This Questionnaire can be viewed via NLM Form Builder (use import from file and then select preview).

An example of a completed QuestionnaireResponse can be found on QuestionnaireResponse Proxy Access Request

Proxy Access Request

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Questionnaire

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Questionnaire.id[0]NationalProxy-Questionnaire-ProxyAccessRequest-Example
Questionnaire.meta[0].versionId[0]52
Questionnaire.meta[0].lastUpdated[0]2024-08-30T13:36:50.663+00:00
Questionnaire.url[0]https://fhir.nhs.uk/England/Questionnaire/ProxyAccessRequest
Questionnaire.version[0]0.0.1-current
Questionnaire.name[0]Consent
Questionnaire.title[0]Questionnaire Proxy Access Request
Questionnaire.status[0]draft
Questionnaire.subjectType[0]RelatedPerson
Questionnaire.date[0]2024-07-12
Questionnaire.publisher[0]NHS England
Questionnaire.contact[0].telecom[0].system[0]url
Questionnaire.contact[0].telecom[0].value[0]https://www.ihe.net/ihe_domains/it_infrastructure/
Questionnaire.contact[1].telecom[0].system[0]email
Questionnaire.contact[1].telecom[0].value[0]iti@ihe.net
Questionnaire.contact[2].name[0]NHS England
Questionnaire.contact[2].telecom[0].system[0]email
Questionnaire.contact[2].telecom[0].value[0]iti@ihe.net
Questionnaire.description[0]A form to request access to health and care services on behalf of someone else.
Questionnaire.useContext[0].code[0].system[0]http://terminology.hl7.org/CodeSystem/usage-context-type
Questionnaire.useContext[0].code[0].code[0]task
Questionnaire.useContext[0].value[0].coding[0].system[0]http://snomed.info/sct
Questionnaire.useContext[0].value[0].coding[0].code[0]887031000000108
Questionnaire.useContext[0].value[0].coding[0].display[0]Consent for information sharing
Questionnaire.jurisdiction[0].coding[0].system[0]http://unstats.un.org/unsd/methods/m49/m49.htm
Questionnaire.jurisdiction[0].coding[0].code[0]001
Questionnaire.purpose[0]Add someone to your NHS account
Questionnaire.item[0].linkId[0]relatedPerson
Questionnaire.item[0].prefix[0]1
Questionnaire.item[0].text[0]Proxy details
Questionnaire.item[0].type[0]group
Questionnaire.item[0].required[0]True
Questionnaire.item[0].readOnly[0]False
Questionnaire.item[0].item[0].linkId[0]relatedPerson_identifier
Questionnaire.item[0].item[0].definition[0]http://hl7.org/fhir/StructureDefinition/RelatedPerson#identifier
Questionnaire.item[0].item[0].prefix[0]1.1
Questionnaire.item[0].item[0].text[0]NHS number
Questionnaire.item[0].item[0].type[0]string
Questionnaire.item[0].item[0].required[0]True
Questionnaire.item[0].item[0].readOnly[0]False
Questionnaire.item[0].item[0].maxLength[0]10
Questionnaire.item[0].item[1].linkId[0]relatedPerson_name
Questionnaire.item[0].item[1].definition[0]http://hl7.org/fhir/StructureDefinition/RelatedPerson#name
Questionnaire.item[0].item[1].prefix[0]1.2
Questionnaire.item[0].item[1].text[0]Name
Questionnaire.item[0].item[1].type[0]group
Questionnaire.item[0].item[1].required[0]False
Questionnaire.item[0].item[1].item[0].linkId[0]relatedPerson_name_first
Questionnaire.item[0].item[1].item[0].definition[0]http://hl7.org/fhir/StructureDefinition/RelatedPerson#name.given
Questionnaire.item[0].item[1].item[0].prefix[0]1.2.1
Questionnaire.item[0].item[1].item[0].text[0]First name
Questionnaire.item[0].item[1].item[0].type[0]string
Questionnaire.item[0].item[1].item[0].required[0]True
Questionnaire.item[0].item[1].item[0].repeats[0]False
Questionnaire.item[0].item[1].item[0].readOnly[0]False
Questionnaire.item[0].item[1].item[1].linkId[0]relatedPerson_name_family
Questionnaire.item[0].item[1].item[1].definition[0]http://hl7.org/fhir/StructureDefinition/RelatedPerson#name.family
Questionnaire.item[0].item[1].item[1].prefix[0]1.2.2
Questionnaire.item[0].item[1].item[1].text[0]Last name
Questionnaire.item[0].item[1].item[1].type[0]string
Questionnaire.item[0].item[1].item[1].required[0]True
Questionnaire.item[0].item[1].item[1].repeats[0]False
Questionnaire.item[0].item[1].item[1].readOnly[0]False
Questionnaire.item[0].item[2].linkId[0]relatedPerson_birthDate
Questionnaire.item[0].item[2].definition[0]http://hl7.org/fhir/StructureDefinition/RelatedPerson#birthDate
Questionnaire.item[0].item[2].prefix[0]1.3
Questionnaire.item[0].item[2].text[0]Date of birth
Questionnaire.item[0].item[2].type[0]date
Questionnaire.item[0].item[2].required[0]False
Questionnaire.item[0].item[2].repeats[0]False
Questionnaire.item[0].item[2].readOnly[0]False
Questionnaire.item[0].item[3].extension[0].url[0]http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl
Questionnaire.item[0].item[3].extension[0].value[0].coding[0].system[0]http://hl7.org/fhir/questionnaire-item-control
Questionnaire.item[0].item[3].extension[0].value[0].coding[0].code[0]drop-down
Questionnaire.item[0].item[3].extension[0].value[0].coding[0].display[0]Drop down
Questionnaire.item[0].item[3].linkId[0]relatedPerson_basisForAccess
Questionnaire.item[0].item[3].definition[0]http://hl7.org/fhir/StructureDefinition/RelatedPerson#relationship
Questionnaire.item[0].item[3].code[0].system[0]http://snomed.info/sct
Questionnaire.item[0].item[3].code[0].code[0]722011000000106
Questionnaire.item[0].item[3].code[0].display[0]Relationship (qualifier value)
Questionnaire.item[0].item[3].prefix[0]1.4
Questionnaire.item[0].item[3].text[0]Basis for Access
Questionnaire.item[0].item[3].type[0]choice
Questionnaire.item[0].item[3].required[0]True
Questionnaire.item[0].item[3].repeats[0]False
Questionnaire.item[0].item[3].readOnly[0]False
Questionnaire.item[0].item[3].answerOption[0].value[0].system[0]http://terminology.hl7.org/CodeSystem/v3-RoleCode
Questionnaire.item[0].item[3].answerOption[0].value[0].code[0]PRN
Questionnaire.item[0].item[3].answerOption[0].value[0].display[0]Parent
Questionnaire.item[0].item[3].answerOption[1].value[0].system[0]https://fhir.hl7.org.uk/CodeSystem/UKCore-AdditionalPersonRelationshipRole
Questionnaire.item[0].item[3].answerOption[1].value[0].code[0]Personal
Questionnaire.item[0].item[3].answerOption[1].value[0].display[0]Personal relationship with the patient
Questionnaire.item[0].item[3].answerOption[2].value[0].system[0]https://fhir.nhs.uk/STU3/CodeSystem/RARecord-ProxyRole-1
Questionnaire.item[0].item[3].answerOption[2].value[0].code[0]002
Questionnaire.item[0].item[3].answerOption[2].value[0].display[0]Best interest decision made on behalf of the patient (Mental Capacity Act 2005)
Questionnaire.item[0].item[4].extension[0].url[0]http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl
Questionnaire.item[0].item[4].extension[0].value[0].coding[0].system[0]http://hl7.org/fhir/questionnaire-item-control
Questionnaire.item[0].item[4].extension[0].value[0].coding[0].code[0]drop-down
Questionnaire.item[0].item[4].extension[0].value[0].coding[0].display[0]Drop down
Questionnaire.item[0].item[4].linkId[0]relatedPerson_relationship
Questionnaire.item[0].item[4].definition[0]http://hl7.org/fhir/StructureDefinition/RelatedPerson#relationship
Questionnaire.item[0].item[4].code[0].system[0]http://snomed.info/sct
