<status value="active" /> <experimental value="false" /> <subjectType value="Patient" /> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> </extension> <linkId value="s" /> <type value="group" /> <item> <linkId value="item47143865" /> <text value="* Indicates a required field"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="display" /> </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="section49999867" /> <text value="Consent" /> <type value="group" /> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#008800;" /> </extension> <extension url="negativeStyle"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> </extension> <linkId value="item37335906" /> <text value="Client is aware of and consented to this referral:" /> <type value="choice" /> <required value="true" /> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </valueCoding> </answerOption> </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="item91779989" /> <type value="display" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="item78668948" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="human"> <valueString value="Please obey rules specified in instructions" /> </extension> <extension url="expression"> <valueExpression> <description value="item37335906.r == 'Y'" /> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='item37335906').answer.exists(value = 'Y')" /> </valueExpression> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="section3264854" /> <text value="STOP" /> <type value="group" /> <enableWhen> <question value="item37335906" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <item> <linkId value="item78668948" /> <text value="Please discuss this referral with the client and receive their consent prior to submitting a referral to this program."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <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="section38273739" /> <text value="Program Referral Criteria" /> <type value="group" /> <enableWhen> <question value="item37335906" /> <operator value="!=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <item> <linkId value="item1967164" /> <text value="Is the client 18 years of age or older:" /> <type value="choice" /> <required value="true" /> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="item54409049" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="human"> <valueString value="Please obey rules specified in instructions" /> </extension> <extension url="expression"> <valueExpression> <description value="item1967164.r == 'Y'" /> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='item1967164').answer.exists(value = 'Y')" /> </valueExpression> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="section39613765" /> <text value="Please Note" /> <type value="group" /> <enableWhen> <question value="item1967164" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <item> <linkId value="item54409049" /> <text value="This program is designed to support patients 18 years of age or older."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="This program is designed to support patients 18 years of age or older.<br/>" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="display" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-supportHyperlink"> <extension url="label"> <valueString value="Click here to access BounceBack Ontario" /> </extension> <extension url="link"> <valueUri value="https://ocean.cognisantmd.com/intake/IntakePortal.html?eReqRef=86b6adda-6749-4cd3-941b-fc10b4abffcf" /> </extension> </extension> <linkId value="item37161478" /> <text value="If the client is 15-17 years of age and seeking services for anxiety and depression, they can submit a referral directly to BounceBack Ontario."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="If the client is 15-17 years of age and seeking services for anxiety and depression, they can submit a referral directly to BounceBack Ontario.<br/>" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="display" /> </item> <item> <linkId value="item19347136" /> <text value="BounceBack is a guided self-help program that is supported by a coach over the telephone and is available in multiple languages – in a feedback survey, 92% of respondents said that they would recommend the service to a family or friend."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-style:italic;" /> </extension> </text> <type value="display" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-supportHyperlink"> <extension url="label"> <valueString value="Click here to access Connex" /> </extension> <extension url="link"> <valueUri value="www.connexontario.ca" /> </extension> </extension> <linkId value="item43979973" /> <text value="If the client needs other services or if they're younger than 15 years of age, additional services can be found at www.connexontario.ca or by calling at 1-866-531-2600."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="display" /> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="listSeparator"> <valueString> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="<br/>" /> </extension> </valueString> </extension> </extension> <linkId value="section12847616" /> <text value="Inclusion Criteria" /> <type value="group" /> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#008800;" /> </extension> <extension url="negativeStyle"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> </extension> <linkId value="item49714327" /> <text value="Client has a main concern of anxiety, depression, or anxiety-related problem (e.g. post-traumatic stress, health anxiety, work stress, obsessive-compulsive concerns):"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Client has a main concern of <b>anxiety, depression, or anxiety-related problem</b> (e.g. post-traumatic stress, health anxiety, work stress, obsessive-compulsive concerns):" /> </extension> </text> <type value="choice" /> <required value="true" /> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </valueCoding> </answerOption> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="item10317633" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="human"> <valueString value="Please obey rules specified in instructions" /> </extension> <extension url="expression"> <valueExpression> <description value="item49714327.r == 'Y'" /> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='item49714327').answer.exists(value = 'Y')" /> </valueExpression> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="section72429917" /> <text value="STOP" /> <type value="group" /> <enableWhen> <question value="item49714327" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-supportHyperlink"> <extension url="label"> <valueString value="https://www.connexontario.ca/en-ca" /> </extension> <extension url="link"> <valueUri value="https://www.connexontario.ca/en-ca" /> </extension> </extension> <linkId value="item10317633" /> <text value="This program is designed to support those with mild to moderate anxiety, depression or anxiety related problems. If these do not describe the client’s main concern, please refer to Connex Ontario to identify alternate resources for the client:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="This program is designed to support those with mild to moderate anxiety, depression or anxiety related problems. If these do not describe the client’s main concern, please refer to Connex Ontario to identify alternate resources for the client:<br/>" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="display" /> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="listSeparator"> <valueString> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="<br/>" /> </extension> </valueString> </extension> </extension> <linkId value="section86254334" /> <text value="Exclusionary Criteria" /> <type value="group" /> <item> <linkId value="item14589028" /> <text value="NOTE: In the circumstances below, the Ontario Structured Psychotherapy program would NOT be suitable for a client's needs. A note to 'STOP' will appear if the patient does not meet the program criteria. Even if the patient is not eligible for the current program, you may still review and select to see alternate resources and/or services available."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="<b>NOTE: In the circumstances below, the Ontario Structured Psychotherapy program would NOT be suitable for a client's needs.</b><br/><i>A note to 'STOP' will appear if the patient does not meet the program criteria. Even if the patient is not eligible for the current program, you may still review and select to see alternate resources and/or services available.</i> <br/>" /> </extension> </text> <type value="display" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> <extension url="negativeStyle"> <valueString value="font-weight:bold;color:#008800;" /> </extension> </extension> <linkId value="item76121425" /> <text value="The client is actively suicidal and with impaired coping skills and/or has attempted suicide in the past 6 months:" /> <type value="choice" /> <required value="true" /> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="item64325896" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="human"> <valueString value="Please obey rules specified in instructions" /> </extension> <extension url="expression"> <valueExpression> <description value="item76121425.r == 'N'" /> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='item76121425').answer.exists(value = 'N')" /> </valueExpression> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="section54495467" /> <text value="STOP" /> <type value="group" /> <enableWhen> <question value="item76121425" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <item> <linkId value="item64325896" /> <text value="Based on your response, this program is not suitable for the client’s needs."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Based on your response, this program is not suitable for the client’s needs.<br/>" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="display" /> </item> <item> <linkId value="item2544954" /> <text value="Paramedic services can be reached at 911. For crisis support services please refer to the resources below: If you live in York Region, please refer to the Crisis Services at York Support Services Network: 1-855-310-COPE (2673). If you live in North York, please refer to the Gerstein Crisis Centre at 416-929-5200. If you live in North Etobicoke, Malton or West Woodbridge, please refer to the Peel Crisis Services at 905-278-9036."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Paramedic services can be reached at 911. For crisis support services please refer to the resources below: <br/>If you live in York Region, please refer to the Crisis Services at York Support Services Network: 1-855-310-COPE (2673). <br/>If you live in North York, please refer to the Gerstein Crisis Centre at 416-929-5200. <br/>If you live in North Etobicoke, Malton or West Woodbridge, please refer to the Peel Crisis Services at 905-278-9036.<br/>" /> </extension> </text> <type value="display" /> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> <extension url="negativeStyle"> <valueString value="font-weight:bold;color:#008800;" /> </extension> </extension> <linkId value="item1990858" /> <text value="The client poses a high risk to themselves, risk to others or is at significant risk of severe self-neglect:" /> <type value="choice" /> <required value="true" /> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="item93430821" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="human"> <valueString value="Please obey rules specified in instructions" /> </extension> <extension url="expression"> <valueExpression> <description value="item1990858.r == 'N'" /> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='item1990858').answer.exists(value = 'N')" /> </valueExpression> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="section95021338" /> <text value="STOP" /> <type value="group" /> <enableWhen> <question value="item1990858" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <item> <linkId value="item93430821" /> <text value="Based on your response, this program is not suitable for the client’s needs."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Based on your response, this program is not suitable for the client’s needs.<br/>" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="display" /> </item> <item> <linkId value="item64923379" /> <text value="Paramedic services can be reached at 911. For crisis support services please refer to the resources below: If you live in York Region, please refer to the Crisis Services at York Support Services Network: 1-855-310-COPE (2673). If you live in North York, please refer to the Gerstein Crisis Centre at 416-929-5200. If you live in North Etobicoke, Malton or West Woodbridge, please refer to the Peel Crisis Services at 905-278-9036."