
</answer>
</item>
</item>
<item>
<linkId value="Descriptionofclinicalquestion"/>
<text
value="Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations"/>
<answer>
<valueString
value="77F, progressive exertional dyspnea and bilateral ankle edema x 2 months. BNP elevated at 480. CXR shows mild cardiomegaly. On furosemide 20mg with partial response. Please assess and advise on HF management."/>
</answer>
</item>
</item>
<item>
<linkId value="cpp_header"/>
<text
value="Cumulative Patient Profile Please delete any sensitive information you do not intend to share from the CPP"/>
<item>
<linkId value="cpp_currentprob"/>
<text value="Current Problem List:"/>
<answer>
<valueString
value="Suspected CHF (onset Jan 2026)
Hypertension
Type 2 diabetes"/>
</answer>
</item>
<item>
<linkId value="cpp_pastmedicalhistory"/>
<text value="Past Medical History:"/>
<answer>
<valueString
value="Left hip replacement (2020)
Type 2 diabetes (2012)"/>
</answer>
</item>
<item>
<linkId value="cpp_currentmedications"/>
<text value="Current Medications :"/>
<answer>
<valueString
value="Furosemide 20 mg PO daily
Perindopril 4 mg PO daily
Metformin 500 mg PO BID
Empagliflozin 10 mg PO daily"/>
</answer>
</item>
<item>
<linkId value="cpp_familyhistory"/>
<text value="Family History:"/>
<answer>
<valueString value="Mother: CHF, deceased age 80"/>
</answer>
</item>
<item>
<linkId value="cpp_allergies"/>
<text value="Allergies:"/>
<answer>
<valueString value="NKDA"/>
</answer>
</item>
</item>
<item>
<linkId value="referrer_header"/>
<text value="Referrer's Information"/>
<item>
<linkId value="referrer_sitename"/>
<text value="Site Name:"/>
<answer>
<valueString value="Amplify Primary Care"/>
</answer>
</item>
<item>
<linkId value="referrer_address_line1"/>
<text value="Address (Line 1):"/>
<answer>
<valueString value="10248 Yonge St"/>
<item>
<linkId value="referrer_address_line2"/>
<text value="Address (Line 2):"/>
<answer>
<valueString value="Suite 515"/>
</answer>
</item>
<item>
<linkId value="referrer_address_city"/>
<text value="City:"/>
<answer>
<valueString value="Richmond Hill"/>
</answer>
</item>
<item>
<linkId value="referrer_address_province"/>
<text value="Province:"/>
<answer>
<valueString value="ON"/>
</answer>
</item>
<item>
<linkId value="referrer_address_postalcode"/>
<text value="Postal Code:"/>
<answer>
<valueString value="L4C 5K9"/>
</answer>
</item>
</answer>
</item>
<item>
<linkId value="referrer_phone"/>
<text value="Phone #:"/>
<answer>
<valueString value=" 416-555-5555"/>
</answer>
</item>
<item>
<linkId value="referrer_fax"/>
<text value="Fax #:"/>
<answer>
<valueString value=" 416-555-5555"/>
</answer>
</item>
<item>
<linkId value="referrer_billing"/>
<text value="Billing Number:"/>
<answer>
<valueInteger value="55554"/>
</answer>
</item>
<item>
<linkId value="referrer_professionalid"/>
<text value="Professional ID:"/>
<answer>
<valueInteger value="55555"/>
</answer>
</item>
<item>
<linkId value="referrer_signature"/>
<text value="Signed:"/>
<answer>
<valueString value="Dr. Sean Sender"/>
</answer>
</item>
<item>
<linkId value="referrer_role"/>
<text value="Role:"/>
<answer>
<valueCoding>
<system value="http://snomed.info/sct"/>
<code value="62247001"/>
<display value="Family Physician"/>
</valueCoding>
</answer>
</item>
</item>
</QuestionnaireResponse>
IG © 2022+ HL7 International / FHIR Infrastructure.
Package hl7.fhir.uv.sdc#4.0.0-ci-build based on FHIR 4.0.1.
Generated
2026-06-11
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