Questionnaire.item[0].item[4].code[0].code[0]722011000000106
Questionnaire.item[0].item[4].code[0].display[0]Relationship (qualifier value)
Questionnaire.item[0].item[4].prefix[0]1.5
Questionnaire.item[0].item[4].text[0]Relationship
Questionnaire.item[0].item[4].type[0]choice
Questionnaire.item[0].item[4].required[0]True
Questionnaire.item[0].item[4].repeats[0]False
Questionnaire.item[0].item[4].readOnly[0]False
Questionnaire.item[0].item[4].answerOption[0].value[0].system[0]http://terminology.hl7.org/CodeSystem/v3-RoleCode
Questionnaire.item[0].item[4].answerOption[0].value[0].code[0]PRN
Questionnaire.item[0].item[4].answerOption[0].value[0].display[0]Parent
Questionnaire.item[0].item[4].answerOption[1].value[0].system[0]http://terminology.hl7.org/CodeSystem/v3-RoleCode
Questionnaire.item[0].item[4].answerOption[1].value[0].code[0]CHILD
Questionnaire.item[0].item[4].answerOption[1].value[0].display[0]Child
Questionnaire.item[0].item[4].answerOption[2].value[0].system[0]http://terminology.hl7.org/CodeSystem/v3-RoleCode
Questionnaire.item[0].item[4].answerOption[2].value[0].code[0]SPS
Questionnaire.item[0].item[4].answerOption[2].value[0].display[0]Partner, wife or husband
Questionnaire.item[0].item[4].answerOption[3].value[0].system[0]http://terminology.hl7.org/CodeSystem/v3-RoleCode
Questionnaire.item[0].item[4].answerOption[3].value[0].code[0]FAMMEMB
Questionnaire.item[0].item[4].answerOption[3].value[0].display[0]Other family member
Questionnaire.item[0].item[4].answerOption[4].value[0].system[0]http://terminology.hl7.org/CodeSystem/v3-RoleCode
Questionnaire.item[0].item[4].answerOption[4].value[0].code[0]FRND
Questionnaire.item[0].item[4].answerOption[4].value[0].display[0]Friend, neighbour or housemate
Questionnaire.item[0].item[4].answerOption[5].value[0].system[0]http://terminology.hl7.org/CodeSystem/v3-RoleClass
Questionnaire.item[0].item[4].answerOption[5].value[0].code[0]CAREGIVER
Questionnaire.item[0].item[4].answerOption[5].value[0].display[0]Paid carer or support worker
Questionnaire.item[0].item[4].answerOption[6].value[0].system[0]http://terminology.hl7.org/CodeSystem/v3-RoleCode
Questionnaire.item[0].item[4].answerOption[6].value[0].code[0]SIGOTHR
Questionnaire.item[0].item[4].answerOption[6].value[0].display[0]Other
Questionnaire.item[0].item[5].linkId[0]9759901615580
Questionnaire.item[0].item[5].prefix[0]1.6
Questionnaire.item[0].item[5].text[0]Relationship - Further information
Questionnaire.item[0].item[5].type[0]string
Questionnaire.item[0].item[5].required[0]False
Questionnaire.item[0].item[5].repeats[0]False
Questionnaire.item[0].item[5].readOnly[0]False
Questionnaire.item[0].item[5].maxLength[0]2000
Questionnaire.item[1].linkId[0]parentalApplicationSupplementaryDetails
Questionnaire.item[1].prefix[0]2
Questionnaire.item[1].text[0]Parental Application Supplementary Details
Questionnaire.item[1].type[0]group
Questionnaire.item[1].required[0]False
Questionnaire.item[1].readOnly[0]False
Questionnaire.item[1].item[0].extension[0].url[0]http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl
Questionnaire.item[1].item[0].extension[0].value[0].coding[0].system[0]http://hl7.org/fhir/questionnaire-item-control
Questionnaire.item[1].item[0].extension[0].value[0].coding[0].code[0]radio-button
Questionnaire.item[1].item[0].extension[0].value[0].coding[0].display[0]Radio Button
Questionnaire.item[1].item[0].linkId[0]parentalApplicationSupplementaryDetails_evidenceOfResponsibility
Questionnaire.item[1].item[0].prefix[0]2.1
Questionnaire.item[1].item[0].text[0]Evidence of parental responsibility
Questionnaire.item[1].item[0].type[0]choice
Questionnaire.item[1].item[0].required[0]True
Questionnaire.item[1].item[0].repeats[0]False
Questionnaire.item[1].item[0].readOnly[0]False
Questionnaire.item[1].item[0].answerOption[0].value[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility
Questionnaire.item[1].item[0].answerOption[0].value[0].code[0]BRTH
Questionnaire.item[1].item[0].answerOption[0].value[0].display[0]Birth certificate
Questionnaire.item[1].item[0].answerOption[1].value[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility
Questionnaire.item[1].item[0].answerOption[1].value[0].code[0]ADPT
Questionnaire.item[1].item[0].answerOption[1].value[0].display[0]Adoption certificate
Questionnaire.item[1].item[0].answerOption[2].value[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility
Questionnaire.item[1].item[0].answerOption[2].value[0].code[0]PRNA
Questionnaire.item[1].item[0].answerOption[2].value[0].display[0]Court-witnessed parental responsibility agreement
Questionnaire.item[1].item[0].answerOption[3].value[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility
Questionnaire.item[1].item[0].answerOption[3].value[0].code[0]SPRNA
Questionnaire.item[1].item[0].answerOption[3].value[0].display[0]Court-witnessed step-parent parental responsibility agreement
Questionnaire.item[1].item[0].answerOption[4].value[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility
Questionnaire.item[1].item[0].answerOption[4].value[0].code[0]PORD
Questionnaire.item[1].item[0].answerOption[4].value[0].display[0]Parental order
Questionnaire.item[1].item[0].answerOption[5].value[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility
Questionnaire.item[1].item[0].answerOption[5].value[0].code[0]SGORD
Questionnaire.item[1].item[0].answerOption[5].value[0].display[0]Special guardianship order
Questionnaire.item[1].item[0].answerOption[6].value[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility
Questionnaire.item[1].item[0].answerOption[6].value[0].code[0]OTHCOURT
Questionnaire.item[1].item[0].answerOption[6].value[0].display[0]Other court order
Questionnaire.item[1].item[0].answerOption[7].value[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility
Questionnaire.item[1].item[0].answerOption[7].value[0].code[0]OTHR
Questionnaire.item[1].item[0].answerOption[7].value[0].display[0]Other
Questionnaire.item[1].item[1].linkId[0]parentalApplicationSupplementaryDetails_evidenceOfResponsibilityMoreinfo
Questionnaire.item[1].item[1].prefix[0]2.2
Questionnaire.item[1].item[1].text[0]Evidence of responsibility - Further Information
Questionnaire.item[1].item[1].type[0]string
Questionnaire.item[1].item[1].enableWhen[0].question[0]parentalApplicationSupplementaryDetails_evidenceOfResponsibility
Questionnaire.item[1].item[1].enableWhen[0].operator[0]=
Questionnaire.item[1].item[1].enableWhen[0].answer[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility
Questionnaire.item[1].item[1].enableWhen[0].answer[0].code[0]OTHR
Questionnaire.item[1].item[1].enableWhen[0].answer[0].display[0]Other
Questionnaire.item[1].item[1].enableBehavior[0]all
Questionnaire.item[1].item[1].required[0]False
Questionnaire.item[1].item[1].repeats[0]False
Questionnaire.item[1].item[1].readOnly[0]False
Questionnaire.item[1].item[1].maxLength[0]2000
Questionnaire.item[1].item[2].linkId[0]parentalApplicationSupplementaryDetails_isCurrentAddressConfirmed
Questionnaire.item[1].item[2].prefix[0]2.3
Questionnaire.item[1].item[2].text[0]Is current address confirmed?