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Paramedic services can be reached at 911. For crisis support services please refer to the resources below: <br/>If you live in York Region, please refer to the Crisis Services at York Support Services Network: 1-855-310-COPE (2673). <br/>If you live in North York, please refer to the Gerstein Crisis Centre at 416-929-5200. <br/>If you live in North Etobicoke, Malton or West Woodbridge, please refer to the Peel Crisis Services at 905-278-9036.<br/>" /> </extension> </text> <type value="display" /> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> <extension url="negativeStyle"> <valueString value="font-weight:bold;color:#008800;" /> </extension> </extension> <linkId value="item456132" /> <text value="The client is self-harming, which is the immediate, primary concern:" /> <type value="choice" /> <required value="true" /> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="item8415293" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="human"> <valueString value="Please obey rules specified in instructions" /> </extension> <extension url="expression"> <valueExpression> <description value="item456132.r == 'N'" /> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='item456132').answer.exists(value = 'N')" /> </valueExpression> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="section21890674" /> <text value="STOP" /> <type value="group" /> <enableWhen> <question value="item456132" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <item> <linkId value="item8415293" /> <text value="Based on your response, this program is not suitable for the client’s needs."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Based on your response, this program is not suitable for the client’s needs.<br/>" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="display" /> </item> <item> <linkId value="item52723333" /> <text value="Paramedic services can be reached at 911. For crisis support services please refer to the resources below: If you live in York Region, please refer to the Crisis Services at York Support Services Network: 1-855-310-COPE (2673). If you live in North York, please refer to the Gerstein Crisis Centre at 416-929-5200. If you live in North Etobicoke, Malton or West Woodbridge, please refer to the Peel Crisis Services at 905-278-9036."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Paramedic services can be reached at 911. For crisis support services please refer to the resources below: <br/>If you live in York Region, please refer to the Crisis Services at York Support Services Network: 1-855-310-COPE (2673). <br/>If you live in North York, please refer to the Gerstein Crisis Centre at 416-929-5200. <br/>If you live in North Etobicoke, Malton or West Woodbridge, please refer to the Peel Crisis Services at 905-278-9036.<br/>" /> </extension> </text> <type value="display" /> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> <extension url="negativeStyle"> <valueString value="font-weight:bold;color:#008800;" /> </extension> </extension> <linkId value="item85478952" /> <text value="The client is experiencing significant symptoms of mania or hypomania currently or has experienced these symptoms within the past year. (not due to medication/substance use):" /> <type value="choice" /> <required value="true" /> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="item10394391" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="human"> <valueString value="Please obey rules specified in instructions" /> </extension> <extension url="expression"> <valueExpression> <description value="item85478952.r == 'N'" /> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='item85478952').answer.exists(value = 'N')" /> </valueExpression> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="section97698246" /> <text value="STOP" /> <type value="group" /> <enableWhen> <question value="item85478952" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <item> <linkId value="item10394391" /> <text value="Based on your response, this program is not suitable for the client’s needs."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Based on your response, this program is not suitable for the client’s needs.<br/>" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="display" /> </item> <item> <linkId value="item16815458" /> <text value="Connex Ontario (https://www.connexontario.ca/en-ca/; 1-866-531-2600) can help you find services that are a better fit for your concerns, age group, and geographical area. An organization that provides services across Ontario is: Mood Disorder Association of Ontario at (416) 486-8046 ext. 237 (1-888-486-8236) If you live in North York, you may wish to refer to; or Canadian Mental Health Association (CMHA) Toronto Branch’s Mood and Psychosis Early Intervention Program; or The Baycrest Mood Clinic (Older adults) (416-785-2500 ext. 4293)."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Connex Ontario (https://www.connexontario.ca/en-ca/; 1-866-531-2600) can help you find services that are a better fit for your concerns, age group, and geographical area. <br/>An organization that provides services across Ontario is: Mood Disorder Association of Ontario at (416) 486-8046 ext. 237 (1-888-486-8236)<br/>If you live in North York, you may wish to refer to; or Canadian Mental Health Association (CMHA) Toronto Branch’s Mood and Psychosis Early Intervention Program; or The Baycrest Mood Clinic (Older adults) (416-785-2500 ext. 4293).<br/>" /> </extension> </text> <type value="display" /> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> <extension url="negativeStyle"> <valueString value="font-weight:bold;color:#008800;" /> </extension> </extension> <linkId value="item35961598" /> <text value="The client is experiencing significant symptoms of a psychotic disorder currently or has experienced these symptoms within the past year (not due to medication/substance use):" /> <type value="choice" /> <required value="true" /> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="item52812283" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="human"> <valueString value="Please obey rules specified in instructions" /> </extension> <extension url="expression"> <valueExpression> <description value="item35961598.r == 'N'" /> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='item35961598').answer.exists(value = 'N')" /> </valueExpression> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="section14136581" /> <text value="STOP" /> <type value="group" /> <enableWhen> <question value="item35961598" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <item> <linkId value="item52812283" /> <text value="Based on your response, this program is not suitable for the client’s needs."