Questionnaire-patients-fetal-death
type: Questionnaire
node role: treeRoot
id:
  v: Questionnaire-patients-fetal-death
meta:
  version id:
    v: 12
  last updated:
    v: 2021-07-09T07:23:29.708Z
text:
  status:
    v: extensions
  div: Generated Narrative: Questionnaire Questionnaire-patients-fetal-death version: versionId: id (PrimitiveType/Questionnaire.meta.versionId): native = id -> 12; Last updated: 2021-07-09 07:23:29+0000 LinkID Text Cardinality Type Description & Constraints<img src="[binary]" alt="doco" style="background-color: inherit"/> QuestionnairePatientsFetalDeathWorksheet This Questionnaire represents the [Patient's Worksheet for the Report of Fetal Death](https://www.cdc.gov/nchs/data/dvs/fetal-death-mother-worksheet-english-2019-508.pdf). Questionnaire https://profiles.ihe.net/QRPH/bfdr/Questionnaire/Questionnaire-patients-fetal-death#1.1.0 intro We are truly sorry about the loss you have experienced. We understand that this is a difficult time for you and your loved ones. We need to ask you a few questions to assist in the completion of the official report of fetal death. State laws provide protection against the unauthorized release of identifying information from the report of fetal death to ensure confidentiality of the parents. This information may also help researchers understand some of the factors that are related to miscarriage and stillbirth. Your assistance in providing complete and accurate information is very important. We appreciate your help, especially during this very difficult time. 0..1 display child-name 1. Would you like to name the child? This is entirely optional. 0..1 group child-first-name First 0..1 string child-middle-name Middle 0..1 string child-last-name Last 0..1 string child-suffix Suffix (Jr., III, etc.) 0..1 string mother-current-legal-name 2. What is your current legal name? 0..1 group mother-first-name First 0..1 string mother-middle-name Middle 0..1 string mother-last-name Last 0..1 string mother-suffix Suffix (Jr., III, etc.) 0..1 string mother-address 3. Where do you usually live - that is - where is your household/residence located? 0..1 group mother-nbr-street Complete number and street (do not enter rural route numbers) 0..1 string mother…
url:
  v: https://profiles.ihe.net/QRPH/bfdr/Questionnaire/Questionnaire-patients-fetal-death
version:
  v: 1.1.0
name:
  v: QuestionnairePatientsFetalDeathWorksheet
title:
  v: Questionnaire - Patient's Worksheet for the Report of Fetal Death
status:
  v: draft
experimental:
  v: false
subject type:
  v: Patient
date:
  v: 2024-07-09T14:11:31+00:00
publisher:
  v: IHE International
contact:
  name:
    v: IHE Quality, Research and Public Health Committee
  telecom:
    system:
      v: url
    value:
      v: https://www.ihe.net/ihe_domains/quality_research_and_public_health
description:
  v: This Questionnaire represents the [Patient's Worksheet for the Report of Fetal Death](https://www.cdc.gov/nchs/data/dvs/fetal-death-mother-worksheet-english-2019-508.pdf).
jurisdiction:
  coding:
    system:
      v: http://unstats.un.org/unsd/methods/m49/m49.htm
    code:
      v: 001
item:
  link id:
    v: intro
  text:
    v: We are truly sorry about the loss you have experienced. We understand that this is a difficult time for you and your loved ones. We need to ask you a few questions to assist in the completion of the official report of fetal death. State laws provide protection against the unauthorized release of identifying information from the report of fetal death to ensure confidentiality of the parents. This information may also help researchers understand some of the factors that are related to miscarriage and stillbirth. Your assistance in providing complete and accurate information is very important. We appreciate your help, especially during this very difficult time.
  type:
    v: display
item:
  link id:
    v: child-name
  prefix:
    v: 1
  text:
    v: Would you like to name the child? This is entirely optional.
  type:
    v: group
  repeats:
    v: false
  item:
    link id:
      v: child-first-name
    text:
      v: First
    type:
      v: string
  item:
    link id:
      v: child-middle-name
    text:
      v: Middle
    type:
      v: string
  item:
    link id:
      v: child-last-name
    text:
      v: Last
    type:
      v: string
  item:
    link id:
      v: child-suffix
    text:
      v: Suffix (Jr., III, etc.)
    type:
      v: string
item:
  link id:
    v: mother-current-legal-name
  prefix:
    v: 2
  text:
    v: What is your current legal name?
  type:
    v: group
  repeats:
    v: false
  item:
    link id:
      v: mother-first-name
    text:
      v: First
    type:
      v: string
  item:
    link id:
      v: mother-middle-name
    text:
      v: Middle
    type:
      v: string
  item:
    link id:
      v: mother-last-name
    text:
      v: Last
    type:
      v: string
  item:
    link id:
      v: mother-suffix
    text:
      v: Suffix (Jr., III, etc.)
    type:
      v: string
item:
  link id:
    v: mother-address
  prefix:
    v: 3
  text:
    v: Where do you usually live - that is - where is your household/residence located?
  type:
    v: group
  item:
    link id:
      v: mother-nbr-street
    text:
      v: Complete number and street (do not enter rural route numbers)
    type:
      v: string
  item:
    link id:
      v: mother-apt-nbr
    text:
      v: Apartment Number
    type:
      v: string
  item:
    link id:
      v: mother-city
    text:
      v: City, Town, or Location
    type:
      v: string
  item:
    link id:
      v: mother-county
    text:
      v: County
    type:
      v: string
  item:
    link id:
      v: mother-state
    text:
      v: State (or U.S. Territory, Canadian Province)
    type:
      v: string
  item:
    link id:
      v: mother-zip
    text:
      v: Zip Code
    type:
      v: string
  item:
    link id:
      v: mother-country
    text:
      v: If not in the United States, country
    type:
      v: string
item:
  link id:
    v: inside-city-limits
  prefix:
    v: 4
  text:
    v: Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)?
  type:
    v: choice
  answer value set:
    v: http://phinvads.cdc.gov/fhir/ValueSet/2.16.840.1.114222.4.11.888
    link: http://phinvads.cdc.gov/fhir/ValueSet/2.16.840.1.114222.4.11.888