Questionnaire.item[1].item[2].type[0]boolean
Questionnaire.item[1].item[2].required[0]True
Questionnaire.item[1].item[2].repeats[0]False
Questionnaire.item[1].item[2].readOnly[0]False
Questionnaire.item[1].item[3].linkId[0]parentalApplicationSupplementaryDetails_newAddress
Questionnaire.item[1].item[3].prefix[0]2.4
Questionnaire.item[1].item[3].text[0]New address
Questionnaire.item[1].item[3].type[0]group
Questionnaire.item[1].item[3].required[0]False
Questionnaire.item[1].item[3].repeats[0]False
Questionnaire.item[1].item[3].readOnly[0]False
Questionnaire.item[1].item[3].item[0].linkId[0]parentalApplicationSupplementaryDetails_line1
Questionnaire.item[1].item[3].item[0].definition[0]http://hl7.org/fhir/datatypes-definitions.html#Address.line
Questionnaire.item[1].item[3].item[0].prefix[0]2.4.1
Questionnaire.item[1].item[3].item[0].text[0]Address line 1
Questionnaire.item[1].item[3].item[0].type[0]string
Questionnaire.item[1].item[3].item[0].required[0]False
Questionnaire.item[1].item[3].item[0].readOnly[0]False
Questionnaire.item[1].item[3].item[1].linkId[0]parentalApplicationSupplementaryDetails_line2
Questionnaire.item[1].item[3].item[1].definition[0]http://hl7.org/fhir/datatypes-definitions.html#Address.line
Questionnaire.item[1].item[3].item[1].prefix[0]2.4.2
Questionnaire.item[1].item[3].item[1].text[0]Address line 2
Questionnaire.item[1].item[3].item[1].type[0]string
Questionnaire.item[1].item[3].item[1].required[0]False
Questionnaire.item[1].item[3].item[1].readOnly[0]False
Questionnaire.item[1].item[3].item[2].linkId[0]parentalApplicationSupplementaryDetails_line3
Questionnaire.item[1].item[3].item[2].definition[0]http://hl7.org/fhir/datatypes-definitions.html#Address.line
Questionnaire.item[1].item[3].item[2].prefix[0]2.4.3
Questionnaire.item[1].item[3].item[2].text[0]Address line 3
Questionnaire.item[1].item[3].item[2].type[0]string
Questionnaire.item[1].item[3].item[2].required[0]False
Questionnaire.item[1].item[3].item[2].readOnly[0]False
Questionnaire.item[1].item[3].item[3].linkId[0]parentalApplicationSupplementaryDetails_city
Questionnaire.item[1].item[3].item[3].definition[0]http://hl7.org/fhir/datatypes-definitions.html#Address.city
Questionnaire.item[1].item[3].item[3].prefix[0]2.4.4
Questionnaire.item[1].item[3].item[3].text[0]Town / City
Questionnaire.item[1].item[3].item[3].type[0]string
Questionnaire.item[1].item[3].item[3].required[0]False
Questionnaire.item[1].item[3].item[3].readOnly[0]False
Questionnaire.item[1].item[3].item[4].linkId[0]parentalApplicationSupplementaryDetails_district
Questionnaire.item[1].item[3].item[4].definition[0]http://hl7.org/fhir/datatypes-definitions.html#Address.district
Questionnaire.item[1].item[3].item[4].prefix[0]2.4.5
Questionnaire.item[1].item[3].item[4].text[0]County
Questionnaire.item[1].item[3].item[4].type[0]string
Questionnaire.item[1].item[3].item[4].required[0]False
Questionnaire.item[1].item[3].item[4].readOnly[0]False
Questionnaire.item[1].item[3].item[5].linkId[0]parentalApplicationSupplementaryDetails_postalCode
Questionnaire.item[1].item[3].item[5].definition[0]http://hl7.org/fhir/datatypes-definitions.html#Address.postalCode
Questionnaire.item[1].item[3].item[5].prefix[0]2.4.6
Questionnaire.item[1].item[3].item[5].text[0]Postcode
Questionnaire.item[1].item[3].item[5].type[0]string
Questionnaire.item[1].item[3].item[5].required[0]False
Questionnaire.item[1].item[3].item[5].readOnly[0]False
Questionnaire.item[1].item[4].linkId[0]parentalApplicationSupplementaryDetails_liveAtSameAddress
Questionnaire.item[1].item[4].prefix[0]2.5
Questionnaire.item[1].item[4].text[0]Do adult and child live at the same address?
Questionnaire.item[1].item[4].type[0]boolean
Questionnaire.item[1].item[4].required[0]True
Questionnaire.item[1].item[4].repeats[0]False
Questionnaire.item[1].item[4].readOnly[0]False
Questionnaire.item[1].item[5].linkId[0]parentalApplicationSupplementaryDetails_canChildConsent
Questionnaire.item[1].item[5].prefix[0]2.6
Questionnaire.item[1].item[5].text[0]Can the child consent?
Questionnaire.item[1].item[5].type[0]boolean
Questionnaire.item[1].item[5].required[0]False
Questionnaire.item[1].item[5].repeats[0]False
Questionnaire.item[1].item[5].readOnly[0]False
Questionnaire.item[1].item[6].linkId[0]parentalApplicationSupplementaryDetails_reasonNoChildConsent
Questionnaire.item[1].item[6].prefix[0]2.7
Questionnaire.item[1].item[6].text[0]Reason the child cannot consent?
Questionnaire.item[1].item[6].type[0]string
Questionnaire.item[1].item[6].enableWhen[0].question[0]parentalApplicationSupplementaryDetails_canChildConsent
Questionnaire.item[1].item[6].enableWhen[0].operator[0]=
Questionnaire.item[1].item[6].enableWhen[0].answer[0]False
Questionnaire.item[1].item[6].enableBehavior[0]all
Questionnaire.item[1].item[6].required[0]False
Questionnaire.item[1].item[6].repeats[0]False
Questionnaire.item[1].item[6].readOnly[0]False
Questionnaire.item[2].linkId[0]patient
Questionnaire.item[2].prefix[0]3
Questionnaire.item[2].text[0]Patient details
Questionnaire.item[2].type[0]group
Questionnaire.item[2].required[0]True
Questionnaire.item[2].item[0].linkId[0]patient_identifier
Questionnaire.item[2].item[0].definition[0]http://hl7.org/fhir/StructureDefinition/Patient#identifier
Questionnaire.item[2].item[0].prefix[0]3.1
Questionnaire.item[2].item[0].text[0]NHS number
Questionnaire.item[2].item[0].type[0]string
Questionnaire.item[2].item[0].required[0]True
Questionnaire.item[2].item[0].repeats[0]False
Questionnaire.item[2].item[0].readOnly[0]False
Questionnaire.item[2].item[0].maxLength[0]10
Questionnaire.item[2].item[1].linkId[0]patient_name
Questionnaire.item[2].item[1].definition[0]http://hl7.org/fhir/StructureDefinition/Patient#name
Questionnaire.item[2].item[1].prefix[0]3.2
Questionnaire.item[2].item[1].text[0]Name
Questionnaire.item[2].item[1].type[0]group
Questionnaire.item[2].item[1].required[0]False
Questionnaire.item[2].item[1].item[0].linkId[0]patient_name_first
Questionnaire.item[2].item[1].item[0].definition[0]http://hl7.org/fhir/StructureDefinition/Patient#name.given
Questionnaire.item[2].item[1].item[0].prefix[0]3.2.1
Questionnaire.item[2].item[1].item[0].text[0]First name
Questionnaire.item[2].item[1].item[0].type[0]string
Questionnaire.item[2].item[1].item[0].required[0]True
Questionnaire.item[2].item[1].item[0].repeats[0]False
Questionnaire.item[2].item[1].item[0].readOnly[0]False
Questionnaire.item[2].item[1].item[1].linkId[0]patient_name_family
Questionnaire.item[2].item[1].item[1].definition[0]http://hl7.org/fhir/StructureDefinition/Patient#name.family
Questionnaire.item[2].item[1].item[1].prefix[0]3.2.2
Questionnaire.item[2].item[1].item[1].text[0]Last name
Questionnaire.item[2].item[1].item[1].type[0]string
Questionnaire.item[2].item[1].item[1].required[0]True
Questionnaire.item[2].item[1].item[1].repeats[0]False
Questionnaire.item[2].item[1].item[1].readOnly[0]False
Questionnaire.item[2].item[2].linkId[0]patient_birthDate
Questionnaire.item[2].item[2].definition[0]http://hl7.org/fhir/StructureDefinition/Patient#birthDate
Questionnaire.item[2].item[2].prefix[0]3.3
Questionnaire.item[2].item[2].text[0]Date of birth
Questionnaire.item[2].item[2].type[0]date
Questionnaire.item[2].item[2].required[0]False
Questionnaire.item[2].item[2].repeats[0]False
Questionnaire.item[2].item[2].readOnly[0]False
Questionnaire.item[3].linkId[0]requestedAccess
Questionnaire.item[3].prefix[0]4
Questionnaire.item[3].text[0]Requested access
Questionnaire.item[3].type[0]group
Questionnaire.item[3].required[0]True
Questionnaire.item[3].item[0].extension[0].url[0]http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl
Questionnaire.item[3].item[0].extension[0].value[0].coding[0].system[0]http://hl7.org/fhir/questionnaire-item-control
Questionnaire.item[3].item[0].extension[0].value[0].coding[0].code[0]check-box
Questionnaire.item[3].item[0].extension[0].value[0].coding[0].display[0]Check-box
Questionnaire.item[3].item[0].linkId[0]requestedAccess_accessLevel
Questionnaire.item[3].item[0].prefix[0]4.1
Questionnaire.item[3].item[0].text[0]Requested access level
Questionnaire.item[3].item[0].type[0]choice
Questionnaire.item[3].item[0].required[0]True
Questionnaire.item[3].item[0].repeats[0]True
Questionnaire.item[3].item[0].readOnly[0]False
Questionnaire.item[3].item[0].answerOption[0].value[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess
Questionnaire.item[3].item[0].answerOption[0].value[0].code[0]APPT
Questionnaire.item[3].item[0].answerOption[0].value[0].display[0]Appointment Booking
Questionnaire.item[3].item[0].answerOption[1].value[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess
Questionnaire.item[3].item[0].answerOption[1].value[0].code[0]CNTCT
Questionnaire.item[3].item[0].answerOption[1].value[0].display[0]Contacting Surgery
Questionnaire.item[3].item[0].answerOption[2].value[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess
Questionnaire.item[3].item[0].answerOption[2].value[0].code[0]RECRD
Questionnaire.item[3].item[0].answerOption[2].value[0].display[0]Medical Records Access
Questionnaire.item[3].item[0].answerOption[3].value[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess
Questionnaire.item[3].item[0].answerOption[3].value[0].code[0]TEST
Questionnaire.item[3].item[0].answerOption[3].value[0].display[0]Test Results
Questionnaire.item[3].item[0].answerOption[4].value[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess
Questionnaire.item[3].item[0].answerOption[4].value[0].code[0]VACC
Questionnaire.item[3].item[0].answerOption[4].value[0].display[0]Vaccination Records
Questionnaire.item[3].item[0].answerOption[5].value[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess
Questionnaire.item[3].item[0].answerOption[5].value[0].code[0]PRESCR
Questionnaire.item[3].item[0].answerOption[5].value[0].display[0]Request and manage repeat prescriptions
Questionnaire.item[3].item[1].linkId[0]requestedAccess_accessLevelMoreinfo
Questionnaire.item[3].item[1].prefix[0]4.2
Questionnaire.item[3].item[1].text[0]Requested access level - further information
Questionnaire.item[3].item[1].type[0]string
Questionnaire.item[3].item[1].enableWhen[0].question[0]requestedAccess_accessLevel
Questionnaire.item[3].item[1].enableWhen[0].operator[0]=
Questionnaire.item[3].item[1].enableWhen[0].answer[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess
Questionnaire.item[3].item[1].enableWhen[0].answer[0].code[0]RECRD
Questionnaire.item[3].item[1].enableWhen[0].answer[0].display[0]Medical Records Access
Questionnaire.item[3].item[1].enableBehavior[0]all
Questionnaire.item[3].item[1].required[0]False
Questionnaire.item[3].item[1].repeats[0]False
Questionnaire.item[3].item[1].readOnly[0]False
Questionnaire.item[3].item[1].maxLength[0]2000
Questionnaire.item[3].item[2].extension[0].url[0]http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl
Questionnaire.item[3].item[2].extension[0].value[0].coding[0].system[0]http://hl7.org/fhir/questionnaire-item-control
Questionnaire.item[3].item[2].extension[0].value[0].coding[0].code[0]check-box
Questionnaire.item[3].item[2].extension[0].value[0].coding[0].display[0]Check-box
Questionnaire.item[3].item[2].linkId[0]requestedAccess_reasonsForAccess
Questionnaire.item[3].item[2].prefix[0]4.3
Questionnaire.item[3].item[2].text[0]Reason for access
Questionnaire.item[3].item[2].type[0]choice
Questionnaire.item[3].item[2].required[0]False
Questionnaire.item[3].item[2].repeats[0]True
