{% for currentItem in QuestionnaireResponse.item.where((linkId = '102173268919') or (linkId = 'patient_header') or (linkId = 'additionalinfo_header') or (linkId = 'cpp_header') or (linkId = 'preferredconsultlocation_header') or (linkId = 'supportingdocumentation_header') or (linkId = 'supportingdocumentation_attachment' and answer.exists()) or (linkId = 'referrer_header')) %}{% if currentItem.linkId = '102173268919' %}
Referral Details
{% for currentItem in currentItem.item.where((linkId = 'cardio_triagecons') or (linkId = '695991571585') or (linkId = '186952778859') or (linkId = 'Descriptionofclinicalquestion' and answer.exists())) %}{% if currentItem.linkId = 'cardio_triagecons' %}Triage Considerations {% for currentItem in currentItem.item.where((linkId = 'referral_requestedpriority' and answer.exists()) or (linkId = 'referral_secondopinion' and answer.exists()) or (linkId = 'referral_secondopinion_reason' and answer.exists())) %}{% if currentItem.linkId = 'referral_requestedpriority' %}{% if currentItem.answer.exists() %}Requested Priority:
{% for answer in currentItem.answer %}{% if answer.value.code = 'routine' %}Routine
{% endif %}{% if answer.value.code = 'urgent' %}Urgent{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'referral_secondopinion' %}{% if currentItem.answer.exists() %}Second Opinion {% for answer in currentItem.answer %}{% if answer.value.code = '77406008' %}Second or third medical opinion{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'referral_secondopinion_reason' %}{% if currentItem.answer.exists() %}Reason for second opinion: {% for answer in currentItem.answer %}{{ answer.value }}{% endfor %}{% endif %}{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}
{% else %}
{% endif %}{% endif %}{% endfor %}{% endif %}{% if currentItem.linkId = '695991571585' %}Service(s) Requested {% for currentItem in currentItem.item.where((linkId = 'referralService' and answer.exists()) or (linkId = '223886162384' and answer.exists()) or (linkId = '660331267409') or (linkId = '785727177547' and answer.exists())) %}{% if currentItem.linkId = 'referralService' %}{% if currentItem.answer.exists() %}HSCs Assigned: {% for answer in currentItem.answer %}{{ answer.value.ofType(string) }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '223886162384' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20001' %}Cardiac Testing{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '660331267409' %}Exam(s) Requested


{% for currentItem in currentItem.item.where((linkId = '720409326878' and answer.exists()) or (linkId = '960455115596' and answer.exists()) or (linkId = '297634898828' and answer.exists()) or (linkId = '443484577720') or (linkId = '894277763438' and answer.exists()) or (linkId = '279226023495' and answer.exists()) or (linkId = '440449731882') or (linkId = '374742834400' and answer.exists()) or (linkId = '159161544747' and answer.exists()) or (linkId = '370275060390') or (linkId = '918517139023' and answer.exists()) or (linkId = '222686221935') or (linkId = '992682216482' and answer.exists()) or (linkId = 'cardiology_referral_services_cardiactesting_other' and answer.exists()) or (linkId = 'cardiology_referral_services_cardiactesting_other_specify' and answer.exists())) %}{% if currentItem.linkId = '720409326878' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20003' %}24 Hour Ambulatory Blood Pressure Monitoring (Not OHIP Covered){% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '960455115596' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20004' %}Coronary Angiogram{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '297634898828' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20005' %}Echocardiogram - Resting{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '443484577720' %}

{% for currentItem in currentItem.item.where((linkId = '165530569567' and answer.exists()) or (linkId = '286552421895' and answer.exists()) or (linkId = '910527687300' and answer.exists()) or (linkId = '657824763133' and answer.exists()) or (linkId = '992743200182' and answer.exists())) %}{% if currentItem.linkId = '165530569567' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20012' %}Echocardiogram (2D){% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '286552421895' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20013' %}Echocardiogram with Contrast{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '910527687300' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20014' %}Echocardiogram with Saline (Bubble){% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '657824763133' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20015' %}Pediatric Echocardiogram{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '992743200182' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20016' %}Transesophageal Echocardiogram (TEE){% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}
{% else %}
{% endif %}{% endif %}{% endfor %}{% endif %}{% if currentItem.linkId = '894277763438' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20006' %}Electrocardiogram (ECG){% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '279226023495' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20007' %}Holter Monitoring{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '440449731882' %}

