Food Allergies ImplementationGuide, published by OpenHIE. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/openhie/FoodAllergy-webinar/ and changes regularly. See the Directory of published versions

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Questionnaire: FoodAllergyQuestionnaire - XML Profile

XML representation of the food-allergy-questionnaire questionnaire.

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<Questionnaire xmlns="http://hl7.org/fhir">
  <id value="food-allergy-questionnaire"/>
  <language value="en"/>
  <text>
    <status value="extensions"/>
    <div xml:lang="en" xmlns="http://www.w3.org/1999/xhtml" lang="en"><p class="res-header-id"><b>Generated Narrative: Questionnaire food-allergy-questionnaire</b></p><a name="food-allergy-questionnaire"> </a><a name="hcfood-allergy-questionnaire"> </a><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Language: en</p></div><table border="1" cellpadding="0" cellspacing="0" style="border: 1px #F0F0F0 solid; font-size: 11px; font-family: verdana; vertical-align: top;"><tr style="border: 2px #F0F0F0 solid; font-size: 11px; font-family: verdana; vertical-align: top"><th style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px" class="hierarchy"><a href="https://hl7.org/fhir/R4/formats.html#table" title="The linkID for the item">LinkID</a></th><th style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px" class="hierarchy"><a href="https://hl7.org/fhir/R4/formats.html#table" title="Text for the item">Text</a></th><th style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px" class="hierarchy"><a href="https://hl7.org/fhir/R4/formats.html#table" title="Minimum and Maximum # of times the item can appear in the instance">Cardinality</a></th><th style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px" class="hierarchy"><a href="https://hl7.org/fhir/R4/formats.html#table" title="The type of the item">Type</a></th><th style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; padding-top: 3px; padding-bottom: 3px" class="hierarchy"><a href="https://hl7.org/fhir/R4/formats.html#table" title="Additional information about the item">Description &amp; Constraints</a><span style="float: right"><a href="https://hl7.org/fhir/R4/formats.html#table" title="Legend for this format"><img src="data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABAAAAAQCAYAAAAf8/9hAAAABmJLR0QA/wD/AP+gvaeTAAAACXBIWXMAAAsTAAALEwEAmpwYAAAAB3RJTUUH3goXBCwdPqAP0wAAAldJREFUOMuNk0tIlFEYhp9z/vE2jHkhxXA0zJCMitrUQlq4lnSltEqCFhFG2MJFhIvIFpkEWaTQqjaWZRkp0g26URZkTpbaaOJkDqk10szoODP//7XIMUe0elcfnPd9zsfLOYplGrpRwZaqTtw3K7PtGem7Q6FoidbGgqHVy/HRb669R+56zx7eRV1L31JGxYbBtjKK93cxeqfyQHbehkZbUkK20goELEuIzEd+dHS+qz/Y8PTSif0FnGkbiwcAjHaU1+QWOptFiyCLp/LnKptpqIuXHx6rbR26kJcBX3yLgBfnd7CxwJmflpP2wUg0HIAoUUpZBmKzELGWcN8nAr6Gpu7tLU/CkwAaoKTWRSQyt89Q8w6J+oVQkKnBoblH7V0PPvUOvDYXfopE/SJmALsxnVm6LbkotrUtNowMeIrVrBcBpaMmdS0j9df7abpSuy7HWehwJdt1lhVwi/J58U5beXGAF6c3UXLycw1wdFklArBn87xdh0ZsZtArghBdAA3+OEDVubG4UEzP6x1FOWneHh2VDAHBAt80IbdXDcesNoCvs3E5AFyNSU5nbrDPZpcUEQQTFZiEVx+51fxMhhyJEAgvlriadIJZZksRuwBYMOPBbO3hePVVqgEJhFeUuFLhIPkRP6BQLIBrmMenujm/3g4zc398awIe90Zb5A1vREALqneMcYgP/xVQWlG+Ncu5vgwwlaUNx+3799rfe96u9K0JSDXcOzOTJg4B6IgmXfsygc7/Bvg9g9E58/cDVmGIBOP/zT8Bz1zqWqpbXIsd0O9hajXfL6u4BaOS6SeWAAAAAElFTkSuQmCC" alt="doco" style="background-color: inherit"/></a></span></th></tr><tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck1.png)" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon_q_root.gif" alt="." style="background-color: white; background-color: inherit" title="QuestionnaireRoot" class="hierarchy"/> FoodAllergyQuestionnaire</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">A form for self-reported food allergies, including the basic information and contained valuesets</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Questionnaire</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">http://openhie.org/fhir/food-allergy/Questionnaire/food-allergy-questionnaire#0.1.0</td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.title" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-display.png" alt="." style="background-color: #F7F7F7; background-color: inherit" title="display" class="hierarchy"/> title</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Food Allergy report</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">0..1</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-display">display</a></td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.instructions" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-display.png" alt="." style="background-color: white; background-color: