{
  "resourceType": "QuestionnaireResponse",
  "id": "CardiologyOHAuthoredQR-JaneDoe",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Patient Information<br/> Surname: Doe<br/>First Name: Jane<br/>DOB: 1953-11-22<br/>Gender: Female<br/>Address (Line 1): 115 Queen St W<br/>Mobile #: 647-555-0291<br/>Email: jane.doe@example.com<br/>[Optional] Additional Patient Information<br/><br/> Sex assigned at birth: Female<br/>Pronouns: She/HerThey/Them<br/>Preferred language: English<br/>Best method of contact: Mobile<br/><br/>Referral Details<br/> Triage Considerations Requested Priority: <br/><span style=\"font-weight:bold;color:#EE6B00;\">Urgent</span><br/>Service(s) Requested <span style=\"display:none;\"><br/></span> Cardiac Testing<br/>Exam(s) Requested<br/><br/><br/> <span style=\"display:none;\"><br/></span> Holter Monitoring<br/><br/><br/> <span style=\"display:none;\"><br/></span> 48 Hours<br/><span style=\"display:none;\"><br/></span> Cardiology Consultation<br/><b>Concern(s) / Indication(s) Triggering Referral</b><br/><i>Select all that apply:</i><br/><br/> <span style=\"display:none;\"><br/></span> Syncope<br/><span style=\"font-weight:bold;\">Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations<br/></span> 72F, two syncopal episodes in past 3 weeks. Witness reports 3-5 sec unresponsiveness, no seizure activity. In-office ECG shows sinus bradycardia 48 bpm. On metoprolol for HTN. Please assess for arrhythmic cause and need for pacemaker evaluation.<br/>Cumulative Patient Profile<br/><br/><i>Please delete any sensitive information you do not intend to share from the CPP</i><br/> Current Problem List: Hypertension\nRecurrent syncope (onset Feb 2026)\nOsteoarthritis, bilateral knees<br/>Past Medical History: Cholecystectomy (2008)\nNo prior cardiac history<br/>Current Medications : Metoprolol 50 mg PO BID\nHydrochlorothiazide 12.5 mg PO daily\nAcetaminophen 500 mg PO PRN<br/>Family History: Non-contributory<br/>Allergies: Penicillin (hives)<br/>Referrer's Information<br/> Site Name: Amplify Primary Care<br/>Address (Line 1): 10248 Yonge St<br/>Phone #: \t416-555-5555<br/>Fax #: \t416-555-5555<br/>Billing Number: 55554<br/>Professional ID: 55555<br/>Signed: Dr. Sean Sender<br/>Role: Family Physician</div>"
  },
  "questionnaire": "urn:uuid:d7176d16-5fd4-48a7-b7e6-b488e8df763d|1.0.0",
  "status": "completed",
  "subject": {
    "reference": "Patient/pat-53234",
    "display": "MOMO ABBAS"
  },
  "authored": "2026-03-12T22:37:03.849Z",
  "author": {
    "reference": "Practitioner/smart-Practitioner-71482713",
    "type": "Practitioner",
    "display": "Susan Clark"
  },
  "item": [
    {
      "linkId": "patient_header",
      "text": "Patient Information",
      "item": [
        {
          "linkId": "patient_surname",
          "text": "Surname:",
          "answer": [
            {
              "valueString": "Doe"
            }
          ]
        },
        {
          "linkId": "patient_firstname",
          "text": "First Name:",
          "answer": [
            {
              "valueString": "Jane"
            }
          ]
        },
        {
          "linkId": "patient_date_of_birth",
          "text": "DOB:",
          "answer": [
            {
              "valueDate": "1953-11-22"
            }
          ]
        },
        {
          "linkId": "patient_gender",
          "text": "Gender:",
          "answer": [
            {
              "valueCoding": {
                "system": "http://hl7.org/fhir/administrative-gender",
                "code": "female",
                "display": "Female"
              }
            }
          ]
        },
        {
          "linkId": "patient_address_line1",
          "text": "Address (Line 1):",
          "answer": [
            {
              "valueString": "115 Queen St W",
              "item": [
                {
                  "linkId": "patient_address_line2",
                  "text": "Address (Line 2):",
                  "answer": [
                    {
                      "valueString": "Apt 804"
                    }
                  ]
                },
                {
                  "linkId": "patient_address_city",
                  "text": "City:",
                  "answer": [
                    {
                      "valueString": "Toronto"
                    }
                  ]
                },
                {
                  "linkId": "patient_address_province",
                  "text": "Province:",
                  "answer": [
                    {
                      "valueString": "ON"
                    }
                  ]
                },
                {
                  "linkId": "patient_address_postalcode",
                  "text": "Postal Code:",
                  "answer": [
                    {
                      "valueString": "M5H 2M5"
                    }
                  ]
                }
              ]
            }
          ]
        },
        {
          "linkId": "patient_phone_mobile",
          "text": "Mobile #:",
          "answer": [
            {
              "valueString": "647-555-0291"
            }
          ]
        },
        {
          "linkId": "patient_email",
          "text": "Email:",
          "answer": [
            {
              "valueString": "jane.doe@example.com"
            }
          ]
        }
      ]
    },
    {
      "linkId": "additionalinfo_header",
      "text": "[Optional] Additional Patient Information",
      "item": [
        {
          "linkId": "additionalinfo_sexassignedatbirth",
          "text": "Sex assigned at birth:",
          "answer": [
            {
              "valueCoding": {
                "system": "http://loinc.org",
                "code": "LA3-6",
                "display": "Female"
              }
            }
          ]
        },
        {