{% for currentItem in currentItem.item.where((linkId = '671328703851' and answer.exists()) or (linkId = '423992261841' and answer.exists()) or (linkId = '419924239187' and answer.exists()) or (linkId = '731054417270' and answer.exists()) or (linkId = '235876421044' and answer.exists())) %}{% if currentItem.linkId = '671328703851' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20017' %}24 Hours{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '423992261841' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20018' %}48 Hours{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '419924239187' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20019' %}72 Hours{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '731054417270' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20020' %}7 Days{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '235876421044' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20021' %}14 Days{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}
{% else %}
{% endif %}{% endif %}{% endfor %}{% endif %}{% if currentItem.linkId = '374742834400' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20008' %}Loop / Event Monitor{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '159161544747' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20009' %}Stress Testing{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '370275060390' %}

{% for currentItem in currentItem.item.where((linkId = '814218498309' and answer.exists()) or (linkId = '307107493993' and answer.exists()) or (linkId = '805303414102' and answer.exists()) or (linkId = '193586908489' and answer.exists())) %}{% if currentItem.linkId = '814218498309' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20022' %}ECG - Exercise Stress Test{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '307107493993' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20023' %}ECG - Dobutamine/Persantine Stress Test{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '805303414102' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20024' %}Echocardiogram - Exercise Stress Test{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '193586908489' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20025' %}Echocardiogram - Dobutamine/Persantine Stress Test{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}
{% else %}
{% endif %}{% endif %}{% endfor %}{% endif %}{% if currentItem.linkId = '918517139023' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20010' %}Nuclear Medicine{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '222686221935' %}

{% for currentItem in currentItem.item.where((linkId = '924189648184' and answer.exists()) or (linkId = '857163514910' and answer.exists()) or (linkId = '892165959617' and answer.exists()) or (linkId = '538288549138')) %}{% if currentItem.linkId = '924189648184' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20026' %}MUGA - Resting{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '857163514910' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20027' %}Cardiac Pyrophosphate{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '892165959617' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20028' %}MIBI Scans / Myocardial Perfusion Imaging (MPI):{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '538288549138' %}

{% for currentItem in currentItem.item.where((linkId = '373435981917' and answer.exists()) or (linkId = '434394942688' and answer.exists()) or (linkId = '913594478162' and answer.exists())) %}{% if currentItem.linkId = '373435981917' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value = 'MIBI Scan - Exercise Stress Test' %}MIBI Scan - Exercise Stress Test{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '434394942688' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value = 'MIBI Scan - Dobutamine/Persantine Stress Test' %}MIBI Scan - Dobutamine/Persantine Stress Test{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '913594478162' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value = 'Thallium Viability Test' %}Thallium Viability Test{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}
{% else %}
{% endif %}{% endif %}{% endfor %}{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}
{% else %}
{% endif %}{% endif %}{% endfor %}{% endif %}{% if currentItem.linkId = '992682216482' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20011' %}Tilt Table Testing{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'cardiology_referral_services_cardiactesting_other' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = 'OTH' %}other{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'cardiology_referral_services_cardiactesting_other_specify' %}{% if currentItem.answer.exists() %}Specify {% for answer in currentItem.answer %}{{ answer.value }}{% endfor %}{% endif %}{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}
{% else %}
{% endif %}{% endif %}{% endfor %}{% endif %}{% if currentItem.linkId = '785727177547' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20002' %}Cardiology Consultation{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}
{% else %}
{% endif %}{% endif %}{% endfor %}{% endif %}{% if currentItem.linkId = '186952778859' %}Concern(s) / Indication(s) Triggering Referral
Select all that apply:

