<Questionnaire xmlns="http://hl7.org/fhir">
  <language value="en" />
  <url value="http://fhir.data4life.care/covid-19/r4/Questionnaire/covid19-recommendation" />
  <version value="4.0.0" />
  <name value="Covid19_assesment_questionnaire" />
  <status value="draft" />
  <subjectType value="Patient" />
  <date value="2021-02-08T22:00:00.000Z" />
  <publisher value="D4L data4life gGmbH" />
  <contact>
    <name value="D4L data4life gGmbH" />
    <telecom>
      <system value="url" />
      <value value="https://www.data4life.care" />
    </telecom>
  </contact>
  <description value="COVID-19 assessment questionnaire" />
  <copyright value="D4L data4life gGmbH, Charité – Universitätsmedizin Berlin, BIH - Berliner Institut für Gesundheitsforschung, hih - health innovation hub des Bundesministeriums für Gesundheit, and MOLIT Institut gGmbH" />
  <code>
    <system value="http://loinc.org" />
    <code value="84170-0" />
    <display value="Infectious disease Risk assessment and screening note" />
  </code>
  <item>
    <linkId value="P" />
    <text value="Personal information" />
    <type value="group" />
    <required value="true" />
    <item>
      <linkId value="P1" />
      <code>
        <system value="http://loinc.org" />
        <code value="21612-7" />
        <display value="Age - Reported" />
      </code>
      <text value="Are you 65 years old or older?" />
      <type value="choice" />
      <required value="true" />
      <answerValueSet value="http://fhir.data4life.care/covid-19/r4/ValueSet/yesno" />
    </item>
    <item>
      <linkId value="P2" />
      <code>
        <system value="http://loinc.org" />
        <code value="71802-3" />
        <display value="Housing status" />
      </code>
      <text value="What is your current living situation?" />
      <type value="choice" />
      <required value="true" />
      <answerValueSet value="http://fhir.data4life.care/covid-19/r4/ValueSet/housing-situation" />
    </item>
    <item>
      <linkId value="P3" />
      <text value="At least once a week, do you privately care for people with age-related conditions, chronic illnesses, or frailty?" />
      <type value="choice" />
      <required value="true" />
      <answerValueSet value="http://fhir.data4life.care/covid-19/r4/ValueSet/yesno" />
      <item>
        <linkId value="P3-Explanation" />
        <text value="Care services or support that you provide in connection with your professional activity isn't meant." />
        <type value="display" />
      </item>
    </item>
    <item>
      <linkId value="P4-revised" />
      <text value="Do you work or are you cared for/accommodated in one of the following areas?" />
      <type value="choice" />
      <required value="true" />
      <answerValueSet value="http://fhir.data4life.care/covid-19/r4/ValueSet/shared-location-class" />
    </item>
    <item>
      <linkId value="P5" />
      <code>
        <system value="http://loinc.org" />
        <code value="72166-2" />
        <display value="Tobacco smoking status" />
      </code>
      <text value="Do you smoke?" />
      <type value="choice" />
      <required value="true" />
      <answerValueSet value="http://fhir.data4life.care/covid-19/r4/ValueSet/yesno" />
    </item>
    <item>
      <linkId value="P6" />
      <code>
        <system value="http://loinc.org" />
        <code value="82810-3" />
        <display value="Pregnancy status" />
      </code>
      <text value="Are you pregnant?" />
      <type value="choice" />
      <required value="true" />
      <answerValueSet value="http://loinc.org/vs/LL4129-4" />
    </item>
  </item>
  <item>
    <linkId value="C" />
    <text value="Contact with COVID-19 cases" />
    <type value="group" />
    <required value="true" />
    <item>
      <linkId value="C0" />
      <code>
        <system value="http://snomed.info/sct" />
        <code value="840546002" />
        <display value="Exposure to SARS-CoV-2" />
      </code>
      <text value="Have you had close contact with a confirmed case?" />
      <type value="choice" />
      <required value="true" />
      <answerValueSet value="http://fhir.data4life.care/covid-19/r4/ValueSet/yesno" />
      <item>
        <linkId value="C0-Explanation" />
        <text value="Close contact with a confirmed case means:&#xA;&#xA;* Face-to-face contact for longer than 15 minutes&#xA;* Direct, physical contact (touching, shaking hands, kissing)&#xA;* Being within 1.5 meters of the person for more than 15 minutes&#xA;* Contact with or exchange of body fluids&#xA;* Living in the same apartment&#xA;&#xA;&#xA;Choose &quot;no&quot; if you have worn adequate protective measures (mask, smock) on contact." />