link id:
  v: mother-mail
prefix:
  v: 5
text:
  v: What is your mailing address
type:
  v: group
repeats:
  v: false
item:
  link id:
    v: mother-mail-same
  text:
    v: Same as residence [Go to next question]
  type:
    v: boolean
item:
  link id:
    v: mother-mail-nbr-street
  text:
    v: Complete number and street
  type:
    v: string
  enable when:
    question:
      v: mother-mail-same
    operator:
      v: =
    answer:
      v: false
item:
  link id:
    v: mother-mail-apt-nbr
  text:
    v: Apartment Number
  type:
    v: string
  enable when:
    question:
      v: mother-mail-same
    operator:
      v: =
    answer:
      v: false
item:
  link id:
    v: mother-mail-po-box
  text:
    v: P.O. Box
  type:
    v: string
  enable when:
    question:
      v: mother-mail-same
    operator:
      v: =
    answer:
      v: false
item:
  link id:
    v: mother-mail-city
  text:
    v: City, Town, or Location
  type:
    v: string
  enable when:
    question:
      v: mother-mail-same
    operator:
      v: =
    answer:
      v: false
item:
  link id:
    v: mother-mail-state
  text:
    v: State (or U.S. Territory, Canadian Province)
  type:
    v: string
  enable when:
    question:
      v: mother-mail-same
    operator:
      v: =
    answer:
      v: false
item:
  link id:
    v: mother-mail-zip
  text:
    v: Zip Code
  type:
    v: string
  enable when:
    question:
      v: mother-mail-same
    operator:
      v: =
    answer:
      v: false
item:
  link id:
    v: mother-mail-country
  text:
    v: If not in the United States, country
  type:
    v: string
  enable when:
    question:
      v: mother-mail-same
    operator:
      v: =
    answer:
      v: false