          "linkId": "additionalinfo_pronouns",
          "text": "Pronouns:",
          "answer": [
            {
              "valueCoding": {
                "system": "http://loinc.org",
                "code": "LA29519-8",
                "display": "She/Her"
              }
            }
          ]
        },
        {
          "linkId": "additionalinfo_preferredlanguage",
          "text": "Preferred language:",
          "answer": [
            {
              "valueCoding": {
                "system": "urn:ietf:bcp:47",
                "code": "en",
                "display": "English"
              }
            }
          ]
        },
        {
          "linkId": "additionalinfo_bestmethodofcontact",
          "text": "Best method of contact:",
          "answer": [
            {
              "valueCoding": {
                "system": "http://hl7.org/fhir/contact-point-use",
                "code": "mobile",
                "display": "Mobile"
              },
              "item": [
                {
                  "linkId": "additionalinfo_bestmethodofcontact_voicemails",
                  "text": "Voicemails acceptable",
                  "answer": [
                    {
                      "valueString": " Voicemails acceptable"
                    }
                  ]
                }
              ]
            }
          ]
        }
      ]
    },
    {
      "linkId": "102173268919",
      "text": "Referral Details",
      "item": [
        {
          "linkId": "cardio_triagecons",
          "text": "Triage Considerations",
          "item": [
            {
              "linkId": "referral_requestedpriority",
              "text": "Requested Priority:",
              "answer": [
                {
                  "valueCoding": {
                    "system": "http://hl7.org/fhir/request-priority",
                    "code": "urgent",
                    "display": "Urgent"
                  },
                  "item": [
                    {
                      "linkId": "referral_requestedpriority_urgentreason",
                      "text": "Reason for urgent triage",
                      "answer": [
                        {
                          "valueString": "Recurrent syncope with witnessed pause, fall risk"
                        }
                      ]
                    }
                  ]
                }
              ]
            }
          ]
        },
        {
          "linkId": "695991571585",
          "text": "Service(s) Requested Select all that apply:",
          "item": [
            {
              "linkId": "223886162384",
              "text": "Cardiac Testing",
              "answer": [
                {
                  "valueCoding": {
                    "system": "http://ontariohealth.ca/fhir/ehr/CodeSystem/standardized-referral-form-codes",
                    "code": "20001",
                    "display": "Cardiac Testing"
                  }
                }
              ]
            },
            {
              "linkId": "660331267409",
              "text": "Exam(s) Requested",
              "item": [
                {
                  "linkId": "279226023495",
                  "text": "Holter Monitoring",
                  "answer": [
                    {
                      "valueCoding": {
                        "system": "http://ontariohealth.ca/fhir/ehr/CodeSystem/standardized-referral-form-codes",
                        "code": "20007",
                        "display": "Holter Monitoring"
                      }
                    }
                  ]
                },
                {
                  "linkId": "440449731882",
                  "text": "sub holter monitoring",
                  "item": [
                    {
                      "linkId": "423992261841",
                      "text": "48 Hours",
                      "answer": [
                        {
                          "valueCoding": {
                            "system": "http://ontariohealth.ca/fhir/ehr/CodeSystem/standardized-referral-form-codes",
                            "code": "20018",
                            "display": "48 Hours"
                          }
                        }
                      ]
                    }
                  ]
                }
              ]
            },
            {
              "linkId": "785727177547",
              "text": "Cardiology Consultation",
              "answer": [
                {
                  "valueCoding": {
                    "system": "http://ontariohealth.ca/fhir/ehr/CodeSystem/standardized-referral-form-codes",
                    "code": "20002",
                    "display": "Cardiology Consultation"
                  }
                }
              ]
            }
          ]
        },
        {
          "linkId": "186952778859",
          "text": "Concern(s) / Indication(s) Triggering Referral Select all that apply:",
          "item": [
            {
              "linkId": "197975129599",
              "text": "Syncope",
              "answer": [
                {
                  "valueCoding": {
                    "system": "http://ontariohealth.ca/fhir/ehr/CodeSystem/standardized-referral-form-codes",
                    "code": "20045",
                    "display": "Syncope"
                  }
                }
              ]
            }
          ]
        },
        {
          "linkId": "Descriptionofclinicalquestion",
          "text": "Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations",
          "answer": [
            {
              "valueString": "72F, two syncopal episodes in past 3 weeks. Witness reports 3-5 sec unresponsiveness, no seizure activity. In-office ECG shows sinus bradycardia 48 bpm. On metoprolol for HTN. Please assess for arrhythmic cause and need for pacemaker evaluation."