        <type value="display" />
      </item>
    </item>
    <item>
      <linkId value="CZ" />
      <code>
        <system value="http://loinc.org" />
        <code value="94652-5" />
        <display value="Known exposure date" />
      </code>
      <text value="What day was the last contact?" />
      <type value="date" />
      <enableWhen>
        <question value="C0" />
        <operator value="=" />
        <answerCoding>
          <system value="http://loinc.org" />
          <code value="LA33-6" />
        </answerCoding>
      </enableWhen>
      <required value="true" />
      <item>
        <linkId value="CZ-Explanation" />
        <text value="Ensure that you enter a full date in the DD MM YYYY format that isn’t in the future." />
        <type value="display" />
      </item>
    </item>
  </item>
  <item>
    <linkId value="S" />
    <text value="Symptoms" />
    <type value="group" />
    <required value="true" />
    <item>
      <linkId value="X0" />
      <code>
        <system value="http://loinc.org" />
        <code value="75325-1" />
        <display value="Symptom" />
      </code>
      <text value="In the past 24 hours, which of the following symptoms have you had? (multiple selection possible)" />
      <type value="choice" />
      <required value="false" />
      <repeats value="true" />
      <answerValueSet value="http://fhir.data4life.care/covid-19/r4/ValueSet/covapp-symptoms-group-1" />
      <item>
        <linkId value="X0-Explanation" />
        <text value="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.&#xA;&#xA;If you haven't had any of the symptoms, choose the &quot;Next&quot; button without selecting a symptom." />
        <type value="display" />
      </item>
    </item>
    <item>
      <linkId value="X2" />
      <code>
        <system value="http://loinc.org" />
        <code value="75325-1" />
        <display value="Symptom" />
      </code>
      <text value="In the past 24 hours, which of the following symptoms have you had? (multiple selection possible)" />
      <type value="choice" />
      <required value="false" />
      <repeats value="true" />
      <answerValueSet value="http://fhir.data4life.care/covid-19/r4/ValueSet/covapp-symptoms-group-2" />
      <item>
        <linkId value="X2-Explanation" />
        <text value="If you haven't had any of the symptoms, choose the &quot;Next&quot; button without selecting a symptom." />
        <type value="display" />
      </item>
    </item>
    <item>
      <linkId value="SB" />
      <code>
        <system value="http://snomed.info/sct" />
        <code value="267036007" />
        <display value="Dyspnea (finding)" />
      </code>
      <text value="In the past 24 hours, did you feel that you were more quickly out of breath than usual?" />
      <type value="choice" />
      <required value="true" />
      <answerValueSet value="http://fhir.data4life.care/covid-19/r4/ValueSet/yesno" />
      <item>
        <linkId value="SB-Explanation" />
        <text value="Choose &quot;Yes&quot; if you have difficulty breathing or shortness of breath:&#xA;- While sitting or lying down&#xA;- When getting up from a bed or a chair&#xA;- After light activity, such as going for a walk or climbing some stairs&#xA;&#xA;If you have chronic lung disease, compare your current breathing problems with your previous breathing problems." />
        <type value="display" />
      </item>
    </item>
    <item>
      <linkId value="SZ" />
      <code>
        <system value="http://loinc.org" />
        <code value="85585-8" />
        <display value="Date of condition onset" />
      </code>
      <text value="With regard to all questions about symptoms: since when have you had the symptoms you specified?" />
      <type value="date" />
      <enableWhen>
        <question value="X0" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </enableWhen>
      <enableWhen>
        <question value="X2" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </enableWhen>
      <enableWhen>
        <question value="SB" />
        <operator value="=" />
        <answerCoding>
          <system value="http://loinc.org" />
          <code value="LA33-6" />
        </answerCoding>
      </enableWhen>
      <enableBehavior value="any" />
      <required value="true" />
      <item>
        <linkId value="SZ-Explanation" />
