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<extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="item17146365" /> <text value="ACEi/ARB" /> <type value="boolean" /> </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" /> </coding> </valueCodeableConcept> </extension> <linkId value="item89954867" /> <text value="Statin" /> <type value="boolean" /> </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" /> </coding> </valueCodeableConcept> </extension> <linkId value="item91202442" /> <text value="Insulin/GLP-1 analog" /> <type value="boolean" /> </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" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="enableWhenExpression"> <valueExpression> <description value="false" /> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> </extension> <linkId value="item98391879" /> <text value="Other" /> <type value="boolean" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other: {{answer}}" /> </extension> </extension> <linkId value="item28596480" /> <text value="Details:" /> <type value="text" /> <enableWhen> <question value="item98391879" /> <operator value="=" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="all" /> <required value="true" /> </item> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="text"> <valueString value="#blank_line#" /> </extension> </extension> <linkId value="item62682819" /> <type value="display" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="style"> <valueString value="font-weight:bold;text-decoration:underline;" /> </extension> </extension> <linkId value="section61428617" /> <text value="Cumulative Patient Profile" /> <type value="group" /> <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" /> </coding> </valueCodeableConcept> </extension> <linkId value="CPPAttachment" /> <text value="CPP Attached Separately" /> <type value="boolean" /> </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" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="enableWhenExpression"> <valueExpression> <description value="false" /> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> <extension url="text"> <valueString> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="<span/>" /> </extension> </valueString> </extension> </extension> <linkId value="CPPRemoved" /> <text value="Do not send CPP" /> <type value="boolean" /> </item> <item> <linkId value="section58148321" /> <type value="group" /> <enableWhen> <question value="CPPAttachment" /> <operator value="!=" /> <answerBoolean value="true" /> </enableWhen> <enableWhen> <question value="CPPRemoved" /> <operator value="!=" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="all" /> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%`var-ptCpp.prob`" /> </valueExpression> </extension> <linkId value="prob" /> <text value="Current Problems:" /> <type value="text" /> </item> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%`var-ptCpp.allg`" /> </valueExpression> </extension> <linkId value="item19532475" /> <text value="Allergies:" /> <type value="text" /> </item> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%`var-ptCpp.rx`" /> </valueExpression> </extension> <linkId value="rx" /> <text value="Current Medications:" /> <type value="text" /> </item> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%`var-ptCpp.pmhx`" /> </valueExpression> </extension> <linkId value="pmhx" /> <text value="Past Medical History:" /> <type value="text" /> </item> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%`var-ptCpp.fhx`" /> </valueExpression> </extension> <linkId value="item68613367" /> <text value="Family History:" /> <type value="text" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="text"> <valueString value="#blank_line#" /> </extension> </extension> <linkId value="item35858285" /> <type value="display" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="text"> <valueString value="Additional Information / Comments:" /> </extension> </extension> <linkId value="section55489124" /> <text value="Additional Information / Comments"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Additional Comments / Special Instructions" /> </extension> </extension> </text> <type value="group" /> <item> <linkId value="item35752766" /> <type value="text" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="text"> <valueString value="#blank_line#" /> </extension> </extension> <linkId value="item61907286" /> <type value="display" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="style"> <valueString value="font-weight:bold;text-decoration:underline;" /> </extension> </extension> <linkId value="section79119148" /> <text value="Supporting Documentation" /> <type value="group" /> <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" /> </coding> </valueCodeableConcept> </extension> <linkId value="item89395197" /> <text value="Lab report including A1C completed within the last 3-6 months, and latest lipid profile, renal function and ACR attached"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Lab report including <b><span style="text-decoration:underline;">A1C</span></b> completed within the last 3-6 months, and <b><span style="text-decoration:underline;">latest lipid profile, renal function and ACR</span></b> attached" /> </extension> </text> <type value="boolean" /> <required value="true" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="enableWhenExpression"> <valueExpression> <description value="false" /> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> <extension url="text"> <valueString value="Export Analytics" /> </extension> </extension> <linkId value="section46860664" /> <text value="Export Analytics"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Export Analytics" /> </extension> </extension> </text> <type value="group" /> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <description value="false" /> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> </extension> <linkId value="noAttachmentWarning" /> <text> <extension url="http://hl7.org/fhir/StructureDefinition/cqf-expression"> <valueExpression> <description value="CPPAttachment.r == 'Y' || item89395197.r == 'Y' ? 