QuestionnaireResponse-mothers-live-birth-jada-quinn
type: QuestionnaireResponse
node role: treeRoot
id:
  v: QuestionnaireResponse-mothers-live-birth-jada-quinn
meta:
  version id:
    v: 11
  last updated:
    v: 2023-06-21T21:34:58.869Z
text:
  status:
    v: generated
  div: Generated Narrative: QuestionnaireResponse QuestionnaireResponse-mothers-live-birth-jada-quinn version: versionId: id (PrimitiveType/QuestionnaireResponse.meta.versionId): element = id -> versionId=id[11]; Last updated: 2023-06-21 21:34:58+0000 LinkID Text Definition Answer<img src="[binary]" alt="doco" style="background-color: inherit"/> QuestionnaireResponse-mothers-live-birth-jada-quinn Questionnaire:Questionnaire - Mother's Worksheet for Child's Birth Certificate mother-current-legal-name What is your current legal name? mother-first-name First Jada mother-middle-name Middle Ann mother-last-name Last Quinn child-name What will be your baby's legal name (as it should appear on the birth certificate)? child-first-name First Baby child-middle-name Middle G child-last-name Last Quinn mother-address Where do you usually live - that is - where is your household/residence located? mother-nbr-street Complete number and street (do not enter rural route numbers) 1875 West Morton Avenue mother-city City, Town, or Location Salt Lake City mother-county County Salt Lake mother-state State (or U.S. Territory, Canadian Province) UT mother-zip Zip Code 84116 inside-city-limits Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)? expandedYes-NoIndicator Y: Yes mother-mail What is your mailing address mother-mail-same Same as residence [Go to next question] false mother-mail-nbr-street Complete number and street 1848 South 1300 East mother-mail-city City, Town, or Location Salt Lake City mother-mail-state State (or U.S. Territory, Canadian Province) UT mother-mail-zip Zip Code 84401 mother-dob What is your date of birth? 1985-01-15 mother-birthplace In what State, U.S. territory, or foreign country were you born? Please specify one of the following: mother-birthplace-state State UT mother-education What is the highest level of schooling that you have completed at the time of delivery? (Check the box that best describe…
questionnaire:
  v: https://profiles.ihe.net/QRPH/bfdr/Questionnaire/Questionnaire-mothers-live-birth
  link: https://profiles.ihe.net/QRPH/bfdr/Questionnaire/Questionnaire-mothers-live-birth
status:
  v: completed
subject:
  link: https://profiles.ihe.net/QRPH/bfdr/Patient/patient-child-babyg-quinn
  reference:
    v: Patient/patient-child-babyg-quinn
  display:
    v: BabyG Quinn
source:
  link: https://profiles.ihe.net/QRPH/bfdr/Patient/patient-mother-jada-ann-quinn
  reference:
    v: Patient/patient-mother-jada-ann-quinn
  display:
    v: Patient - Mother (Jada Ann Quinn)
item:
  link id:
    v: mother-current-legal-name
  text:
    v: What is your current legal name?
  item:
    link id:
      v: mother-first-name
    text:
      v: First
    answer:
      value:
        v: Jada
  item:
    link id:
      v: mother-middle-name
    text:
      v: Middle
    answer:
      value:
        v: Ann
  item:
    link id:
      v: mother-last-name
    text:
      v: Last
    answer:
      value:
        v: Quinn
item:
  link id:
    v: child-name
  text:
    v: What will be your baby's legal name (as it should appear on the birth certificate)?
  item:
    link id:
      v: child-first-name
    text:
      v: First
    answer:
      value:
        v: Baby
  item:
    link id:
      v: child-middle-name
    text:
      v: Middle
    answer:
      value:
        v: G
  item:
    link id:
      v: child-last-name
    text:
      v: Last
    answer:
      value:
        v: Quinn
item:
  link id:
    v: mother-address
  text:
    v: Where do you usually live - that is - where is your household/residence located?
  item:
    link id:
      v: mother-nbr-street
    text:
      v: Complete number and street (do not enter rural route numbers)
    answer:
      value:
        v: 1875 West Morton Avenue
  item:
    link id:
      v: mother-city
    text:
      v: City, Town, or Location
    answer:
      value:
        v: Salt Lake City
  item:
    link id:
      v: mother-county
    text:
      v: County
    answer:
      value:
        v: Salt Lake
  item:
    link id:
      v: mother-state
    text:
      v: State (or U.S. Territory, Canadian Province)
    answer:
      value:
        v: UT
  item:
    link id:
      v: mother-zip
    text:
      v: Zip Code
    answer:
      value:
        v: 84116
item:
  link id:
    v: inside-city-limits
  text:
    v: Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)?
  answer:
    value: Coding
      system:
        v: http://terminology.hl7.org/CodeSystem/v2-0532
      code:
        v: Y
      display:
        v: Yes
item:
  link id:
    v: mother-mail
  text:
    v: What is your mailing address
  item:
    link id:
      v: mother-mail-same
    text:
      v: Same as residence [Go to next question]
    answer:
      value:
        v: false
  item:
    link id:
      v: mother-mail-nbr-street
    text:
      v: Complete number and street
    answer:
      value:
        v: 1848 South 1300 East
  item:
    link id:
      v: mother-mail-city
    text:
      v: City, Town, or Location
    answer:
      value:
        v: Salt Lake City
  item:
    link id:
      v: mother-mail-state
    text:
      v: State (or U.S. Territory, Canadian Province)
    answer:
      value:
        v: UT
  item:
    link id:
      v: mother-mail-zip
    text:
      v: Zip Code
    answer:
      value:
        v: 84401
item:
  link id:
    v: mother-dob
  text:
    v: What is your date of birth?
  answer:
    value:
      v: 1985-01-15
item:
  link id:
    v: mother-birthplace