link id:
  v: mother-dob
prefix:
  v: 6
text:
  v: What is your date of birth?
type:
  v: date
repeats:
  v: false

link id:
  v: mother-birthplace
prefix:
  v: 7
text:
  v: In what State, U.S. territory, or foreign country were you born? Please specify one of the following:
type:
  v: group
repeats:
  v: false
item:
  link id:
    v: mother-birthplace-state
  text:
    v: State
  type:
    v: string
item:
  link id:
    v: mother-birthplace-territory
  text:
    v: or U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas
  type:
    v: string
item:
  link id:
    v: mother-birthplace-country
  text:
    v: or Foreign country
  type:
    v: string

link id:
  v: mother-education
code: https://loinc.org/rdf/57712-2
  system:
    v: http://loinc.org
  code:
    v: 57712-2
  display:
    v: Highest level of education Mother
prefix:
  v: 8
text:
  v: What is the highest level of schooling that you have completed at the time of delivery? (Check the box that best describes your education. If you are currently enrolled, check the box that indicates the previous grade or highest degree received).
type:
  v: choice
repeats:
  v: false
answer value set:
  v: http://phinvads.cdc.gov/fhir/ValueSet/2.16.840.1.114222.4.11.7582
  link: http://phinvads.cdc.gov/fhir/ValueSet/2.16.840.1.114222.4.11.7582

link id:
  v: mother-ethnicity
prefix:
  v: 9
text:
  v: Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.
type:
  v: group
repeats:
  v: false
item:
  link id:
    v: mother-shl
  text:
    v: Are you Spanish/Hispanic/Latina
  type:
    v: choice
  repeats:
    v: true
  answer value set:
    v: http://hl7.org/fhir/us/core/ValueSet/omb-ethnicity-category
    link: http://hl7.org/fhir/us/core/ValueSet/omb-ethnicity-category
item:
  link id:
    v: mother-detailed-shl
  text:
    v: If Spanish/Hispanic/Latina, check the appropriate box.
  type:
    v: choice
  enable when:
    question:
      v: mother-shl
    operator:
      v: =
    answer: Coding
      system:
        v: urn:oid:2.16.840.1.113883.6.238
      code:
        v: 2135-2
  repeats:
    v: false
  answer value set:
    v: http://hl7.org/fhir/us/core/ValueSet/detailed-ethnicity
    link: http://hl7.org/fhir/us/core/ValueSet/detailed-ethnicity

link id:
  v: mother-race
prefix:
  v: 10
text:
  v: What is your race? (Please check one or more races to indicate what you consider yourself to be).
type:
  v: group
repeats:
  v: false
item:
  link id:
    v: mother-race-category
  text:
    v: Race categories
  type:
    v: choice
  repeats:
    v: true
  answer value set:
    v: http://hl7.org/fhir/us/core/ValueSet/omb-race-category
    link: http://hl7.org/fhir/us/core/ValueSet/omb-race-category
item:
  link id:
    v: mother-detailed-race
  text:
    v: Extended race codes
  type:
    v: choice
  repeats:
    v: true
  answer value set:
    v: http://hl7.org/fhir/us/core/ValueSet/detailed-race
    link: http://hl7.org/fhir/us/core/ValueSet/detailed-race

link id:
  v: father-current-legal-name
prefix:
  v: 11
text:
  v: What is the current legal name of your baby's father?
type:
  v: group
repeats:
  v: false
item:
  link id:
    v: father-first-name
  text:
    v: First
  type:
    v: string
item:
  link id:
    v: father-middle-name
  text:
    v: Middle
  type:
    v: string
item:
  link id:
    v: father-last-name
  text:
    v: Last
  type:
    v: string
item:
  link id:
    v: father-suffix
  text:
    v: Suffix (Jr., III, etc.)
  type:
    v: string