inherit" title="display" class="hierarchy"/> instructions</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Reporting instructions: Please report any allergy or allergic reaction</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">0..1</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-display">display</a></td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.patient" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-string.png" alt="." style="background-color: #F7F7F7; background-color: inherit" title="string" class="hierarchy"/> patient</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Patient ID</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">0..1</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string">string</a></td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.allergen" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-coding.png" alt="." style="background-color: white; background-color: inherit" title="coding" class="hierarchy"/> allergen</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Substance that the person is allergic to</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">0..1</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-choice">choice</a></td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Value Set: <a href="ValueSet-food-allergy-questionnaire_vs-food-allergy-cont.html">FoodAllergyVS</a></td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.clinicalStatus" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-coding.png" alt="." style="background-color: #F7F7F7; background-color: inherit" title="coding" class="hierarchy"/> clinicalStatus</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Status of the allergy - active or resolved</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">0..1</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-choice">choice</a></td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Value Set: <a href="ValueSet-food-allergy-questionnaire_vs-food-allergy-clinstatus-cont.html">FoodAllergyVS</a></td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.verificationStatus" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-coding.png" alt="." style="background-color: white; background-color: inherit" title="coding" class="hierarchy"/> verificationStatus</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Verification status of the allergy - confirmed or suspected or refuted</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">0..1</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-choice">choice</a></td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Value Set: <a href="ValueSet-food-allergy-questionnaire_vs-food-allergy-verifstatus-cont.html">FoodAllergyVerificationStatusVS</a></td></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.recordedDate" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-date.png" alt="." style="background-color: #F7F7F7; background-color: inherit" title="date" class="hierarchy"/> recordedDate</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">When was it reported</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">0..1</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-date">date</a></td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.recorder" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-string.png" alt="." style="background-color: white; background-color: inherit" title="string" class="hierarchy"/> recorder</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Who recorded the allergy</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">0..1</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string">string</a></td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck10.png)" id="item.asserter" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-string.png" alt="." style="background-color: #F7F7F7; background-color: inherit" title="string" class="hierarchy"/> asserter</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Who asserted the allergy</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">0..1</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string">string</a></td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck01.png)" id="item.reactions" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-group.png" alt="." style="background-color: white; background-color: inherit" title="group" class="hierarchy"/> reactions</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Reactions</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">0..1</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-group">group</a></td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck010.png)" id="item.substance" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_blank.