v: In what State, U.S. territory, or foreign country were you born? Please specify one of the following:

link id:
  v: mother-birthplace-state
text:
  v: State
answer:
  value:
    v: UT

link id:
  v: mother-education
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).
answer:
  value: Coding
    system:
      v: urn:oid:2.16.840.1.114222.4.5.274
    code:
      v: PHC1455
    display:
      v: Doctorate Degree or Professional Degree

link id:
  v: mother-ethnicity
text:
  v: Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.
item:
  link id:
    v: mother-shl
  text:
    v: Are you Spanish/Hispanic/Latina
  answer:
    value: Coding
      system:
        v: urn:oid:2.16.840.1.113883.6.238
      code:
        v: 2186-5
      display:
        v: Not Hispanic or Latino

link id:
  v: mother-race
text:
  v: What is your race? (Please check one or more races to indicate what you consider yourself to be).
item:
  link id:
    v: mother-race-category
  text:
    v: Race categories
  answer:
    value: Coding
      system:
        v: urn:oid:2.16.840.1.113883.6.238
      code:
        v: 2106-3
      display:
        v: White
item:
  link id:
    v: mother-detailed-race
  text:
    v: Extended race codes
  answer:
    value: Coding
      system:
        v: urn:oid:2.16.840.1.113883.6.238
      code:
        v: 1004-1
      display:
        v: American Indian

link id:
  v: receive-wic
text:
  v: Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy?
answer:
  value: Coding
    system:
      v: http://terminology.hl7.org/CodeSystem/v2-0532
    code:
      v: Y
    display:
      v: Yes

link id:
  v: infertility-treatment
text:
  v: Did this pregnancy result from infertility treatment? (If yes, please answer 12a and 12b)
answer:
  value:
    v: true
  item:
    link id:
      v: drugs-ai-ii
    text:
      v: If yes, did this pregnancy result from fertility-enhancing drugs, artificial insemination, or intrauterine insemination?
    answer:
      value:
        v: false
  item:
    link id:
      v: art-ivf-gift
    text:
      v: If yes, did this pregnancy result from assisted reproductive technology (e.g., in-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT))?
    answer:
      value:
        v: true

link id:
  v: mothers-height
text:
  v: What is your height?
item:
  link id:
    v: mothers-height-feet
  text:
    v: Feet
  answer:
    value: Quantity
      value:
        v: 5
      unit:
        v: ft
      system:
        v: http://unitsofmeasure.org
      code:
        v: ft
item:
  link id:
    v: mothers-height-inches
  text:
    v: Inches
  answer:
    value: Quantity
      value:
        v: 7
      unit:
        v: [in_i]
      system:
        v: http://unitsofmeasure.org
      code:
        v: [in_i]

link id:
  v: mothers-prepregnancy-weight
text:
  v: lbs
answer:
  value: Quantity
    value:
      v: 145
    unit:
      v: [lb_av]
    system:
      v: http://unitsofmeasure.org
    code:
      v: [lb_av]

link id:
  v: mothers-smoking
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.
item:
  link id:
    v: mothers-smoking-3-months-prior
  text:
    v: Three months before pregnancy
  item:
    link id:
      v: mothers-smoking-3-months-prior-cig
    text:
      v: # of cigarettes*
    answer:
      value:
        v: 0
  item:
    link id:
      v: mothers-smoking-3-months-prior-pck
    text:
      v: # of packs
    answer:
      value:
        v: 1
item:
  link id:
    v: mothers-smoking-trimester-1
  text:
    v: First three months of pregnancy
  item:
    link id:
      v: mothers-smoking-trimester-1-cig
    text:
      v: # of cigarettes*
    answer:
      value:
        v: 3
  item:
    link id:
      v: mothers-smoking-trimester-1-pck
    text:
      v: # of packs
    answer:
      value:
        v: 0
item:
  link id:
    v: mothers-smoking-trimester-2
  text:
    v: Second three months of pregnancy
  item:
    link id:
      v: mothers-smoking-trimester-2-cig
    text:
      v: # of cigarettes*
    answer:
      value:
        v: 1
  item:
    link id:
      v: mothers-smoking-trimester-2-pck
    text:
      v: # of packs
    answer:
      value:
        v: 0
item:
  link id:
    v: mothers-smoking-trimester-3
  text:
    v: Third trimester of pregnancy
  item:
    link id:
      v: mothers-smoking-trimester-3-cig
    text:
      v: # of cigarettes*
    answer:
      value:
        v: 0
  item:
    link id:
      v: mothers-smoking-trimester-3-pck
    text:
      v: # of packs
    answer:
      value:
        v: 0