Questionnaire.item[3].item[2].readOnly[0]False
Questionnaire.item[3].item[2].answerOption[0].value[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess
Questionnaire.item[3].item[2].answerOption[0].value[0].code[0]COMB
Questionnaire.item[3].item[2].answerOption[0].value[0].display[0]Communication Barriers
Questionnaire.item[3].item[2].answerOption[1].value[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess
Questionnaire.item[3].item[2].answerOption[1].value[0].code[0]MHEA
Questionnaire.item[3].item[2].answerOption[1].value[0].display[0]Mental Health Condition
Questionnaire.item[3].item[2].answerOption[2].value[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess
Questionnaire.item[3].item[2].answerOption[2].value[0].code[0]PHYS
Questionnaire.item[3].item[2].answerOption[2].value[0].display[0]Physical Condition
Questionnaire.item[3].item[2].answerOption[3].value[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess
Questionnaire.item[3].item[2].answerOption[3].value[0].code[0]PRAC
Questionnaire.item[3].item[2].answerOption[3].value[0].display[0]Practical Reasons
Questionnaire.item[3].item[2].answerOption[4].value[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess
Questionnaire.item[3].item[2].answerOption[4].value[0].code[0]TECH
Questionnaire.item[3].item[2].answerOption[4].value[0].display[0]Technical Barriers
Questionnaire.item[3].item[2].answerOption[5].value[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess
Questionnaire.item[3].item[2].answerOption[5].value[0].code[0]NEUR
Questionnaire.item[3].item[2].answerOption[5].value[0].display[0]Neurodiverse
Questionnaire.item[3].item[2].answerOption[6].value[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess
Questionnaire.item[3].item[2].answerOption[6].value[0].code[0]LRN
Questionnaire.item[3].item[2].answerOption[6].value[0].display[0]Learning Disability
Questionnaire.item[3].item[2].answerOption[7].value[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess
Questionnaire.item[3].item[2].answerOption[7].value[0].code[0]OTHR
Questionnaire.item[3].item[2].answerOption[7].value[0].display[0]Other
Questionnaire.item[3].item[2].answerOption[8].value[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess
Questionnaire.item[3].item[2].answerOption[8].value[0].code[0]NotSpecified
Questionnaire.item[3].item[2].answerOption[8].value[0].display[0]Prefer not to say
Questionnaire.item[3].item[3].linkId[0]requestedAccess_reasonsForAccessMoreinfo
Questionnaire.item[3].item[3].prefix[0]4.4
Questionnaire.item[3].item[3].text[0]Reason for access - further information
Questionnaire.item[3].item[3].type[0]string
Questionnaire.item[3].item[3].enableWhen[0].question[0]requestedAccess_reasonsForAccess
Questionnaire.item[3].item[3].enableWhen[0].operator[0]=
Questionnaire.item[3].item[3].enableWhen[0].answer[0].system[0]https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess
Questionnaire.item[3].item[3].enableWhen[0].answer[0].code[0]OTHR
Questionnaire.item[3].item[3].enableWhen[0].answer[0].display[0]Other
Questionnaire.item[3].item[3].enableBehavior[0]all
Questionnaire.item[3].item[3].required[0]False
Questionnaire.item[3].item[3].repeats[0]False
Questionnaire.item[3].item[3].readOnly[0]False
Questionnaire.item[3].item[3].maxLength[0]2000

XML View

<Questionnaire xmlns="http://hl7.org/fhir">
    <id value="NationalProxy-Questionnaire-ProxyAccessRequest-Example" />
    <meta>
        <versionId value="52" />
        <lastUpdated value="2024-08-30T13:36:50.663Z" />
    </meta>
    <url value="https://fhir.nhs.uk/England/Questionnaire/ProxyAccessRequest" />
    <version value="0.0.1-current" />
    <name value="Consent" />
    <title value="Questionnaire Proxy Access Request" />
    <status value="draft" />
    <subjectType value="RelatedPerson" />
    <date value="2024-07-12" />
    <publisher value="NHS England" />
    <contact>
        <telecom>
            <system value="url" />
            <value value="https://www.ihe.net/ihe_domains/it_infrastructure/" />
        </telecom>
    </contact>
    <contact>
        <telecom>
            <system value="email" />
            <value value="iti@ihe.net" />
        </telecom>
    </contact>
    <contact>
        <name value="NHS England" />
        <telecom>
            <system value="email" />
            <value value="iti@ihe.net" />
        </telecom>
    </contact>
    <description value="A form to request access to health and care services on behalf of someone else." />
    <useContext>
        <code>
            <system value="http://terminology.hl7.org/CodeSystem/usage-context-type" />
            <code value="task" />
        </code>
        <valueCodeableConcept>
            <coding>
                <system value="http://snomed.info/sct" />
                <code value="887031000000108" />
                <display value="Consent for information sharing" />
            </coding>
        </valueCodeableConcept>
    </useContext>
    <jurisdiction>
        <coding>
            <system value="http://unstats.un.org/unsd/methods/m49/m49.htm" />
            <code value="001" />
        </coding>
    </jurisdiction>
    <purpose value="Add someone to your NHS account" />
    <item>
        <linkId value="relatedPerson" />
        <prefix value="1" />
        <text value="Proxy details" />
        <type value="group" />
        <required value="true" />
        <readOnly value="false" />
        <item>
            <linkId value="relatedPerson_identifier" />
            <definition value="http://hl7.org/fhir/StructureDefinition/RelatedPerson#identifier" />
            <prefix value="1.1" />
            <text value="NHS number" />
            <type value="string" />
            <required value="true" />
            <readOnly value="false" />
            <maxLength value="10" />
        </item>
        <item>
            <linkId value="relatedPerson_name" />
            <definition value="http://hl7.org/fhir/StructureDefinition/RelatedPerson#name" />
            <prefix value="1.2" />
            <text value="Name" />
            <type value="group" />
            <required value="false" />
            <item>
                <linkId value="relatedPerson_name_first" />
                <definition value="http://hl7.org/fhir/StructureDefinition/RelatedPerson#name.given" />
                <prefix value="1.2.1" />
                <text value="First name" />
                <type value="string" />
                <required value="true" />
                <repeats value="false" />
                <readOnly value="false" />
            </item>
            <item>
                <linkId value="relatedPerson_name_family" />
                <definition value="http://hl7.org/fhir/StructureDefinition/RelatedPerson#name.family" />
                <prefix value="1.2.2" />
                <text value="Last name" />
                <type value="string" />
                <required value="true" />
                <repeats value="false" />
                <readOnly value="false" />
            </item>
        </item>
        <item>
            <linkId value="relatedPerson_birthDate" />
            <definition value="http://hl7.org/fhir/StructureDefinition/RelatedPerson#birthDate" />
            <prefix value="1.3" />
            <text value="Date of birth" />
            <type value="date" />
            <required value="false" />
            <repeats value="false" />
            <readOnly value="false" />
        </item>
        <item>
            <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl">
                <valueCodeableConcept>
                    <coding>
                        <system value="http://hl7.org/fhir/questionnaire-item-control" />
                        <code value="drop-down" />
                        <display value="Drop down" />
                    </coding>
                </valueCodeableConcept>
            </extension>
            <linkId value="relatedPerson_basisForAccess" />
            <definition value="http://hl7.org/fhir/StructureDefinition/RelatedPerson#relationship" />
            <code>
                <system value="http://snomed.info/sct" />
                <code value="722011000000106" />
                <display value="Relationship (qualifier value)" />
            </code>
            <prefix value="1.4" />
            <text value="Basis for Access" />
            <type value="choice" />
            <required value="true" />
            <repeats value="false" />
            <readOnly value="false" />
            <answerOption>
                <valueCoding>
                    <system value="http://terminology.hl7.org/CodeSystem/v3-RoleCode" />
                    <code value="PRN" />
                    <display value="Parent" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-AdditionalPersonRelationshipRole" />
                    <code value="Personal" />
                    <display value="Personal relationship with the patient" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.nhs.uk/STU3/CodeSystem/RARecord-ProxyRole-1" />
                    <code value="002" />
                    <display value="Best interest decision made on behalf of the patient (Mental Capacity Act 2005)" />
                </valueCoding>
            </answerOption>
        </item>
        <item>
            <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl">
                <valueCodeableConcept>
                    <coding>
                        <system value="http://hl7.org/fhir/questionnaire-item-control" />
                        <code value="drop-down" />
                        <display value="Drop down" />
                    </coding>
                </valueCodeableConcept>
            </extension>
            <linkId value="relatedPerson_relationship" />
            <definition value="http://hl7.org/fhir/StructureDefinition/RelatedPerson#relationship" />
            <code>
                <system value="http://snomed.info/sct" />
                <code value="722011000000106" />
                <display value="Relationship (qualifier value)" />
            </code>
            <prefix value="1.5" />
            <text value="Relationship" />
            <type value="choice" />
            <required value="true" />
            <repeats value="false" />
            <readOnly value="false" />
            <answerOption>
                <valueCoding>
                    <system value="http://terminology.hl7.org/CodeSystem/v3-RoleCode" />
                    <code value="PRN" />
                    <display value="Parent" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="http://terminology.hl7.org/CodeSystem/v3-RoleCode" />
                    <code value="CHILD" />
                    <display value="Child" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="http://terminology.hl7.org/CodeSystem/v3-RoleCode" />
                    <code value="SPS" />
                    <display value="Partner, wife or husband" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="http://terminology.hl7.org/CodeSystem/v3-RoleCode" />
                    <code value="FAMMEMB" />
                    <display value="Other family member" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="http://terminology.hl7.org/CodeSystem/v3-RoleCode" />
                    <code value="FRND" />