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-string.png" alt="." style="background-color: #F7F7F7; background-color: inherit" title="string" class="hierarchy"/> substance</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Substance that is thought to have triggered the reaction</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">0..1</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string">string</a></td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: white"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck010.png)" id="item.manifestation" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_blank.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-string.png" alt="." style="background-color: white; background-color: inherit" title="string" class="hierarchy"/> manifestation</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Manifestation</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">0..1</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string">string</a></td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: white; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/></tr>
<tr style="border: 1px #F0F0F0 solid; padding:0px; vertical-align: top; background-color: #F7F7F7"><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px; white-space: nowrap; background-image: url(tbl_bck000.png)" id="item.note" class="hierarchy"><img src="tbl_spacer.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_blank.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end.png" alt="." style="background-color: inherit" class="hierarchy"/><img src="icon-q-string.png" alt="." style="background-color: #F7F7F7; background-color: inherit" title="string" class="hierarchy"/> note</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">Note</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy">0..1</td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"><a href="https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string">string</a></td><td style="vertical-align: top; text-align : var(--ig-left,left); background-color: #F7F7F7; border: 1px #F0F0F0 solid; padding:0px 4px 0px 4px" class="hierarchy"/></tr>
<tr><td colspan="5" class="hierarchy"><br/><a href="https://hl7.org/fhir/R4/formats.html#table" title="Legend for this format"><img src="data:image/png;base64,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" alt="doco" style="background-color: inherit"/> Documentation for this format</a></td></tr></table><h2>Contained Resources</h2><hr/><p class="res-header-id"><b>ValueSet #vs-food-allergy-cont</b></p><a name="food-allergy-questionnaire/vs-food-allergy-cont"> </a><a name="hcfood-allergy-questionnaire/vs-food-allergy-cont"> </a><p>This value set expansion contains 11 concepts.</p><table class="codes"><tr><td style="white-space:nowrap"><b>Code</b></td><td><b>System</b></td><td><b>Display</b></td></tr><tr><td style="white-space:nowrap"><a name="food-allergy-questionnaire/vs-food-allergy-cont-http://snomed.info/sct-91935009"> </a>  <a href="http://snomed.info/id/91935009">91935009</a></td><td>http://snomed.info/sct</td><td>Allergy to peanut</td></tr><tr><td style="white-space:nowrap"><a name="food-allergy-questionnaire/vs-food-allergy-cont-http://snomed.info/sct-48821000119104"> </a>  <a href="http://snomed.info/id/48821000119104">48821000119104</a></td><td>http://snomed.info/sct</td><td>Allergy to tree nut</td></tr><tr><td style="white-space:nowrap"><a name="food-allergy-questionnaire/vs-food-allergy-cont-http://snomed.info/sct-782555009"> </a>  <a href="http://snomed.info/id/782555009">782555009</a></td><td>http://snomed.info/sct</td><td>Allergy to cow’s milk protein</td></tr><tr><td style="white-space:nowrap"><a name="food-allergy-questionnaire/vs-food-allergy-cont-http://snomed.info/sct-213020009"> </a>  <a href="http://snomed.info/id/213020009">213020009</a></td><td>http://snomed.info/sct</td><td>Allergy to egg protein</td></tr><tr><td style="white-space:nowrap"><a name="food-allergy-questionnaire/vs-food-allergy-cont-http://snomed.info/sct-417532002"> </a>  <a href="http://snomed.info/id/417532002">417532002</a></td><td>http://snomed.info/sct</td><td>Allergy to fish</td></tr><tr><td style="white-space:nowrap"><a name="food-allergy-questionnaire/vs-food-allergy-cont-http://snomed.info/sct-300913006"> </a>  <a href="http://snomed.info/id/300913006">300913006</a></td><td>http://snomed.info/sct</td><td>Allergy to shellfish</td></tr><tr><td style="white-space:nowrap"><a name="food-allergy-questionnaire/vs-food-allergy-cont-http://snomed.info/sct-782594005"> </a>  <a href="http://snomed.info/id/782594005">782594005</a></td><td>http://snomed.info/sct</td><td>Allergy