link id:
  v: mother-prior-name
text:
  v: What name did you use prior to your first marriage?
item:
  link id:
    v: mother-prior-first-name
  text:
    v: First
  answer:
    value:
      v: Jada
item:
  link id:
    v: mother-prior-middle-name
  text:
    v: Middle
  answer:
    value:
      v: Ann
item:
  link id:
    v: mother-prior-last-name
  text:
    v: Last
  answer:
    value:
      v: King

link id:
  v: married-conception
text:
  v: Were you married at the time you conceived this child, at the time of birth, or at any time between conception and giving birth? [If yes, please go to question 19; If no, please see below]
answer:
  value:
    v: true

link id:
  v: father-current-legal-name
text:
  v: What is the current legal name of your baby's father?
item:
  link id:
    v: father-first-name
  text:
    v: First
  answer:
    value:
      v: James
item:
  link id:
    v: father-middle-name
  text:
    v: Middle
  answer:
    value:
      v: Brandon
item:
  link id:
    v: father-last-name
  text:
    v: Last
  answer:
    value:
      v: Quinn

link id:
  v: father-dob
text:
  v: What the father's date of birth?
answer:
  value:
    v: 1983-09-27

link id:
  v: father-birthplace
text:
  v: In what State, U.S. territory, or foreign country was the father born? Please specify one of the following:
item:
  link id:
    v: father-birthplace-state
  text:
    v: State
  answer:
    value:
      v: NY

link id:
  v: father-education
text:
  v: What is the highest level of schooling that the father will have completed at the time of delivery? (Check the box that best describes his education. If he is currently enrolled, check the box that indicates the previous grade or highest degree received).
answer:
  value: Coding
    system:
      v: urn:oid:2.16.840.1.114222.4.5.274
    code:
      v: PHC1455
    display:
      v: Doctorate Degree or Professional Degree

link id:
  v: father-ethnicity
text:
  v: Is the father Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.
item:
  link id:
    v: father-shl
  text:
    v: Is the father Spanish/Hispanic/Latina
  answer:
    value: Coding
      system:
        v: urn:oid:2.16.840.1.113883.6.238
      code:
        v: 2186-5
      display:
        v: Not Hispanic or Latino

link id:
  v: father-race
text:
  v: What is the father's race? (Please check one or more races to indicate what he considers himself to be).
item:
  link id:
    v: father-race-category
  text:
    v: Race categories
  answer:
    value: Coding
      system:
        v: urn:oid:2.16.840.1.113883.6.238
      code:
        v: 2106-3
      display:
        v: White

link id:
  v: parents-ssn
text:
  v: Furnishing parent(s) Social Security Number(s) (SSNs) is required by Federal Law, 42 USC 405(c) (section 205(c) of the Social Security Act). The number(s) will be made available to the (State Social Services Agency) to assist with child support enforcement activities and to the Internal Revenue Service for the purpose of determining Earned Income Tax Credit compliance.
item:
  link id:
    v: mother-ssn
  text:
    v: What is your Social Security Number?
  answer:
    value:
      v: 132-22-5986
item:
  link id:
    v: father-ssn
  text:
    v: What is the father’s Social Security Number? If you are not married, and if a paternity acknowledgment has not been completed, leave this item blank.
  answer:
    value:
      v: 132-22-5987

link id:
  v: baby-ssn
text:
  v: Do you want a Social Security Number issued for your baby? [If yes, please sign request below
answer:
  value:
    v: false

link id:
  v: informant-name
text:
  v: If other than the mother, what is the name of the person providing information for this worksheet?
item:
  link id:
    v: informant-first-name
  text:
    v: First
  answer:
    value:
      v: Jane
item:
  link id:
    v: informant-last-name
  text:
    v: Last
  answer:
    value:
      v: King

link id:
  v: informant-relationship
text:
  v: What is your relationship to the baby's mother?
answer:
  value: Coding
    system:
      v: urn:oid:2.16.840.1.114222.4.5.274
    code:
      v: PHC1497
    display:
      v: Other relative