{% for currentItem in currentItem.item.where((linkId = '219569805461' and answer.exists()) or (linkId = '571934328499' and answer.exists()) or (linkId = '459737733395' and answer.exists()) or (linkId = '929919815516' and answer.exists()) or (linkId = '832263816528' and answer.exists()) or (linkId = '803760213460' and answer.exists()) or (linkId = '129767162379' and answer.exists()) or (linkId = '116150628533' and answer.exists()) or (linkId = '513825527027' and answer.exists()) or (linkId = '975075898688' and answer.exists()) or (linkId = '704148928571' and answer.exists()) or (linkId = '886489617115' and answer.exists()) or (linkId = '621745958993' and answer.exists()) or (linkId = '873024527134' and answer.exists()) or (linkId = '197975129599' and answer.exists()) or (linkId = '675849150752' and answer.exists()) or (linkId = '721982740516' and answer.exists()) or (linkId = '720594942482' and answer.exists())) %}{% if currentItem.linkId = '219569805461' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '698247007' %}Arrhythmias or Palpitations{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '571934328499' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20033' %}Cardiovascular Risk Assessment{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '459737733395' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20034' %}Chest Pain or Angina{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '929919815516' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20035' %}Congenital Heart Disease{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '832263816528' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20036' %}Congestive Heart Failure{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '803760213460' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20037' %}Coronary Artery Disease{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '129767162379' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20038' %}Dyspnea{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '116150628533' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20039' %}Hypertension{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '513825527027' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20040' %}Murmur{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '975075898688' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20041' %}Pericardial Disease{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '704148928571' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20042' %}Peripheral Edema{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '886489617115' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20043' %}Post-Myocardial Infarction{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '621745958993' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20044' %}Pre-operative Consultation{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '873024527134' %}{% if currentItem.answer.exists() %}Procedure Date (if known) {% for answer in currentItem.answer %}{{ answer.value.ofType(date) }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '197975129599' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '20045' %}Syncope{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '675849150752' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '368009' %}Valvular Heart Disease or Prosthetic Heart Valve{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '721982740516' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = 'OTH' %}other{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = '720594942482' %}{% if currentItem.answer.exists() %}Specify {% for answer in currentItem.answer %}{{ answer.value }}{% endfor %}{% endif %}{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}
{% else %}
{% endif %}{% endif %}{% endfor %}{% endif %}{% if currentItem.linkId = 'Descriptionofclinicalquestion' %}{% if currentItem.answer.exists() %}Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations
{% for answer in currentItem.answer %}{{ answer.value }}{% endfor %}{% endif %}{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}
{% else %}
{% endif %}{% endif %}{% endfor %}{% endif %}{% if currentItem.linkId = 'patient_header' %}Patient Information
{% for currentItem in currentItem.item.where((linkId = 'patient_surname' and answer.exists()) or (linkId = 'patient_firstname' and answer.exists()) or (linkId = 'patient_date_of_birth' and answer.exists()) or (linkId = 'patient_gender' and answer.exists()) or (linkId = 'patient_hc_pc' and answer.exists()) or (linkId = 'patient_address_line1' and answer.exists()) or (linkId = 'patient_phone_mobile' and answer.exists()) or (linkId = 'patient_phone_home' and answer.exists()) or (linkId = 'patient_phone_business' and answer.exists()) or (linkId = 'patient_email' and answer.exists())) %}{% if currentItem.linkId = 'patient_surname' %}{% if currentItem.answer.exists() %}Surname: {% for answer in currentItem.answer %}{{ answer.value.ofType(string) }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'patient_firstname' %}{% if currentItem.answer.exists() %}First Name: {% for answer in currentItem.answer %}{{ answer.value.ofType(string) }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'patient_date_of_birth' %}{% if currentItem.answer.exists() %}DOB: {% for answer in currentItem.answer %}{{ answer.value.ofType(date) }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'patient_gender' %}{% if currentItem.answer.exists() %}Gender: {% for answer in currentItem.answer %}{% if answer.value.code = 'male' %}Male{% endif %}{% if answer.value.code = 'female' %}Female{% endif %}{% if answer.value.code = 'other' %}Other{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'patient_hc_pc' %}{% if currentItem.answer.exists() %}HN PC: {% for answer in currentItem.answer %}{{ answer.value.ofType(string) }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'patient_address_line1' %}{% if currentItem.answer.exists() %}Address (Line 1): {% for answer in currentItem.answer %}{{ answer.value.ofType(string) }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'patient_phone_mobile' %}{% if currentItem.answer.exists() %}Mobile #: {% for answer in currentItem.answer %}{{ answer.value.ofType(string) }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'patient_phone_home' %}{% if currentItem.answer.exists() %}Home #: {% for answer in currentItem.answer %}{{ answer.value.ofType(string) }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'patient_phone_business' %}{% if currentItem.answer.exists() %}Business #: {% for answer in currentItem.answer %}{{ answer.value.ofType(string) }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'patient_email' %}{% if currentItem.answer.exists() %}Email: {% for answer in currentItem.answer %}{{ answer.value.ofType(string) }}{% endfor %}{% endif %}{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}
{% else %}
{% endif %}{% endif %}{% endfor %}{% endif %}{% if currentItem.linkId = 'additionalinfo_header' %}[Optional] Additional Patient Information