                    <display value="Friend, neighbour or housemate" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="http://terminology.hl7.org/CodeSystem/v3-RoleClass" />
                    <code value="CAREGIVER" />
                    <display value="Paid carer or support worker" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="http://terminology.hl7.org/CodeSystem/v3-RoleCode" />
                    <code value="SIGOTHR" />
                    <display value="Other" />
                </valueCoding>
            </answerOption>
        </item>
        <item>
            <linkId value="9759901615580" />
            <prefix value="1.6" />
            <text value="Relationship - Further information" />
            <type value="string" />
            <required value="false" />
            <repeats value="false" />
            <readOnly value="false" />
            <maxLength value="2000" />
        </item>
    </item>
    <item>
        <linkId value="parentalApplicationSupplementaryDetails" />
        <prefix value="2" />
        <text value="Parental Application Supplementary Details" />
        <type value="group" />
        <required value="false" />
        <readOnly value="false" />
        <item>
            <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl">
                <valueCodeableConcept>
                    <coding>
                        <system value="http://hl7.org/fhir/questionnaire-item-control" />
                        <code value="radio-button" />
                        <display value="Radio Button" />
                    </coding>
                </valueCodeableConcept>
            </extension>
            <linkId value="parentalApplicationSupplementaryDetails_evidenceOfResponsibility" />
            <prefix value="2.1" />
            <text value="Evidence of parental responsibility" />
            <type value="choice" />
            <required value="true" />
            <repeats value="false" />
            <readOnly value="false" />
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility" />
                    <code value="BRTH" />
                    <display value="Birth certificate" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility" />
                    <code value="ADPT" />
                    <display value="Adoption certificate" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility" />
                    <code value="PRNA" />
                    <display value="Court-witnessed parental responsibility agreement" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility" />
                    <code value="SPRNA" />
                    <display value="Court-witnessed step-parent parental responsibility agreement" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility" />
                    <code value="PORD" />
                    <display value="Parental order" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility" />
                    <code value="SGORD" />
                    <display value="Special guardianship order" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility" />
                    <code value="OTHCOURT" />
                    <display value="Other court order" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility" />
                    <code value="OTHR" />
                    <display value="Other" />
                </valueCoding>
            </answerOption>
        </item>
        <item>
            <linkId value="parentalApplicationSupplementaryDetails_evidenceOfResponsibilityMoreinfo" />
            <prefix value="2.2" />
            <text value="Evidence of responsibility - Further Information" />
            <type value="string" />
            <enableWhen>
                <question value="parentalApplicationSupplementaryDetails_evidenceOfResponsibility" />
                <operator value="=" />
                <answerCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility" />
                    <code value="OTHR" />
                    <display value="Other" />
                </answerCoding>
            </enableWhen>
            <enableBehavior value="all" />
            <required value="false" />
            <repeats value="false" />
            <readOnly value="false" />
            <maxLength value="2000" />
        </item>
        <item>
            <linkId value="parentalApplicationSupplementaryDetails_isCurrentAddressConfirmed" />
            <prefix value="2.3" />
            <text value="Is current address confirmed?" />
            <type value="boolean" />
            <required value="true" />
            <repeats value="false" />
            <readOnly value="false" />
        </item>
        <item>
            <linkId value="parentalApplicationSupplementaryDetails_newAddress" />
            <prefix value="2.4" />
            <text value="New address" />
            <type value="group" />
            <required value="false" />
            <repeats value="false" />
            <readOnly value="false" />
            <item>
                <linkId value="parentalApplicationSupplementaryDetails_line1" />
                <definition value="http://hl7.org/fhir/datatypes-definitions.html#Address.line" />
                <prefix value="2.4.1" />
                <text value="Address line 1" />
                <type value="string" />
                <required value="false" />
                <readOnly value="false" />
            </item>
            <item>
                <linkId value="parentalApplicationSupplementaryDetails_line2" />
                <definition value="http://hl7.org/fhir/datatypes-definitions.html#Address.line" />
                <prefix value="2.4.2" />
                <text value="Address line 2" />
                <type value="string" />
                <required value="false" />
                <readOnly value="false" />
            </item>
            <item>
                <linkId value="parentalApplicationSupplementaryDetails_line3" />
                <definition value="http://hl7.org/fhir/datatypes-definitions.html#Address.line" />
                <prefix value="2.4.3" />
                <text value="Address line 3" />
                <type value="string" />
                <required value="false" />
                <readOnly value="false" />
            </item>
            <item>
                <linkId value="parentalApplicationSupplementaryDetails_city" />
                <definition value="http://hl7.org/fhir/datatypes-definitions.html#Address.city" />
                <prefix value="2.4.4" />
                <text value="Town / City" />
                <type value="string" />
                <required value="false" />
                <readOnly value="false" />
            </item>
            <item>
                <linkId value="parentalApplicationSupplementaryDetails_district" />
                <definition value="http://hl7.org/fhir/datatypes-definitions.html#Address.district" />
                <prefix value="2.4.5" />
                <text value="County" />
                <type value="string" />
                <required value="false" />
                <readOnly value="false" />
            </item>
            <item>
                <linkId value="parentalApplicationSupplementaryDetails_postalCode" />
                <definition value="http://hl7.org/fhir/datatypes-definitions.html#Address.postalCode" />
                <prefix value="2.4.6" />
                <text value="Postcode" />
                <type value="string" />
                <required value="false" />
                <readOnly value="false" />
            </item>
        </item>
        <item>
            <linkId value="parentalApplicationSupplementaryDetails_liveAtSameAddress" />
            <prefix value="2.5" />
            <text value="Do adult and child live at the same address?" />
            <type value="boolean" />
            <required value="true" />
            <repeats value="false" />
            <readOnly value="false" />
        </item>
        <item>
            <linkId value="parentalApplicationSupplementaryDetails_canChildConsent" />
            <prefix value="2.6" />
            <text value="Can the child consent?" />
            <type value="boolean" />
            <required value="false" />
            <repeats value="false" />
            <readOnly value="false" />
        </item>
        <item>
            <linkId value="parentalApplicationSupplementaryDetails_reasonNoChildConsent" />
            <prefix value="2.7" />
            <text value="Reason the child cannot consent?" />
            <type value="string" />
            <enableWhen>
                <question value="parentalApplicationSupplementaryDetails_canChildConsent" />
                <operator value="=" />
                <answerBoolean value="false" />
            </enableWhen>
            <enableBehavior value="all" />
            <required value="false" />
            <repeats value="false" />
            <readOnly value="false" />
        </item>
    </item>
    <item>
        <linkId value="patient" />
        <prefix value="3" />
        <text value="Patient details" />
        <type value="group" />
        <required value="true" />
        <item>
            <linkId value="patient_identifier" />
            <definition value="http://hl7.org/fhir/StructureDefinition/Patient#identifier" />
            <prefix value="3.1" />
            <text value="NHS number" />
            <type value="string" />
            <required value="true" />
            <repeats value="false" />
            <readOnly value="false" />
            <maxLength value="10" />
        </item>
        <item>
            <linkId value="patient_name" />
            <definition value="http://hl7.org/fhir/StructureDefinition/Patient#name" />
            <prefix value="3.2" />
            <text value="Name" />
            <type value="group" />
            <required value="false" />
            <item>
                <linkId value="patient_name_first" />
                <definition value="http://hl7.org/fhir/StructureDefinition/Patient#name.given" />
                <prefix value="3.2.1" />
                <text value="First name" />
                <type value="string" />
                <required value="true" />
                <repeats value="false" />
                <readOnly value="false" />
            </item>
            <item>
                <linkId value="patient_name_family" />
                <definition value="http://hl7.org/fhir/StructureDefinition/Patient#name.family" />
                <prefix value="3.2.2" />
                <text value="Last name" />
                <type value="string" />
                <required value="true" />
                <repeats value="false" />
                <readOnly value="false" />
            </item>
        </item>
        <item>
            <linkId value="patient_birthDate" />
            <definition value="http://hl7.org/fhir/StructureDefinition/Patient#birthDate" />
            <prefix value="3.3" />
            <text value="Date of birth" />
            <type value="date" />
            <required value="false" />
            <repeats value="false" />
            <readOnly value="false" />
        </item>
    </item>
    <item>
        <linkId value="requestedAccess" />
        <prefix value="4" />
        <text value="Requested access" />
        <type value="group" />
        <required value="true" />
