Women for FHIR

Heavy Menstrual Bleeding Implementation Guide
0.1.0 - Draft

Please note, this guide is currently under development and subject to change.

Specialist Referral Form

Questionnaire

To view a rendered version of this form with the FHIR Questionnaire Viewer by LHC-Forms:
Open the Questionnaire in the Simplifier project, click on Tools (top right), and select Open with LHC-Forms – R4 Questionnaire.

Questionnaire
Questionnaire.id[0]SpecialistReferralQuestionnaire
Questionnaire.meta[0].profile[0]http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire
Questionnaire.url[0]https://simplifier.net/guide/hmb-fhir-ig/Questionnaire/specialist-referral-questionnaire
Questionnaire.name[0]SpecialistReferralQuestionnaire
Questionnaire.title[0]Specialist Referral Questionnaire
Questionnaire.status[0]draft
Questionnaire.experimental[0]True
Questionnaire.description[0]FHIR Questionnaire to refer a patient to a specialist
Questionnaire.item[0].linkId[0]1
Questionnaire.item[0].text[0]TBD
Questionnaire.item[0].type[0]group
Questionnaire.item[0].item[0].linkId[0]1.1
Questionnaire.item[0].item[0].text[0]Date
Questionnaire.item[0].item[0].type[0]date
Questionnaire.item[0].item[0].required[0]True
<Questionnaire xmlns="http://hl7.org/fhir">
    <id value="SpecialistReferralQuestionnaire" />
    <meta>
        <profile value="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire" />
    </meta>
    <url value="https://simplifier.net/guide/hmb-fhir-ig/Questionnaire/specialist-referral-questionnaire" />
    <name value="SpecialistReferralQuestionnaire" />
    <title value="Specialist Referral Questionnaire" />
    <status value="draft" />
    <experimental value="true" />
    <description value="FHIR Questionnaire to refer a patient to a specialist" />
    <item>
        <linkId value="1" />
        <text value="TBD" />
        <type value="group" />
        <item>
            <linkId value="1.1" />
            <text value="Date" />
            <type value="date" />
            <required value="true" />
        </item>
    </item>
</Questionnaire>

{
    "resourceType": "Questionnaire",
    "id": "SpecialistReferralQuestionnaire",
    "meta": {
        "profile":  [
            "http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire"
        ]
    },
    "url": "https://simplifier.net/guide/hmb-fhir-ig/Questionnaire/specialist-referral-questionnaire",
    "name": "SpecialistReferralQuestionnaire",
    "title": "Specialist Referral Questionnaire",
    "status": "draft",
    "experimental": true,
    "description": "FHIR Questionnaire to refer a patient to a specialist",
    "item":  [
        {
            "linkId": "1",
            "text": "TBD",
            "type": "group",
            "item":  [
                {
                    "linkId": "1.1",
                    "text": "Date",
                    "type": "date",
                    "required": true
                }
            ]
        }
    ]
}

QuestionnaireResponse

QuestionnaireResponse
QuestionnaireResponse.id[0]SpecialistReferralQuestionnaireResponseEmmaClark
QuestionnaireResponse.questionnaire[0]https://simplifier.net/guide/hmb-fhir-ig/Questionnaire/specialist-referral-questionnaire
QuestionnaireResponse.status[0]in-progress
QuestionnaireResponse.item[0].linkId[0]1
QuestionnaireResponse.item[0].text[0]TBD
QuestionnaireResponse.item[0].item[0].linkId[0]1.1
QuestionnaireResponse.item[0].item[0].text[0]Date
QuestionnaireResponse.item[0].item[0].answer[0].value[0]2025-05-29
<QuestionnaireResponse xmlns="http://hl7.org/fhir">
    <id value="SpecialistReferralQuestionnaireResponseEmmaClark" />
    <questionnaire value="https://simplifier.net/guide/hmb-fhir-ig/Questionnaire/specialist-referral-questionnaire" />
    <status value="in-progress" />
    <item>
        <linkId value="1" />
        <text value="TBD" />
        <item>
            <linkId value="1.1" />
            <text value="Date" />
            <answer>
                <valueDate value="2025-05-29" />
            </answer>
        </item>
    </item>
</QuestionnaireResponse>

{
    "resourceType": "QuestionnaireResponse",
    "id": "SpecialistReferralQuestionnaireResponseEmmaClark",
    "questionnaire": "https://simplifier.net/guide/hmb-fhir-ig/Questionnaire/specialist-referral-questionnaire",
    "status": "in-progress",
    "item":  [
        {
            "linkId": "1",
            "text": "TBD",
            "item":  [
                {
                    "linkId": "1.1",
                    "text": "Date",
                    "answer":  [
                        {
                            "valueDate": "2025-05-29"
                        }
                    ]
                }
            ]
        }
    ]
}