to soy protein</td></tr><tr><td style="white-space:nowrap"><a name="food-allergy-questionnaire/vs-food-allergy-cont-http://snomed.info/sct-260167008"> </a>  <a href="http://snomed.info/id/260167008">260167008</a></td><td>http://snomed.info/sct</td><td>Sesame seed</td></tr><tr><td style="white-space:nowrap"><a name="food-allergy-questionnaire/vs-food-allergy-cont-http://snomed.info/sct-21191000122102"> </a>  <a href="http://snomed.info/id/21191000122102">21191000122102</a></td><td>http://snomed.info/sct</td><td>Allergy to mustard</td></tr><tr><td style="white-space:nowrap"><a name="food-allergy-questionnaire/vs-food-allergy-cont-http://snomed.info/sct-712843002"> </a>  <a href="http://snomed.info/id/712843002">712843002</a></td><td>http://snomed.info/sct</td><td>Allergy to celery</td></tr><tr><td style="white-space:nowrap"><a name="food-allergy-questionnaire/vs-food-allergy-cont-http://snomed.info/sct-782575000"> </a>  <a href="http://snomed.info/id/782575000">782575000</a></td><td>http://snomed.info/sct</td><td>Allergy to lupine seed</td></tr></table><hr/><p class="res-header-id"><b>ValueSet #vs-food-allergy-verifstatus-cont</b></p><a name="food-allergy-questionnaire/vs-food-allergy-verifstatus-cont"> </a><a name="hcfood-allergy-questionnaire/vs-food-allergy-verifstatus-cont"> </a><p>This value set expansion contains 2 concepts.</p><table class="codes"><tr><td style="white-space:nowrap"><b>Code</b></td><td><b>System</b></td><td><b>Display</b></td></tr><tr><td style="white-space:nowrap"><a name="food-allergy-questionnaire/vs-food-allergy-verifstatus-cont-http://snomed.info/sct-410605003"> </a>  <a href="http://snomed.info/id/410605003">410605003</a></td><td>http://snomed.info/sct</td><td>Confirmed present</td></tr><tr><td style="white-space:nowrap"><a name="food-allergy-questionnaire/vs-food-allergy-verifstatus-cont-http://snomed.info/sct-415684004"> </a>  <a href="http://snomed.info/id/415684004">415684004</a></td><td>http://snomed.info/sct</td><td>Suspected</td></tr></table><hr/><p class="res-header-id"><b>ValueSet #vs-food-allergy-clinstatus-cont</b></p><a name="food-allergy-questionnaire/vs-food-allergy-clinstatus-cont"> </a><a name="hcfood-allergy-questionnaire/vs-food-allergy-clinstatus-cont"> </a><p>This value set expansion contains 2 concepts.</p><table class="codes"><tr><td style="white-space:nowrap"><b>Code</b></td><td><b>System</b></td><td><b>Display</b></td></tr><tr><td style="white-space:nowrap"><a name="food-allergy-questionnaire/vs-food-allergy-clinstatus-cont-http://snomed.info/sct-723506003"> </a>  <a href="http://snomed.info/id/723506003">723506003</a></td><td>http://snomed.info/sct</td><td>Resolved</td></tr><tr><td style="white-space:nowrap"><a name="food-allergy-questionnaire/vs-food-allergy-clinstatus-cont-http://snomed.info/sct-55561003"> </a>  <a href="http://snomed.info/id/55561003">55561003</a></td><td>http://snomed.info/sct</td><td>Active</td></tr></table></div>
  </text>
  <contained>
    <ValueSet>
      <id value="vs-food-allergy-cont"/>
      <name value="FoodAllergyVS"/>
      <status value="active"/>
      <expansion>
        <timestamp value="2022-01-27"/>
        <contains>
          <system value="http://snomed.info/sct"/>
          <code value="91935009"/>
          <display value="Allergy to peanut"/>
        </contains>
        <contains>
          <system value="http://snomed.info/sct"/>
          <code value="48821000119104"/>
          <display value="Allergy to tree nut"/>
        </contains>
        <contains>
          <system value="http://snomed.info/sct"/>
          <code value="782555009"/>
          <display value="Allergy to cow’s milk protein"/>
        </contains>
        <contains>
          <system value="http://snomed.info/sct"/>
          <code value="213020009"/>
          <display value="Allergy to egg protein"/>
        </contains>
        <contains>
          <system value="http://snomed.info/sct"/>
          <code value="417532002"/>
          <display value="Allergy to fish"/>
        </contains>
        <contains>
          <system value="http://snomed.info/sct"/>
          <code value="300913006"/>
          <display value="Allergy to shellfish"/>
        </contains>
        <contains>
          <system value="http://snomed.info/sct"/>
          <code value="782594005"/>
          <display value="Allergy to soy protein"/>
        </contains>
        <contains>
          <system value="http://snomed.info/sct"/>
          <code value="260167008"/>
          <display value="Sesame seed"/>
        </contains>
        <contains>
          <system value="http://snomed.info/sct"/>
          <code value="21191000122102"/>