        <item>
            <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl">
                <valueCodeableConcept>
                    <coding>
                        <system value="http://hl7.org/fhir/questionnaire-item-control" />
                        <code value="check-box" />
                        <display value="Check-box" />
                    </coding>
                </valueCodeableConcept>
            </extension>
            <linkId value="requestedAccess_accessLevel" />
            <prefix value="4.1" />
            <text value="Requested access level" />
            <type value="choice" />
            <required value="true" />
            <repeats value="true" />
            <readOnly value="false" />
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess" />
                    <code value="APPT" />
                    <display value="Appointment Booking" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess" />
                    <code value="CNTCT" />
                    <display value="Contacting Surgery" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess" />
                    <code value="RECRD" />
                    <display value="Medical Records Access" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess" />
                    <code value="TEST" />
                    <display value="Test Results" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess" />
                    <code value="VACC" />
                    <display value="Vaccination Records" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess" />
                    <code value="PRESCR" />
                    <display value="Request and manage repeat prescriptions" />
                </valueCoding>
            </answerOption>
        </item>
        <item>
            <linkId value="requestedAccess_accessLevelMoreinfo" />
            <prefix value="4.2" />
            <text value="Requested access level - further information" />
            <type value="string" />
            <enableWhen>
                <question value="requestedAccess_accessLevel" />
                <operator value="=" />
                <answerCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess" />
                    <code value="RECRD" />
                    <display value="Medical Records Access" />
                </answerCoding>
            </enableWhen>
            <enableBehavior value="all" />
            <required value="false" />
            <repeats value="false" />
            <readOnly value="false" />
            <maxLength value="2000" />
        </item>
        <item>
            <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl">
                <valueCodeableConcept>
                    <coding>
                        <system value="http://hl7.org/fhir/questionnaire-item-control" />
                        <code value="check-box" />
                        <display value="Check-box" />
                    </coding>
                </valueCodeableConcept>
            </extension>
            <linkId value="requestedAccess_reasonsForAccess" />
            <prefix value="4.3" />
            <text value="Reason for access" />
            <type value="choice" />
            <required value="false" />
            <repeats value="true" />
            <readOnly value="false" />
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess" />
                    <code value="COMB" />
                    <display value="Communication Barriers" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess" />
                    <code value="MHEA" />
                    <display value="Mental Health Condition" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess" />
                    <code value="PHYS" />
                    <display value="Physical Condition" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess" />
                    <code value="PRAC" />
                    <display value="Practical Reasons" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess" />
                    <code value="TECH" />
                    <display value="Technical Barriers" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess" />
                    <code value="NEUR" />
                    <display value="Neurodiverse" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess" />
                    <code value="LRN" />
                    <display value="Learning Disability" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess" />
                    <code value="OTHR" />
                    <display value="Other" />
                </valueCoding>
            </answerOption>
            <answerOption>
                <valueCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess" />
                    <code value="NotSpecified" />
                    <display value="Prefer not to say" />
                </valueCoding>
            </answerOption>
        </item>
        <item>
            <linkId value="requestedAccess_reasonsForAccessMoreinfo" />
            <prefix value="4.4" />
            <text value="Reason for access - further information" />
            <type value="string" />
            <enableWhen>
                <question value="requestedAccess_reasonsForAccess" />
                <operator value="=" />
                <answerCoding>
                    <system value="https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess" />
                    <code value="OTHR" />
                    <display value="Other" />
                </answerCoding>
            </enableWhen>
            <enableBehavior value="all" />
            <required value="false" />
            <repeats value="false" />
            <readOnly value="false" />
            <maxLength value="2000" />
        </item>
    </item>
</Questionnaire>

JSON View

{
    "resourceType": "Questionnaire",
    "id": "NationalProxy-Questionnaire-ProxyAccessRequest-Example",
    "meta": {
        "versionId": "52",
        "lastUpdated": "2024-08-30T13:36:50.663Z"
    },
    "url": "https://fhir.nhs.uk/England/Questionnaire/ProxyAccessRequest",
    "version": "0.0.1-current",
    "name": "Consent",
    "title": "Questionnaire Proxy Access Request",
    "status": "draft",
    "subjectType":  [
        "RelatedPerson"
    ],
    "date": "2024-07-12",
    "publisher": "NHS England",
    "contact":  [
        {
            "telecom":  [
                {
                    "system": "url",
                    "value": "https://www.ihe.net/ihe_domains/it_infrastructure/"
                }
            ]
        },
        {
            "telecom":  [
                {
                    "system": "email",
                    "value": "iti@ihe.net"
                }
            ]
        },
        {
            "name": "NHS England",
            "telecom":  [
                {
                    "system": "email",
                    "value": "iti@ihe.net"
                }
            ]
        }
    ],
    "description": "A form to request access to health and care services on behalf of someone else.",
    "useContext":  [
        {
            "code": {
                "system": "http://terminology.hl7.org/CodeSystem/usage-context-type",
                "code": "task"
            },
            "valueCodeableConcept": {
                "coding":  [
                    {
                        "system": "http://snomed.info/sct",
                        "code": "887031000000108",
                        "display": "Consent for information sharing"
                    }
                ]
            }
        }
    ],
    "jurisdiction":  [
        {
            "coding":  [
                {
                    "system": "http://unstats.un.org/unsd/methods/m49/m49.htm",
                    "code": "001"
                }
            ]
        }
    ],
    "purpose": "Add someone to your NHS account",
    "item":  [
        {
            "linkId": "relatedPerson",
            "prefix": "1",
            "text": "Proxy details",
            "type": "group",
            "required": true,
            "readOnly": false,
            "item":  [
                {
                    "linkId": "relatedPerson_identifier",
                    "definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#identifier",
                    "prefix": "1.1",
                    "text": "NHS number",
                    "type": "string",
                    "required": true,
                    "readOnly": false,
                    "maxLength": 10
                },
                {
                    "linkId": "relatedPerson_name",
                    "definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#name",
                    "prefix": "1.2",
                    "text": "Name",
                    "type": "group",
                    "required": false,
                    "item":  [
                        {
                            "linkId": "relatedPerson_name_first",
                            "definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#name.given",
                            "prefix": "1.2.1",
                            "text": "First name",
                            "type": "string",
                            "required": true,
                            "repeats": false,
                            "readOnly": false
                        },
                        {
                            "linkId": "relatedPerson_name_family",
                            "definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#name.family",
                            "prefix": "1.2.2",
                            "text": "Last name",
                            "type": "string",
                            "required": true,
                            "repeats": false,
                            "readOnly": false
                        }
                    ]
                },
                {
                    "linkId": "relatedPerson_birthDate",
                    "definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#birthDate",
                    "prefix": "1.3",
                    "text": "Date of birth",
                    "type": "date",
                    "required": false,
                    "repeats": false,
                    "readOnly": false
                },
                {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
                            "valueCodeableConcept": {
                                "coding":  [
                                    {
                                        "system": "http://hl7.org/fhir/questionnaire-item-control",
                                        "code": "drop-down",
                                        "display": "Drop down"
                                    }
                                ]
                            }
                        }
                    ],
                    "linkId": "relatedPerson_basisForAccess",
                    "definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#relationship",
                    "code":  [
                        {
                            "system": "http://snomed.info/sct",
                            "code": "722011000000106",
                            "display": "Relationship (qualifier value)"