link id:
  v: father-dob
prefix:
  v: 12
text:
  v: What is the father's date of birth?
type:
  v: date
repeats:
  v: false

link id:
  v: father-birthplace
prefix:
  v: 13
text:
  v: In what State, U.S. territory, or foreign country was the father born? Please specify one of the following:
type:
  v: group
repeats:
  v: false
item:
  link id:
    v: father-birthplace-state
  text:
    v: State
  type:
    v: string
item:
  link id:
    v: father-birthplace-territory
  text:
    v: or U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas
  type:
    v: string
item:
  link id:
    v: father-birthplace-country
  text:
    v: or Foreign country
  type:
    v: string

link id:
  v: receive-wic
prefix:
  v: 14
text:
  v: Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy?
type:
  v: choice
repeats:
  v: false
answer value set:
  v: http://phinvads.cdc.gov/fhir/ValueSet/2.16.840.1.114222.4.11.888
  link: http://phinvads.cdc.gov/fhir/ValueSet/2.16.840.1.114222.4.11.888

link id:
  v: mothers-height
prefix:
  v: 15
text:
  v: What is your height?
type:
  v: group
item:
  link id:
    v: mothers-height-feet
  text:
    v: Feet
  type:
    v: quantity
  repeats:
    v: false
item:
  link id:
    v: mothers-height-inches
  text:
    v: Inches
  type:
    v: quantity
  repeats:
    v: false

link id:
  v: mothers-prepregnancy-weight
prefix:
  v: 16
text:
  v: lbs
type:
  v: quantity
repeats:
  v: false

link id:
  v: mothers-smoking
prefix:
  v: 17
text:
  v: How many cigarettes OR packs of cigarettes did you smoke on an average day during each of the following time periods? If you NEVER smoked, enter zero for each time period.
type:
  v: group
item:
  link id:
    v: mothers-smoking-3-months-prior
  text:
    v: Three months before pregnancy
  type:
    v: group
  item:
    link id:
      v: mothers-smoking-3-months-prior-cig
    text:
      v: # of cigarettes*
    type:
      v: integer
    repeats:
      v: false
  item:
    link id:
      v: mothers-smoking-3-months-prior-pck
    text:
      v: # of packs
    type:
      v: integer
    repeats:
      v: false
item:
  link id:
    v: mothers-smoking-trimester-1
  text:
    v: First three months of pregnancy
  type:
    v: group
  item:
    link id:
      v: mothers-smoking-trimester-1-cig
    text:
      v: # of cigarettes*
    type:
      v: integer
    repeats:
      v: false
  item:
    link id:
      v: mothers-smoking-trimester-1-pck
    text:
      v: # of packs
    type:
      v: integer
    repeats:
      v: false
item:
  link id:
    v: mothers-smoking-trimester-2
  text:
    v: Second three months of pregnancy
  type:
    v: group
  item:
    link id:
      v: mothers-smoking-trimester-2-cig
    text:
      v: # of cigarettes*
    type:
      v: integer
    repeats:
      v: false
  item:
    link id:
      v: mothers-smoking-trimester-2-pck
    text:
      v: # of packs
    type:
      v: integer
    repeats:
      v: false
item:
  link id:
    v: mothers-smoking-trimester-3
  text:
    v: Third trimester of pregnancy
  type:
    v: group
  item:
    link id:
      v: mothers-smoking-trimester-3-cig
    text:
      v: # of cigarettes*
    type:
      v: integer
    repeats:
      v: false
  item:
    link id:
      v: mothers-smoking-trimester-3-pck
    text:
      v: # of packs
    type:
      v: integer
    repeats:
      v: false
item:
  link id:
    v: cigarette-note
  text:
    v: *refers to tobacco products only, NOT e-cigarettes.
  type:
    v: display

link id:
  v: outro
text:
  v: Thank you for completing this worksheet at this very difficult time. The information you have provided is very important; it will be used by researchers to better understand factors related to miscarriage and stillbirth and lead to improved prevention strategies for the future.
type:
  v: display