        <text value="Make sure to enter a full date in the DD MM YYYY format that isn’t in the future." />
        <type value="display" />
      </item>
    </item>
  </item>
  <item>
    <linkId value="D" />
    <text value="Chronic illnesses" />
    <type value="group" />
    <required value="false" />
    <item>
      <linkId value="X3" />
      <text value="Has a doctor diagnosed you with any of the following illnesses?" />
      <type value="choice" />
      <required value="false" />
      <repeats value="true" />
      <answerValueSet value="http://fhir.data4life.care/covid-19/r4/ValueSet/covapp-chronic-disease" />
      <item>
        <linkId value="X3-Explanation" />
        <text value="If you don't have any of the illnesses, choose the &quot;Next&quot; button without selecting a symptom." />
        <type value="display" />
      </item>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/maxValue">
        <valueDecimal value="300" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/minValue">
        <valueDecimal value="10" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-unit">
        <valueCoding>
          <system value="http://unitsofmeasure.org" />
          <code value="cm" />
          <display value="[cm]" />
        </valueCoding>
      </extension>
      <linkId value="D6" />
      <code>
        <system value="http://loinc.org" />
        <code value="8302-2" />
        <display value="Body height" />
      </code>
      <text value="What's your height? (in cm)" />
      <type value="integer" />
      <required value="false" />
      <item>
        <linkId value="D6-Explanation" />
        <text value="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 value="display" />
      </item>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/maxValue">
        <valueDecimal value="600" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/minValue">
        <valueDecimal value="0" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-unit">
        <valueCoding>
          <system value="http://unitsofmeasure.org" />
          <code value="kg" />
          <display value="[kg]" />
        </valueCoding>
      </extension>
      <linkId value="D5" />
      <code>
        <system value="http://loinc.org" />
        <code value="29463-7" />
        <display value="Body Weight" />
      </code>
      <text value="What's your weight? (in kg)" />
      <type value="integer" />
      <required value="false" />
      <item>
        <linkId value="D5-Explanation" />
        <text value="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 value="display" />
      </item>
    </item>
  </item>
  <item>
    <linkId value="M" />
    <text value="Medication" />
    <type value="group" />
    <required value="true" />
    <item>
      <linkId value="M0" />
      <code>
        <system value="http://fhir.data4life.care/covid-19/r4/CodeSystem/medication-questions" />
        <code value="steroid-intake" />
        <display value="Taking steroids" />
      </code>
      <text value="Are you currently taking steroids?" />
      <type value="choice" />
      <required value="true" />
      <answerValueSet value="http://fhir.data4life.care/covid-19/r4/ValueSet/yesnodontknow" />
    </item>
    <item>
      <linkId value="M1" />
      <code>
        <system value="http://fhir.data4life.care/covid-19/r4/CodeSystem/medication-questions" />
        <code value="immunosuppressant-intake" />
        <display value="Taking immunosuppressants" />
      </code>
      <text value="Are you currently taking immunosuppressants?" />
      <type value="choice" />
      <required value="true" />
      <answerValueSet value="http://fhir.data4life.care/covid-19/r4/ValueSet/yesnodontknow" />
      <item>
        <linkId value="M1-Explanation" />
        <text value="You take or get immunosuppressants after an organ transplant, during therapy for an autoimmune disease, or during chemotherapy." />
        <type value="display" />
      </item>
    </item>
    <item>
      <linkId value="M2" />
      <code>
        <system value="http://fhir.data4life.care/covid-19/r4/CodeSystem/medication-questions" />
        <code value="recent-influenza-vaccine" />
        <display value="Influenza vaccine for the current influenza season" />
      </code>
      <text value="Have you been vaccinated against flu between August 1, 2020 and today?" />
      <type value="choice" />
      <required value="true" />
      <answerValueSet value="http://fhir.data4life.care/covid-19/r4/ValueSet/yesno" />
    </item>
  </item>
</Questionnaire>