English
COVID-19 questionnaire
Canonical URL: http://fhir.data4life.care/covid-19/r4/Questionnaire/covid19-recommendation
Version: 4.0.0
Questionnaire resource representing the questionnaire used for patient assessment in the CovApp (link to resource: COVID-19 assessment questionnaire (EN)).
| Questionnaire |
| url : http://fhir.data4life.care/covid-19/r4/Questionnaire/covid19-recommendation |
| version : 4.0.0 |
| date : 2021-02-08T22:00:00.000Z |
| 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 |
| item |
| 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 |
| item |
| 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. |
| item |
| 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 |
| item |
| 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 |
| item |
| 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 |
| item |
| 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: * Face-to-face contact for longer than 15 minutes * Direct, physical contact (touching, shaking hands, kissing) * Being within 1.5 meters of the person for more than 15 minutes * Contact with or exchange of body fluids * Living in the same apartment Choose "no" if you have worn adequate protective measures (mask, smock) on contact. |
| item |
| 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 : = |
| answer |
| 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. |
| item |
| 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. If you haven't had any of the symptoms, choose the "Next" button without selecting a symptom. |
| item |
| 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. |
| item |
| 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: - While sitting or lying down - When getting up from a bed or a chair - After light activity, such as going for a walk or climbing some stairs If you have chronic lung disease, compare your current breathing problems with your previous breathing problems. |
| item |
| 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 |
| answer : True |
| enableWhen |
| question : X2 |
| operator : exists |
| answer : True |
| enableWhen |
| question : SB |
| operator : = |
| answer |
| 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. |
| item |
| 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. |
| item |
| 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 |
| value : 300 |
| extension |
| url : http://hl7.org/fhir/StructureDefinition/minValue |
| value : 10 |
| extension |
| url : http://hl7.org/fhir/StructureDefinition/questionnaire-unit |
| value |
| 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. |
| item |
| 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 |
| value : 600 |
| extension |
| url : http://hl7.org/fhir/StructureDefinition/minValue |
| value : 0 |
| extension |
| url : http://hl7.org/fhir/StructureDefinition/questionnaire-unit |
| value |
| 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. |
| item |
| 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 |
| item |
| 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. |
| item |
| 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 |
Example questionnaire response
A QuestionnaireResponse representing an example of a response to the COVID-19 assessment questionnaire (link to resource: Example QuestionnaireResponse for COVID-19 assessment (EN)).
| QuestionnaireResponse |
| questionnaire : http://fhir.data4life.care/covid-19/r4/Questionnaire/covid19-recommendation|4.0.0 |
| status : completed |
| authored : 2020-05-04T14:15:00-05:00 |
| item |
| linkId : P |
| text : Personal information |
| item |
| linkId : P1 |
| text : Are you 65 years old or older? |
| answer |
| value |
| system : http://loinc.org |
| code : LA33-6 |
| item |
| linkId : P2 |
| text : What is your current living situation? |
| answer |
| value |
| system : http://loinc.org |
| code : LA6255-9 |
| item |
| linkId : P3 |
| text : At least once a week, do you privately care for people with age-related conditions, chronic illnesses, or frailty? |
| answer |
| value |
| system : http://loinc.org |
| code : LA32-8 |
| item |
| linkId : P4-revised |
| text : Do you work or are you cared for/accommodated in one of the following areas? |
| answer |
| value |
| system : http://fhir.data4life.care/covid-19/r4/CodeSystem/accommodation-class |
| code : community-accommodation |
| item |
| linkId : P5 |
| text : Do you smoke? |
| answer |
| value |
| system : http://loinc.org |
| code : LA32-8 |
| item |
| linkId : P6 |
| text : Are you pregnant? |
| answer |
| value |
| system : http://loinc.org |
| code : LA26683-5 |
| item |
| linkId : C |
| text : Contact with COVID-19 cases |
| item |
| linkId : C0 |
| text : Have you had close contact with a confirmed case? |
| answer |
| value |
| system : http://loinc.org |
| code : LA33-6 |
| item |
| linkId : CZ |
| text : What day was the last contact? |
| answer |
| value : 2020-03-27 |
| item |
| linkId : S |
| text : Symptoms |
| item |
| linkId : X0 |
| text : In the past 24 hours, which of the following symptoms have you had? (multiple selection possible) |
| answer |
| value |
| code : 386661006 |
| system : http://snomed.info/sct |
| display : Fever above 38°C |
| answer |
| value |
| code : 43724002 |
| system : http://snomed.info/sct |
| display : Chills |
| item |
| linkId : X2 |
| text : In the past 24 hours, which of the following symptoms have you had? (multiple selection possible) |
| answer |
| value |
| code : 62315008 |
| system : http://snomed.info/sct |
| display : Diarrhea |
| answer |
| value |
| code : 162397003 |
| system : http://snomed.info/sct |
| display : Sore throat |
| item |
| linkId : SB |
| text : In the past 24 hours, did you feel that you were more quickly out of breath than usual? |
| answer |
| value |
| system : http://loinc.org |
| code : LA32-8 |
| item |
| linkId : SZ |
| text : With regard to all questions about symptoms: since when have you had the symptoms you specified? |
| answer |
| value : 2021-01-30 |
| item |
| linkId : D |
| text : Chronic illnesses |
| item |
| linkId : X3 |
| text : Has a doctor diagnosed you with any of the following illnesses? |
| answer |
| value |
| code : 73211009 |
| system : http://snomed.info/sct |
| display : Diabetes |
| answer |
| value |
| code : 56265001 |
| system : http://snomed.info/sct |
| display : Heart disease |
| item |
| linkId : D6 |
| text : What's your height? (in cm) |
| answer |
| value : 160 |
| item |
| linkId : D5 |
| text : What's your weight? (in kg) |
| answer |
| value : 65 |
| item |
| linkId : M |
| text : Medication |
| item |
| linkId : M0 |
| text : Are you currently taking steroids? |
| answer |
| value |
| system : http://loinc.org |
| code : LA32-8 |
| item |
| linkId : M1 |
| text : Are you currently taking immunosuppressants? |
| answer |
| value |
| system : http://loinc.org |
| code : LA32-8 |
| item |
| linkId : M2 |
| text : Have you been vaccinated against flu between August 1, 2020 and today? |
| answer |
| value |
| system : http://loinc.org |
| code : LA33-6 |
| language : en |