                        }
                    ],
                    "prefix": "1.4",
                    "text": "Basis for Access",
                    "type": "choice",
                    "required": true,
                    "repeats": false,
                    "readOnly": false,
                    "answerOption":  [
                        {
                            "valueCoding": {
                                "system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
                                "code": "PRN",
                                "display": "Parent"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-AdditionalPersonRelationshipRole",
                                "code": "Personal",
                                "display": "Personal relationship with the patient"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "https://fhir.nhs.uk/STU3/CodeSystem/RARecord-ProxyRole-1",
                                "code": "002",
                                "display": "Best interest decision made on behalf of the patient (Mental Capacity Act 2005)"
                            }
                        }
                    ]
                },
                {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
                            "valueCodeableConcept": {
                                "coding":  [
                                    {
                                        "system": "http://hl7.org/fhir/questionnaire-item-control",
                                        "code": "drop-down",
                                        "display": "Drop down"
                                    }
                                ]
                            }
                        }
                    ],
                    "linkId": "relatedPerson_relationship",
                    "definition": "http://hl7.org/fhir/StructureDefinition/RelatedPerson#relationship",
                    "code":  [
                        {
                            "system": "http://snomed.info/sct",
                            "code": "722011000000106",
                            "display": "Relationship (qualifier value)"
                        }
                    ],
                    "prefix": "1.5",
                    "text": "Relationship",
                    "type": "choice",
                    "required": true,
                    "repeats": false,
                    "readOnly": false,
                    "answerOption":  [
                        {
                            "valueCoding": {
                                "system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
                                "code": "PRN",
                                "display": "Parent"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
                                "code": "CHILD",
                                "display": "Child"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
                                "code": "SPS",
                                "display": "Partner, wife or husband"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
                                "code": "FAMMEMB",
                                "display": "Other family member"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
                                "code": "FRND",
                                "display": "Friend, neighbour or housemate"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "http://terminology.hl7.org/CodeSystem/v3-RoleClass",
                                "code": "CAREGIVER",
                                "display": "Paid carer or support worker"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
                                "code": "SIGOTHR",
                                "display": "Other"
                            }
                        }
                    ]
                },
                {
                    "linkId": "9759901615580",
                    "prefix": "1.6",
                    "text": "Relationship - Further information",
                    "type": "string",
                    "required": false,
                    "repeats": false,
                    "readOnly": false,
                    "maxLength": 2000
                }
            ]
        },
        {
            "linkId": "parentalApplicationSupplementaryDetails",
            "prefix": "2",
            "text": "Parental Application Supplementary Details",
            "type": "group",
            "required": false,
            "readOnly": false,
            "item":  [
                {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
                            "valueCodeableConcept": {
                                "coding":  [
                                    {
                                        "system": "http://hl7.org/fhir/questionnaire-item-control",
                                        "code": "radio-button",
                                        "display": "Radio Button"
                                    }
                                ]
                            }
                        }
                    ],
                    "linkId": "parentalApplicationSupplementaryDetails_evidenceOfResponsibility",
                    "prefix": "2.1",
                    "text": "Evidence of parental responsibility",
                    "type": "choice",
                    "required": true,
                    "repeats": false,
                    "readOnly": false,
                    "answerOption":  [
                        {
                            "valueCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
                                "code": "BRTH",
                                "display": "Birth certificate"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
                                "code": "ADPT",
                                "display": "Adoption certificate"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
                                "code": "PRNA",
                                "display": "Court-witnessed parental responsibility agreement"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
                                "code": "SPRNA",
                                "display": "Court-witnessed step-parent parental responsibility agreement"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
                                "code": "PORD",
                                "display": "Parental order"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
                                "code": "SGORD",
                                "display": "Special guardianship order"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
                                "code": "OTHCOURT",
                                "display": "Other court order"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
                                "code": "OTHR",
                                "display": "Other"
                            }
                        }
                    ]
                },
                {
                    "linkId": "parentalApplicationSupplementaryDetails_evidenceOfResponsibilityMoreinfo",
                    "prefix": "2.2",
                    "text": "Evidence of responsibility - Further Information",
                    "type": "string",
                    "enableWhen":  [
                        {
                            "question": "parentalApplicationSupplementaryDetails_evidenceOfResponsibility",
                            "operator": "=",
                            "answerCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-EvidenceOfResponsibility",
                                "code": "OTHR",
                                "display": "Other"
                            }
                        }
                    ],
                    "enableBehavior": "all",
                    "required": false,
                    "repeats": false,
                    "readOnly": false,
                    "maxLength": 2000
                },
                {
                    "linkId": "parentalApplicationSupplementaryDetails_isCurrentAddressConfirmed",
                    "prefix": "2.3",
                    "text": "Is current address confirmed?",
                    "type": "boolean",
                    "required": true,
                    "repeats": false,
                    "readOnly": false
                },
                {
                    "linkId": "parentalApplicationSupplementaryDetails_newAddress",
                    "prefix": "2.4",
                    "text": "New address",
                    "type": "group",
                    "required": false,
                    "repeats": false,
                    "readOnly": false,
                    "item":  [
                        {
                            "linkId": "parentalApplicationSupplementaryDetails_line1",
                            "definition": "http://hl7.org/fhir/datatypes-definitions.html#Address.line",
                            "prefix": "2.4.1",
                            "text": "Address line 1",
                            "type": "string",
                            "required": false,
                            "readOnly": false
                        },
                        {
                            "linkId": "parentalApplicationSupplementaryDetails_line2",
                            "definition": "http://hl7.org/fhir/datatypes-definitions.html#Address.line",
                            "prefix": "2.4.2",
                            "text": "Address line 2",
                            "type": "string",
                            "required": false,
                            "readOnly": false
                        },
                        {
                            "linkId": "parentalApplicationSupplementaryDetails_line3",
                            "definition": "http://hl7.org/fhir/datatypes-definitions.html#Address.line",
                            "prefix": "2.4.3",
                            "text": "Address line 3",
                            "type": "string",
                            "required": false,
                            "readOnly": false
                        },
                        {
                            "linkId": "parentalApplicationSupplementaryDetails_city",
                            "definition": "http://hl7.org/fhir/datatypes-definitions.html#Address.city",
                            "prefix": "2.4.4",
                            "text": "Town / City",
                            "type": "string",
                            "required": false,
                            "readOnly": false
                        },
                        {
                            "linkId": "parentalApplicationSupplementaryDetails_district",
                            "definition": "http://hl7.org/fhir/datatypes-definitions.html#Address.district",
                            "prefix": "2.4.5",
                            "text": "County",
                            "type": "string",
                            "required": false,
                            "readOnly": false
                        },
                        {
                            "linkId": "parentalApplicationSupplementaryDetails_postalCode",