{% for currentItem in currentItem.item.where((linkId = 'additionalinfo_sexassignedatbirth' and answer.exists()) or (linkId = 'additionalinfo_pronouns' and answer.exists()) or (linkId = 'additionalinfo_preferredlanguage' and answer.exists()) or (linkId = 'additionalinfo_bestmethodofcontact' and answer.exists()) or (linkId = 'additionalinfo_preferredname_select' and answer.exists()) or (linkId = 'additionalinfo_preferredname' and answer.exists()) or (linkId = 'additionalinfo_alternatecontact_select' and answer.exists()) or (linkId = 'additionalinfo_alternatecontact_name' and answer.exists()) or (linkId = 'additionalinfo_alternatecontact_phone' and answer.exists()) or (linkId = 'additionalinfo_alternatecontact_relationship' and answer.exists()) or (linkId = 'additionalinfo_alternatecontact_bookingcontact' and answer.exists()) or (linkId = 'additionalinfo_unsafecontacts_select' and answer.exists()) or (linkId = 'additionalinfo_unsafecontacts_speakwithpatientdirectly' and answer.exists()) or (linkId = 'additionalinfo_unsafecontacts_donotspeakwith' and answer.exists()) or (linkId = 'additionalinfo_accessibilityconcernsordisability_selectt' and answer.exists()) or (linkId = 'additionalinfo_accessibilityconcernsordisability' and answer.exists()) or (linkId = 'additionalinfo_specialconsiderations_select' and answer.exists()) or (linkId = 'additionalinfo_specialconsiderations' and answer.exists()) or (linkId = 'additionalinfo_sendcopiestoadditionalproviders' and answer.exists()) or (linkId = 'additionalinfo_sendcopiestoadditionalproviders_names' and answer.exists())) %}{% if currentItem.linkId = 'additionalinfo_sexassignedatbirth' %}{% if currentItem.answer.exists() %}Sex assigned at birth: {% for answer in currentItem.answer %}{% if answer.value.code = 'LA3-6' %}Female{% endif %}{% if answer.value.code = 'LA2-8' %}Male{% endif %}{% if answer.value.code = 'Intersex' %}Intersex{% endif %}{% if answer.value.code = 'LA4489-6' %}Unknown{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'additionalinfo_pronouns' %}{% if currentItem.answer.exists() %}Pronouns: {% for answer in currentItem.answer %}{% if answer.value.code = 'LA29519-8' %}She/Her{% endif %}{% if answer.value.code = 'LA29518-0' %}He/Him{% endif %}{% if answer.value.code = 'LA29519-8' %}They/Them{% endif %}{% if answer.value.code = 'OTH' %}other{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'additionalinfo_preferredlanguage' %}{% if currentItem.answer.exists() %}Preferred language: {% for answer in currentItem.answer %}{% if answer.value.code = 'en' %}English{% endif %}{% if answer.value.code = 'fr' %}French{% endif %}{% if answer.value.code = 'OTH' %}other{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'additionalinfo_bestmethodofcontact' %}{% if currentItem.answer.exists() %}Best method of contact: {% for answer in currentItem.answer %}{% if answer.value.code = 'mobile' %}Mobile{% endif %}{% if answer.value.code = 'home' %}Home{% endif %}{% if answer.value.code = 'work' %}Work{% endif %}{% if answer.value.code = 'email' %}Email{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'additionalinfo_preferredname_select' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value = 'Preferred Name' %}Preferred Name{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'additionalinfo_preferredname' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{{ answer.value.ofType(string) }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'additionalinfo_alternatecontact_select' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value = 'Alternate contact' %}Alternate contact{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'additionalinfo_alternatecontact_name' %}{% if currentItem.answer.exists() %}Name: {% for answer in currentItem.answer %}{{ answer.value.ofType(string) }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'additionalinfo_alternatecontact_phone' %}{% if currentItem.answer.exists() %}Alternate contact phone #: {% for answer in currentItem.answer %}{{ answer.value.ofType(string) }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'additionalinfo_alternatecontact_relationship' %}{% if currentItem.answer.exists() %}Relationship: {% for answer in currentItem.answer %}{{ answer.value.ofType(string) }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'additionalinfo_alternatecontact_bookingcontact' %}{% if currentItem.answer.exists() %}Is Alternate contact the appointment booking contact?: {% for answer in currentItem.answer %}{% if answer.value.code = 'Y' %}Yes{% endif %}{% if answer.value.code = 'N' %}No{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'additionalinfo_unsafecontacts_select' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value = 'Unsafe contact persons (do not speak with)' %}Unsafe contact persons (do not speak with){% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'additionalinfo_unsafecontacts_speakwithpatientdirectly' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value = 'Only speak with patient directly' %}Only speak with patient directly{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'additionalinfo_unsafecontacts_donotspeakwith' %}{% if currentItem.answer.exists() %}Do not speak with: {% for answer in currentItem.answer %}{{ answer.value.ofType(string) }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'additionalinfo_accessibilityconcernsordisability_selectt' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value = 'Accessibility concerns or disability' %}Accessibility concerns or disability{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'additionalinfo_accessibilityconcernsordisability' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value.code = '129839007' %}Falls risk{% endif %}{% if answer.value.code = '301621006' %}Patient requires lift{% endif %}{% if answer.value.code = '105503008' %}Wheelchair{% endif %}{% if answer.value.code = '15188001' %}Hearing impaired{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'additionalinfo_specialconsiderations_select' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value = 'Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)' %}Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues){% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'additionalinfo_specialconsiderations' %}{% if currentItem.answer.exists() %}Details of special considerations: {% for answer in currentItem.answer %}{{ answer.value }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'additionalinfo_sendcopiestoadditionalproviders' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value = 'Send copies of reports to additional providers' %}Send copies of reports to additional providers{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'additionalinfo_sendcopiestoadditionalproviders_names' %}{% if currentItem.answer.exists() %}Name(s): {% for answer in currentItem.answer %}{{ answer.value.ofType(string) }}{% endfor %}{% endif %}{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}
{% else %}
{% endif %}{% endif %}{% endfor %}{% endif %}{% if currentItem.linkId = 'cpp_header' %}Cumulative Patient Profile

