{
  "resourceType": "Questionnaire",
  "url": "http://fhir.data4life.care/covid-19/r4/Questionnaire/covid19-recommendation",
  "version": "4.0.0",
  "date": "2021-02-08T22:00:00Z",
  "subjectType": [
    "Patient"
  ],
  "status": "draft",
  "publisher": "D4L data4life gGmbH",
  "contact": [
    {
      "name": "D4L data4life gGmbH",
      "telecom": [
        {
          "system": "url",
          "value": "https://www.data4life.care"
        }
      ]
    }
  ],
  "copyright": "D4L data4life gGmbH, Charité – Universitätsmedizin Berlin, BIH - Berliner Institut für Gesundheitsforschung, hih - health innovation hub des Bundesministeriums für Gesundheit, and MOLIT Institut gGmbH",
  "description": "COVID-19 assessment questionnaire",
  "name": "Covid19_assesment_questionnaire",
  "code": [
    {
      "system": "http://loinc.org",
      "code": "84170-0",
      "display": "Infectious disease Risk assessment and screening note"
    }
  ],
  "item": [
    {
      "type": "group",
      "required": true,
      "linkId": "P",
      "text": "Personal information",
      "item": [
        {
          "type": "choice",
          "required": true,
          "linkId": "P1",
          "code": [
            {
              "code": "21612-7",
              "display": "Age - Reported",
              "system": "http://loinc.org"
            }
          ],
          "text": "Are you 65 years old or older?",
          "answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesno"
        },
        {
          "type": "choice",
          "required": true,
          "linkId": "P2",
          "code": [
            {
              "code": "71802-3",
              "display": "Housing status",
              "system": "http://loinc.org"
            }
          ],
          "text": "What is your current living situation?",
          "answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/housing-situation"
        },
        {
          "type": "choice",
          "required": true,
          "linkId": "P3",
          "text": "At least once a week, do you privately care for people with age-related conditions, chronic illnesses, or frailty?",
          "answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesno",
          "item": [
            {
              "linkId": "P3-Explanation",
              "type": "display",
              "text": "Care services or support that you provide in connection with your professional activity isn't meant."
            }
          ]
        },
        {
          "type": "choice",
          "required": true,
          "linkId": "P4-revised",
          "text": "Do you work or are you cared for/accommodated in one of the following areas?",
          "answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/shared-location-class"
        },
        {
          "type": "choice",
          "required": true,
          "linkId": "P5",
          "code": [
            {
              "code": "72166-2",
              "display": "Tobacco smoking status",
              "system": "http://loinc.org"
            }
          ],
          "text": "Do you smoke?",
          "answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesno"
        },
        {
          "type": "choice",
          "required": true,
          "linkId": "P6",
          "code": [
            {
              "code": "82810-3",
              "display": "Pregnancy status",
              "system": "http://loinc.org"
            }
          ],
          "text": "Are you pregnant?",
          "answerValueSet": "http://loinc.org/vs/LL4129-4"
        }
      ]
    },
    {
      "type": "group",
      "required": true,
      "linkId": "C",
      "text": "Contact with COVID-19 cases",
      "item": [
        {
          "type": "choice",
          "required": true,
          "linkId": "C0",
          "code": [
            {
              "code": "840546002",
              "display": "Exposure to SARS-CoV-2",
              "system": "http://snomed.info/sct"
            }
          ],
          "text": "Have you had close contact with a confirmed case?",
          "answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesno",
          "item": [
            {
              "linkId": "C0-Explanation",
              "type": "display",
              "text": "Close contact with a confirmed case means:\n\n* Face-to-face contact for longer than 15 minutes\n* Direct, physical contact (touching, shaking hands, kissing)\n* Being within 1.5 meters of the person for more than 15 minutes\n* Contact with or exchange of body fluids\n* Living in the same apartment\n\n\nChoose \"no\" if you have worn adequate protective measures (mask, smock) on contact."