          <display value="Allergy to mustard"/>
        </contains>
        <contains>
          <system value="http://snomed.info/sct"/>
          <code value="712843002"/>
          <display value="Allergy to celery"/>
        </contains>
        <contains>
          <system value="http://snomed.info/sct"/>
          <code value="782575000"/>
          <display value="Allergy to lupine seed"/>
        </contains>
      </expansion>
    </ValueSet>
  </contained>
  <contained>
    <ValueSet>
      <id value="vs-food-allergy-verifstatus-cont"/>
      <name value="FoodAllergyVerificationStatusVS"/>
      <status value="active"/>
      <expansion>
        <timestamp value="2022-01-27"/>
        <contains>
          <system value="http://snomed.info/sct"/>
          <code value="410605003"/>
          <display value="Confirmed present"/>
        </contains>
        <contains>
          <system value="http://snomed.info/sct"/>
          <code value="415684004"/>
          <display value="Suspected"/>
        </contains>
      </expansion>
    </ValueSet>
  </contained>
  <contained>
    <ValueSet>
      <id value="vs-food-allergy-clinstatus-cont"/>
      <name value="FoodAllergyVS"/>
      <status value="active"/>
      <expansion>
        <timestamp value="2022-01-27"/>
        <contains>
          <system value="http://snomed.info/sct"/>
          <code value="723506003"/>
          <display value="Resolved"/>
        </contains>
        <contains>
          <system value="http://snomed.info/sct"/>
          <code value="55561003"/>
          <display value="Active"/>
        </contains>
      </expansion>
    </ValueSet>
  </contained>
  <url
       value="http://openhie.org/fhir/food-allergy/Questionnaire/food-allergy-questionnaire"/>
  <version value="0.1.0"/>
  <name value="FoodAllergyQuestionnaire"/>
  <title value="Food Allergy self-report"/>
  <status value="draft"/>
  <subjectType value="Patient"/>
  <date value="2025-07-25T20:08:14+00:00"/>
  <publisher value="OpenHIE"/>
  <contact>
    <telecom>
      <system value="url"/>
      <value value="http://ohie.org"/>
    </telecom>
  </contact>
  <description
               value="A form for self-reported food allergies, including the basic information and contained valuesets"/>
  <jurisdiction>
    <coding>
      <system value="http://unstats.un.org/unsd/methods/m49/m49.htm"/>
      <code value="001"/>
    </coding>
  </jurisdiction>
  <item>
    <linkId value="title"/>
    <text value="Food Allergy report"/>
    <type value="display"/>
  </item>
  <item>
    <linkId value="instructions"/>
    <text
          value="Reporting instructions: Please report any allergy or allergic reaction"/>
    <type value="display"/>
  </item>
  <item>
    <linkId value="patient"/>
    <text value="Patient ID"/>
    <type value="string"/>
    <repeats value="false"/>
  </item>
  <item>
    <linkId value="allergen"/>
    <text value="Substance that the person is allergic to"/>
    <type value="choice"/>
    <repeats value="false"/>
    <answerValueSet value="#vs-food-allergy-cont"/>
  </item>
  <item>
    <linkId value="clinicalStatus"/>
    <text value="Status of the allergy - active or resolved"/>
    <type value="choice"/>
    <repeats value="false"/>
    <answerValueSet value="#vs-food-allergy-clinstatus-cont"/>
  </item>
  <item>
    <linkId value="verificationStatus"/>
    <text
          value="Verification status of the allergy - confirmed or suspected or refuted"/>
    <type value="choice"/>
    <repeats value="false"/>
    <answerValueSet value="#vs-food-allergy-verifstatus-cont"/>
  </item>
  <item>
    <linkId value="recordedDate"/>
    <text value="When was it reported"/>
    <type value="date"/>
    <repeats value="false"/>
  </item>
  <item>
    <linkId value="recorder"/>
    <text value="Who recorded the allergy"/>
    <type value="string"/>
    <repeats value="false"/>
  </item>
  <item>
    <linkId value="asserter"/>
    <text value="Who asserted the allergy"/>
    <type value="string"/>
    <repeats value="false"/>
  </item>
  <item>
    <linkId value="reactions"/>
    <text value="Reactions"/>
    <type value="group"/>
    <repeats value="false"/>
    <item>
      <linkId value="substance"/>
      <text value="Substance that is thought to have triggered the reaction"/>
      <type value="string"/>
      <repeats value="false"/>
    </item>
    <item>
      <linkId value="manifestation"/>
      <text value="Manifestation"/>
      <type value="string"/>
      <repeats value="false"/>
    </item>
    <item>
      <linkId value="note"/>
      <text value="Note"/>
      <type value="string"/>
      <repeats value="false"/>
    </item>
  </item>
</Questionnaire>