Please delete any sensitive information you do not intend to share from the CPP
{% for currentItem in currentItem.item.where((linkId = 'cpp_separate' and answer.exists()) or (linkId = 'cpp_currentprob' and answer.exists()) or (linkId = 'cpp_pastmedicalhistory' and answer.exists()) or (linkId = 'cpp_currentmedications' and answer.exists()) or (linkId = 'cpp_familyhistory' and answer.exists()) or (linkId = 'cpp_allergies' and answer.exists())) %}{% if currentItem.linkId = 'cpp_separate' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value = 'CPP attached separately (if not entered below)' %}CPP attached separately (if not entered below){% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'cpp_currentprob' %}{% if currentItem.answer.exists() %}Current Problem List: {% for answer in currentItem.answer %}{{ answer.value }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'cpp_pastmedicalhistory' %}{% if currentItem.answer.exists() %}Past Medical History: {% for answer in currentItem.answer %}{{ answer.value }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'cpp_currentmedications' %}{% if currentItem.answer.exists() %}Current Medications : {% for answer in currentItem.answer %}{{ answer.value }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'cpp_familyhistory' %}{% if currentItem.answer.exists() %}Family History: {% for answer in currentItem.answer %}{{ answer.value }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'cpp_allergies' %}{% if currentItem.answer.exists() %}Allergies: {% for answer in currentItem.answer %}{{ answer.value }}{% endfor %}{% endif %}{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}
{% else %}
{% endif %}{% endif %}{% endfor %}{% endif %}{% if currentItem.linkId = 'preferredconsultlocation_header' %}Preferred Consultant or Location

All patients will be triaged to the shortest wait time unless a preferred consultant or location is entered.
{% for currentItem in currentItem.item.where((linkId = 'preferredconsultlocation_selector' and answer.exists()) or (linkId = 'preferredconsultlocation_specify') or (linkId = 'preferredconsultlocation_willingtotravel' and answer.exists()) or (linkId = 'preferredconsultlocation_otherconsiderations' and answer.exists())) %}{% if currentItem.linkId = 'preferredconsultlocation_selector' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value = 'Preferred consultant or location' %}Preferred consultant or location{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'preferredconsultlocation_specify' %}Please specify either a preferred consultant or location
{% for currentItem in currentItem.item.where((linkId = 'preferredconsultlocation_consultant' and answer.exists()) or (linkId = 'preferredconsultlocation_location' and answer.exists())) %}{% if currentItem.linkId = 'preferredconsultlocation_consultant' %}{% if currentItem.answer.exists() %}Consultant: {% for answer in currentItem.answer %}{{ answer.value.ofType(string) }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'preferredconsultlocation_location' %}{% if currentItem.answer.exists() %}Location: {% for answer in currentItem.answer %}{{ answer.value.ofType(string) }}{% endfor %}{% endif %}{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}
{% else %}
{% endif %}{% endif %}{% endfor %}{% endif %}{% if currentItem.linkId = 'preferredconsultlocation_willingtotravel' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value = 'Patient willing to travel for shorter wait time' %}Patient willing to travel for shorter wait time{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'preferredconsultlocation_otherconsiderations' %}{% if currentItem.answer.exists() %}Other considerations: {% for answer in currentItem.answer %}{{ answer.value.ofType(string) }}{% endfor %}{% endif %}{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}
{% else %}
{% endif %}{% endif %}{% endfor %}{% endif %}{% if currentItem.linkId = 'supportingdocumentation_header' %}Supporting Documentation
Please attach all relevant laboratory and diagnostic investigations.