            }
          ]
        },
        {
          "type": "date",
          "required": true,
          "linkId": "CZ",
          "code": [
            {
              "code": "94652-5",
              "display": "Known exposure date",
              "system": "http://loinc.org"
            }
          ],
          "text": "What day was the last contact?",
          "enableWhen": [
            {
              "question": "C0",
              "operator": "=",
              "answerCoding": {
                "system": "http://loinc.org",
                "code": "LA33-6"
              }
            }
          ],
          "item": [
            {
              "linkId": "CZ-Explanation",
              "type": "display",
              "text": "Ensure that you enter a full date in the DD MM YYYY format that isn’t in the future."
            }
          ]
        }
      ]
    },
    {
      "type": "group",
      "required": true,
      "linkId": "S",
      "text": "Symptoms",
      "item": [
        {
          "type": "choice",
          "required": false,
          "linkId": "X0",
          "code": [
            {
              "code": "75325-1",
              "display": "Symptom",
              "system": "http://loinc.org"
            }
          ],
          "text": "In the past 24 hours, which of the following symptoms have you had? (multiple selection possible)",
          "repeats": true,
          "answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/covapp-symptoms-group-1",
          "item": [
            {
              "linkId": "X0-Explanation",
              "type": "display",
              "text": "The question relates to acute or exacerbated symptoms and excludes chronic complaints or seasonal or allergic complaints. If you have a chronic illness, compare your current symptoms with your previous problems to answer the question.\n\nIf you haven't had any of the symptoms, choose the \"Next\" button without selecting a symptom."
            }
          ]
        },
        {
          "type": "choice",
          "required": false,
          "linkId": "X2",
          "code": [
            {
              "code": "75325-1",
              "display": "Symptom",
              "system": "http://loinc.org"
            }
          ],
          "text": "In the past 24 hours, which of the following symptoms have you had? (multiple selection possible)",
          "repeats": true,
          "answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/covapp-symptoms-group-2",
          "item": [
            {
              "linkId": "X2-Explanation",
              "type": "display",
              "text": "If you haven't had any of the symptoms, choose the \"Next\" button without selecting a symptom."
            }
          ]
        },
        {
          "type": "choice",
          "required": true,
          "linkId": "SB",
          "code": [
            {
              "code": "267036007",
              "display": "Dyspnea (finding)",
              "system": "http://snomed.info/sct"
            }
          ],
          "text": "In the past 24 hours, did you feel that you were more quickly out of breath than usual?",
          "answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesno",
          "item": [
            {
              "linkId": "SB-Explanation",
              "type": "display",
              "text": "Choose \"Yes\" if you have difficulty breathing or shortness of breath:\n- While sitting or lying down\n- When getting up from a bed or a chair\n- After light activity, such as going for a walk or climbing some stairs\n\nIf you have chronic lung disease, compare your current breathing problems with your previous breathing problems."
            }
          ]
        },
        {
          "type": "date",
          "required": true,
          "linkId": "SZ",
          "code": [
            {
              "code": "85585-8",
              "display": "Date of condition onset",
              "system": "http://loinc.org"
            }
          ],
          "text": "With regard to all questions about symptoms: since when have you had the symptoms you specified?",
          "enableWhen": [
            {
              "question": "X0",
              "operator": "exists",
              "answerBoolean": true
            },
            {
              "question": "X2",
              "operator": "exists",
              "answerBoolean": true
            },
            {
              "question": "SB",
              "operator": "=",
              "answerCoding": {
                "system": "http://loinc.org",
                "code": "LA33-6"
              }
            }
          ],
          "enableBehavior": "any",
          "item": [
            {
              "linkId": "SZ-Explanation",
              "type": "display",
              "text": "Make sure to enter a full date in the DD MM YYYY format that isn’t in the future."