'Did you forget to attach a file?' : ''" /> <language value="text/fhirpath" /> <expression value="iif((%resource.repeat(item).where(linkId='CPPAttachment').answer.exists(value = 'Y') or %resource.repeat(item).where(linkId='item89395197').answer.exists(value = 'Y') ), 'Did you forget to attach a file?', '')" /> </valueExpression> </extension> </text> <type value="display" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <description value="false" /> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> <extension url="text"> <valueString value="referralService: {{answer}}" /> </extension> </extension> <linkId value="referralService" /> <text value="DIABETES_EDUCATION" /> <type value="display" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <description value="false" /> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> <extension url="text"> <valueString value="referralDescription: {{answer}}" /> </extension> </extension> <linkId value="referralDescription" /> <text value="Diabetes Education Program" /> <type value="display" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <description value="false" /> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> <extension url="text"> <valueString value="ax_diagnosis: {{answer}}" /> </extension> </extension> <linkId value="ax_diagnosis" /> <text> <extension url="http://hl7.org/fhir/StructureDefinition/cqf-expression"> <valueExpression> <description value="(function() {; var descs = ""; if (diabetesType.r == 'Pre-Diabetes') {descs+='Pre-Diabetes';} if (diabetesType.r == 'Type 2 Diabetes') {descs+='Type 2 Diabetes';} if (diabetesType.r == 'At Risk') {descs+='At Risk for Diabetes';} return descs.substring(0, (descs.length-0)); })()" /> <language value="text/fhirpath" /> <expression value="(iif(%resource.repeat(item).where(linkId='diabetesType').answer.exists(value = 'Pre-Diabetes'),'Pre-Diabetes') | iif(%resource.repeat(item).where(linkId='diabetesType').answer.exists(value = 'Type 2 Diabetes'),'Type 2 Diabetes') | iif(%resource.repeat(item).where(linkId='diabetesType').answer.exists(value = 'At Risk'),'At Risk for Diabetes')).aggregate($total & $this, '')" /> </valueExpression> </extension> </text> <type value="display" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <description value="false" /> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> </extension> <linkId value="ax_reasonForReferral" /> <text> <extension url="http://hl7.org/fhir/StructureDefinition/cqf-expression"> <valueExpression> <description value="(function() {; var descs = ""; if (item76597097.r == 'Y' || item84430472.r == 'Y') {descs+='Diabetes Education' + '; ';} if (item93032788.p) {descs+='Diabetes Foot Care' + '; ';} if (item90036939.p || item88820032.p || item93616553.p || item91333221.p) {descs+='Diabetes Medication Initiation/Review' + '; ';} if (item61998839.p) {descs+='Social Worker' + '; ';} if (item4180826.p) {descs+='Endocrinologist Consult' + '; ';} return descs.substring(0, (descs.length-2)); })()" /> <language value="text/fhirpath" /> <expression value="(iif(%resource.repeat(item).where(linkId='item76597097').answer.exists(value = 'Y') or %resource.repeat(item).where(linkId='item84430472').answer.exists(value = 'Y'),'Diabetes Education' + '; ') | iif(%resource.repeat(item).where(linkId='item93032788').answer.iif(value=true, 1, 0),'Diabetes Foot Care' + '; ') | iif(%resource.repeat(item).where(linkId='item90036939').answer.iif(value=true, 1, 0) or %resource.repeat(item).where(linkId='item88820032').answer.iif(value=true, 1, 0) or %resource.repeat(item).where(linkId='item93616553').answer.iif(value=true, 1, 0) or %resource.repeat(item).where(linkId='item91333221').answer.iif(value=true, 1, 0),'Diabetes Medication Initiation/Review' + '; ') | iif(%resource.repeat(item).where(linkId='item61998839').answer.iif(value=true, 1, 0),'Social Worker' + '; ') | iif(%resource.repeat(item).where(linkId='item4180826').answer.iif(value=true, 1, 0),'Endocrinologist Consult' + '; ')).aggregate($total & $this, '')" /> </valueExpression> </extension> </text> <type value="display" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <description value="false" /> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> <extension url="text"> <valueString value="ax_diagnosis: {{answer}}" /> </extension> </extension> <linkId value="ax_bodySite" /> <text value="Pancreas" /> <type value="display" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <description value="false" /> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> </extension> <linkId value="ax_v_bp" /> <text value="Carefirst Family Health Team Diabetes Education Program (DEP) eReferral Form [FINAL SEPT 2022]; 2022.09.30" /> <type value="display" /> </item> </item> </item> </Questionnaire>