            }
          ]
        }
      ]
    },
    {
      "linkId": "cpp_header",
      "text": "Cumulative Patient Profile Please delete any sensitive information you do not intend to share from the CPP",
      "item": [
        {
          "linkId": "cpp_currentprob",
          "text": "Current Problem List:",
          "answer": [
            {
              "valueString": "Hypertension\nRecurrent syncope (onset Feb 2026)\nOsteoarthritis, bilateral knees"
            }
          ]
        },
        {
          "linkId": "cpp_pastmedicalhistory",
          "text": "Past Medical History:",
          "answer": [
            {
              "valueString": "Cholecystectomy (2008)\nNo prior cardiac history"
            }
          ]
        },
        {
          "linkId": "cpp_currentmedications",
          "text": "Current Medications :",
          "answer": [
            {
              "valueString": "Metoprolol 50 mg PO BID\nHydrochlorothiazide 12.5 mg PO daily\nAcetaminophen 500 mg PO PRN"
            }
          ]
        },
        {
          "linkId": "cpp_familyhistory",
          "text": "Family History:",
          "answer": [
            {
              "valueString": "Non-contributory"
            }
          ]
        },
        {
          "linkId": "cpp_allergies",
          "text": "Allergies:",
          "answer": [
            {
              "valueString": "Penicillin (hives)"
            }
          ]
        }
      ]
    },
    {
      "linkId": "referrer_header",
      "text": "Referrer's Information",
      "item": [
        {
          "linkId": "referrer_sitename",
          "text": "Site Name:",
          "answer": [
            {
              "valueString": "Amplify Primary Care"
            }
          ]
        },
        {
          "linkId": "referrer_address_line1",
          "text": "Address (Line 1):",
          "answer": [
            {
              "valueString": "10248 Yonge St",
              "item": [
                {
                  "linkId": "referrer_address_line2",
                  "text": "Address (Line 2):",
                  "answer": [
                    {
                      "valueString": "Suite 515"
                    }
                  ]
                },
                {
                  "linkId": "referrer_address_city",
                  "text": "City:",
                  "answer": [
                    {
                      "valueString": "Richmond Hill"
                    }
                  ]
                },
                {
                  "linkId": "referrer_address_province",
                  "text": "Province:",
                  "answer": [
                    {
                      "valueString": "ON"
                    }
                  ]
                },
                {
                  "linkId": "referrer_address_postalcode",
                  "text": "Postal Code:",
                  "answer": [
                    {
                      "valueString": "L4C 5K9"
                    }
                  ]
                }
              ]
            }
          ]
        },
        {
          "linkId": "referrer_phone",
          "text": "Phone #:",
          "answer": [
            {
              "valueString": "\t416-555-5555"
            }
          ]
        },
        {
          "linkId": "referrer_fax",
          "text": "Fax #:",
          "answer": [
            {
              "valueString": "\t416-555-5555"
            }
          ]
        },
        {
          "linkId": "referrer_billing",
          "text": "Billing Number:",
          "answer": [
            {
              "valueInteger": 55554
            }
          ]
        },
        {
          "linkId": "referrer_professionalid",
          "text": "Professional ID:",
          "answer": [
            {
              "valueInteger": 55555
            }
          ]
        },
        {
          "linkId": "referrer_signature",
          "text": "Signed:",
          "answer": [
            {
              "valueString": "Dr. Sean Sender"
            }
          ]
        },
        {
          "linkId": "referrer_role",
          "text": "Role:",
          "answer": [
            {
              "valueCoding": {
                "system": "http://snomed.info/sct",
                "code": "62247001",
                "display": "Family Physician"
              }
            }
          ]
        }
      ]
    }
  ]
}