            }
          ]
        }
      ]
    },
    {
      "type": "group",
      "required": false,
      "linkId": "D",
      "text": "Chronic illnesses",
      "item": [
        {
          "type": "choice",
          "required": false,
          "linkId": "X3",
          "text": "Has a doctor diagnosed you with any of the following illnesses?",
          "repeats": true,
          "answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/covapp-chronic-disease",
          "item": [
            {
              "linkId": "X3-Explanation",
              "type": "display",
              "text": "If you don't have any of the illnesses, choose the \"Next\" button without selecting a symptom."
            }
          ]
        },
        {
          "type": "integer",
          "required": false,
          "linkId": "D6",
          "code": [
            {
              "system": "http://loinc.org",
              "code": "8302-2",
              "display": "Body height"
            }
          ],
          "text": "What's your height? (in cm)",
          "extension": [
            {
              "url": "http://hl7.org/fhir/StructureDefinition/maxValue",
              "valueDecimal": 300
            },
            {
              "url": "http://hl7.org/fhir/StructureDefinition/minValue",
              "valueDecimal": 10
            },
            {
              "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unit",
              "valueCoding": {
                "system": "http://unitsofmeasure.org",
                "code": "cm",
                "display": "[cm]"
              }
            }
          ],
          "item": [
            {
              "linkId": "D6-Explanation",
              "type": "display",
              "text": "We use your height and weight to calculate your body mass index (BMI). The BMI can be a risk factor in the context of COVID-19."
            }
          ]
        },
        {
          "type": "integer",
          "required": false,
          "linkId": "D5",
          "code": [
            {
              "system": "http://loinc.org",
              "code": "29463-7",
              "display": "Body Weight"
            }
          ],
          "text": "What's your weight? (in kg)",
          "extension": [
            {
              "url": "http://hl7.org/fhir/StructureDefinition/maxValue",
              "valueDecimal": 600
            },
            {
              "url": "http://hl7.org/fhir/StructureDefinition/minValue",
              "valueDecimal": 0
            },
            {
              "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-unit",
              "valueCoding": {
                "system": "http://unitsofmeasure.org",
                "code": "kg",
                "display": "[kg]"
              }
            }
          ],
          "item": [
            {
              "linkId": "D5-Explanation",
              "type": "display",
              "text": "We use your height and weight to calculate your body mass index (BMI). The BMI can be a risk factor in the context of COVID-19."
            }
          ]
        }
      ]
    },
    {
      "type": "group",
      "required": true,
      "linkId": "M",
      "text": "Medication",
      "item": [
        {
          "type": "choice",
          "required": true,
          "linkId": "M0",
          "code": [
            {
              "code": "steroid-intake",
              "display": "Taking steroids",
              "system": "http://fhir.data4life.care/covid-19/r4/CodeSystem/medication-questions"
            }
          ],
          "text": "Are you currently taking steroids?",
          "answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesnodontknow"
        },
        {
          "type": "choice",
          "required": true,
          "linkId": "M1",
          "code": [
            {
              "code": "immunosuppressant-intake",
              "display": "Taking immunosuppressants",
              "system": "http://fhir.data4life.care/covid-19/r4/CodeSystem/medication-questions"
            }
          ],
          "text": "Are you currently taking immunosuppressants?",
          "answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesnodontknow",
          "item": [
            {
              "linkId": "M1-Explanation",
              "type": "display",
              "text": "You take or get immunosuppressants after an organ transplant, during therapy for an autoimmune disease, or during chemotherapy."
            }
          ]
        },
        {
          "type": "choice",
          "required": true,
          "linkId": "M2",
          "code": [
            {
              "code": "recent-influenza-vaccine",
              "display": "Influenza vaccine for the current influenza season",
              "system": "http://fhir.data4life.care/covid-19/r4/CodeSystem/medication-questions"
            }
          ],
          "text": "Have you been vaccinated against flu between August 1, 2020 and today?",
          "answerValueSet": "http://fhir.data4life.care/covid-19/r4/ValueSet/yesno"
        }
      ]
    }
  ],
  "language": "en"
}