{% for currentItem in currentItem.item.where((linkId = 'supportingdocumentation_details' and answer.exists())) %}{% if currentItem.linkId = 'supportingdocumentation_details' %}{% if currentItem.answer.exists() %}
{% for answer in currentItem.answer %}{% if answer.value = 'Personal Health Information that is medically relevant has not been disclosed at the request of the patient.' %}Personal Health Information that is medically relevant has not been disclosed at the request of the patient.{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}; {% else %}; {% endif %}{% endif %}{% endfor %}{% endif %}{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}
{% else %}
{% endif %}{% endif %}{% endfor %}{% endif %}{% if currentItem.linkId = 'supportingdocumentation_attachment' %}{% if currentItem.answer.exists() %}Add Attachments {% for answer in currentItem.answer %}{{ answer.value }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'referrer_header' %}Referrer's Information
{% for currentItem in currentItem.item.where((linkId = 'referrer_sitename' and answer.exists()) or (linkId = 'referrer_address_line1' and answer.exists()) or (linkId = 'referrer_phone' and answer.exists()) or (linkId = 'referrer_fax' and answer.exists()) or (linkId = 'referrer_billing' and answer.exists()) or (linkId = 'referrer_professionalid' and answer.exists()) or (linkId = 'referrer_signature' and answer.exists()) or (linkId = 'referrer_role' and answer.exists())) %}{% if currentItem.linkId = 'referrer_sitename' %}{% if currentItem.answer.exists() %}Site Name: {% for answer in currentItem.answer %}{{ answer.value.ofType(string) }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'referrer_address_line1' %}{% if currentItem.answer.exists() %}Address (Line 1): {% for answer in currentItem.answer %}{{ answer.value.ofType(string) }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'referrer_phone' %}{% if currentItem.answer.exists() %}Phone #: {% for answer in currentItem.answer %}{{ answer.value.ofType(string) }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'referrer_fax' %}{% if currentItem.answer.exists() %}Fax #: {% for answer in currentItem.answer %}{{ answer.value.ofType(string) }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'referrer_billing' %}{% if currentItem.answer.exists() %}Billing Number: {% for answer in currentItem.answer %}{{ answer.value.ofType(integer) }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'referrer_professionalid' %}{% if currentItem.answer.exists() %}Professional ID: {% for answer in currentItem.answer %}{{ answer.value.ofType(integer) }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'referrer_signature' %}{% if currentItem.answer.exists() %}Signed: {% for answer in currentItem.answer %}{{ answer.value }}{% endfor %}{% endif %}{% endif %}{% if currentItem.linkId = 'referrer_role' %}{% if currentItem.answer.exists() %}Role: {% for answer in currentItem.answer %}{% if answer.value.code = '309398001' %}Allied Health Professional{% endif %}{% if answer.value.code = '62247001' %}Family Physician{% endif %}{% if answer.value.code = '449161006' %}Physician Assistant{% endif %}{% if answer.value.code = '398130009' %}Medical Student{% endif %}{% if answer.value.code = '106292003' %}Nurse{% endif %}{% if answer.value.code = '224571005' %}Nurse Practitioner{% endif %}{% if answer.value.code = '405277009' %}Resident{% endif %}{% if answer.value.code = '69280009' %}Specialist{% endif %}{% if answer.value.code = 'OTH' %}other{% endif %}{% endfor %}{% endif %}{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}
{% else %}
{% endif %}{% endif %}{% endfor %}{% endif %}{% if forloop.last.not() %}{% if forloop.nextitem %}
{% else %}
{% endif %}{% endif %}{% endfor %}