                            "definition": "http://hl7.org/fhir/datatypes-definitions.html#Address.postalCode",
                            "prefix": "2.4.6",
                            "text": "Postcode",
                            "type": "string",
                            "required": false,
                            "readOnly": false
                        }
                    ]
                },
                {
                    "linkId": "parentalApplicationSupplementaryDetails_liveAtSameAddress",
                    "prefix": "2.5",
                    "text": "Do adult and child live at the same address?",
                    "type": "boolean",
                    "required": true,
                    "repeats": false,
                    "readOnly": false
                },
                {
                    "linkId": "parentalApplicationSupplementaryDetails_canChildConsent",
                    "prefix": "2.6",
                    "text": "Can the child consent?",
                    "type": "boolean",
                    "required": false,
                    "repeats": false,
                    "readOnly": false
                },
                {
                    "linkId": "parentalApplicationSupplementaryDetails_reasonNoChildConsent",
                    "prefix": "2.7",
                    "text": "Reason the child cannot consent?",
                    "type": "string",
                    "enableWhen":  [
                        {
                            "question": "parentalApplicationSupplementaryDetails_canChildConsent",
                            "operator": "=",
                            "answerBoolean": false
                        }
                    ],
                    "enableBehavior": "all",
                    "required": false,
                    "repeats": false,
                    "readOnly": false
                }
            ]
        },
        {
            "linkId": "patient",
            "prefix": "3",
            "text": "Patient details",
            "type": "group",
            "required": true,
            "item":  [
                {
                    "linkId": "patient_identifier",
                    "definition": "http://hl7.org/fhir/StructureDefinition/Patient#identifier",
                    "prefix": "3.1",
                    "text": "NHS number",
                    "type": "string",
                    "required": true,
                    "repeats": false,
                    "readOnly": false,
                    "maxLength": 10
                },
                {
                    "linkId": "patient_name",
                    "definition": "http://hl7.org/fhir/StructureDefinition/Patient#name",
                    "prefix": "3.2",
                    "text": "Name",
                    "type": "group",
                    "required": false,
                    "item":  [
                        {
                            "linkId": "patient_name_first",
                            "definition": "http://hl7.org/fhir/StructureDefinition/Patient#name.given",
                            "prefix": "3.2.1",
                            "text": "First name",
                            "type": "string",
                            "required": true,
                            "repeats": false,
                            "readOnly": false
                        },
                        {
                            "linkId": "patient_name_family",
                            "definition": "http://hl7.org/fhir/StructureDefinition/Patient#name.family",
                            "prefix": "3.2.2",
                            "text": "Last name",
                            "type": "string",
                            "required": true,
                            "repeats": false,
                            "readOnly": false
                        }
                    ]
                },
                {
                    "linkId": "patient_birthDate",
                    "definition": "http://hl7.org/fhir/StructureDefinition/Patient#birthDate",
                    "prefix": "3.3",
                    "text": "Date of birth",
                    "type": "date",
                    "required": false,
                    "repeats": false,
                    "readOnly": false
                }
            ]
        },
        {
            "linkId": "requestedAccess",
            "prefix": "4",
            "text": "Requested access",
            "type": "group",
            "required": true,
            "item":  [
                {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
                            "valueCodeableConcept": {
                                "coding":  [
                                    {
                                        "system": "http://hl7.org/fhir/questionnaire-item-control",
                                        "code": "check-box",
                                        "display": "Check-box"
                                    }
                                ]
                            }
                        }
                    ],
                    "linkId": "requestedAccess_accessLevel",
                    "prefix": "4.1",
                    "text": "Requested access level",
                    "type": "choice",
                    "required": true,
                    "repeats": true,
                    "readOnly": false,
                    "answerOption":  [
                        {
                            "valueCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess",
                                "code": "APPT",
                                "display": "Appointment Booking"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess",
                                "code": "CNTCT",
                                "display": "Contacting Surgery"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess",
                                "code": "RECRD",
                                "display": "Medical Records Access"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess",
                                "code": "TEST",
                                "display": "Test Results"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess",
                                "code": "VACC",
                                "display": "Vaccination Records"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess",
                                "code": "PRESCR",
                                "display": "Request and manage repeat prescriptions"
                            }
                        }
                    ]
                },
                {
                    "linkId": "requestedAccess_accessLevelMoreinfo",
                    "prefix": "4.2",
                    "text": "Requested access level - further information",
                    "type": "string",
                    "enableWhen":  [
                        {
                            "question": "requestedAccess_accessLevel",
                            "operator": "=",
                            "answerCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-RequestedAccess",
                                "code": "RECRD",
                                "display": "Medical Records Access"
                            }
                        }
                    ],
                    "enableBehavior": "all",
                    "required": false,
                    "repeats": false,
                    "readOnly": false,
                    "maxLength": 2000
                },
                {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl",
                            "valueCodeableConcept": {
                                "coding":  [
                                    {
                                        "system": "http://hl7.org/fhir/questionnaire-item-control",
                                        "code": "check-box",
                                        "display": "Check-box"
                                    }
                                ]
                            }
                        }
                    ],
                    "linkId": "requestedAccess_reasonsForAccess",
                    "prefix": "4.3",
                    "text": "Reason for access",
                    "type": "choice",
                    "required": false,
                    "repeats": true,
                    "readOnly": false,
                    "answerOption":  [
                        {
                            "valueCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
                                "code": "COMB",
                                "display": "Communication Barriers"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
                                "code": "MHEA",
                                "display": "Mental Health Condition"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
                                "code": "PHYS",
                                "display": "Physical Condition"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
                                "code": "PRAC",
                                "display": "Practical Reasons"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
                                "code": "TECH",
                                "display": "Technical Barriers"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
                                "code": "NEUR",
                                "display": "Neurodiverse"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
                                "code": "LRN",
                                "display": "Learning Disability"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
                                "code": "OTHR",
                                "display": "Other"
                            }
                        },
                        {
                            "valueCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
                                "code": "NotSpecified",
                                "display": "Prefer not to say"
                            }
                        }
                    ]
                },
                {
                    "linkId": "requestedAccess_reasonsForAccessMoreinfo",
                    "prefix": "4.4",
                    "text": "Reason for access - further information",
                    "type": "string",
                    "enableWhen":  [
                        {
                            "question": "requestedAccess_reasonsForAccess",
                            "operator": "=",
                            "answerCoding": {
                                "system": "https://fhir.nhs.uk/CodeSystem/Proxy-Placeholder-ReasonForAccess",
                                "code": "OTHR",
                                "display": "Other"
                            }
                        }
                    ],
                    "enableBehavior": "all",
                    "required": false,
                    "repeats": false,
                    "readOnly": false,
                    "maxLength": 2000
                }
            ]
        }
    ]
}