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Based on your response, this program is not suitable for the client’s needs.<br/>" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="display" /> </item> <item> <linkId value="item31242980" /> <text value="Connex Ontario (https://www.connexontario.ca/en-ca/; 1-866-531-2600) can help you find services that are a better fit for your concerns, age group, and geographical area. An organization that provides services across Ontario is: Mood Disorder Association of Ontario at (416) 486-8046 ext. 237 (1-888-486-8236) If you live in North York, you may wish to refer to; or Canadian Mental Health Association (CMHA) Toronto Branch’s Mood and Psychosis Early Intervention Program; or The Baycrest Mood Clinic (Older adults) (416-785-2500 ext. 4293)."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Connex Ontario (https://www.connexontario.ca/en-ca/; 1-866-531-2600) can help you find services that are a better fit for your concerns, age group, and geographical area. <br/>An organization that provides services across Ontario is: Mood Disorder Association of Ontario at (416) 486-8046 ext. 237 (1-888-486-8236)<br/>If you live in North York, you may wish to refer to; or Canadian Mental Health Association (CMHA) Toronto Branch’s Mood and Psychosis Early Intervention Program; or The Baycrest Mood Clinic (Older adults) (416-785-2500 ext. 4293).<br/>" /> </extension> </text> <type value="display" /> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> <extension url="negativeStyle"> <valueString value="font-weight:bold;color:#008800;" /> </extension> </extension> <linkId value="item4954473" /> <text value="The client has a severe/complex personality disorder that would impact their ability to actively participate in CBT for anxiety or depression:" /> <type value="choice" /> <required value="true" /> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </valueCoding> </answerOption> </item> <item> <linkId value="item96990073" /> <text value="Note: This program is not appropriate for clients for which personality disorder is the problem currently causing the most distress and impairment."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-style:italic;" /> </extension> </text> <type value="display" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="item73674408" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="human"> <valueString value="Please obey rules specified in instructions" /> </extension> <extension url="expression"> <valueExpression> <description value="item4954473.r == 'N'" /> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='item4954473').answer.exists(value = 'N')" /> </valueExpression> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="section10441379" /> <text value="STOP" /> <type value="group" /> <enableWhen> <question value="item4954473" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <item> <linkId value="item73674408" /> <text value="Based on your response, this program is not suitable for the client’s needs."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Based on your response, this program is not suitable for the client’s needs.<br/>" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="display" /> </item> <item> <linkId value="item24357537" /> <text value="Connex Ontario (https://www.connexontario.ca/en-ca/; 1-866-531-2600) can help you find services that are a better fit for your concerns, age group, and geographical area. An organization that provides services across Ontario is: Ontario Shores Borderline Personality Disorder Program at https://www.ontarioshores.ca/services/borderline-personality-self-regulation-clinic at 1.866.345.0183, ext. 3321 If you live in North York, you may wish to refer to the Centre of Addiction and Mental Health’s Borderline Personality Disorder Clinic at 416 535-8501 ext. 32437; or Toronto’s Youth Wellness Hub at 416-482-0081 ext. 5. If you live in North Etobicoke, Malton or West Woodbridge, you may wish to refer to William Osler Hospital at 905-494-2120 ext 56709."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Connex Ontario (https://www.connexontario.ca/en-ca/; 1-866-531-2600) can help you find services that are a better fit for your concerns, age group, and geographical area. <br/>An organization that provides services across Ontario is: Ontario Shores Borderline Personality Disorder Program at https://www.ontarioshores.ca/services/borderline-personality-self-regulation-clinic at 1.866.345.0183, ext. 3321 <br/>If you live in North York, you may wish to refer to the Centre of Addiction and Mental Health’s Borderline Personality Disorder Clinic at 416 535-8501 ext. 32437; or Toronto’s Youth Wellness Hub at 416-482-0081 ext. 5. <br/> <br/>If you live in North Etobicoke, Malton or West Woodbridge, you may wish to refer to William Osler Hospital at 905-494-2120 ext 56709." /> </extension> </text> <type value="display" /> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> <extension url="negativeStyle"> <valueString value="font-weight:bold;color:#008800;" /> </extension> </extension> <linkId value="item7249653" /> <text value="The client has exclusively requested medication management:" /> <type value="choice" /> <required value="true" /> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="item68139337" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="human"> <valueString value="Please obey rules specified in instructions" /> </extension> <extension url="expression"> <valueExpression> <description value="item7249653.r == 'N'" /> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='item7249653').answer.exists(value = 'N')" /> </valueExpression> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="section90430589" /> <text value="STOP" /> <type value="group" /> <enableWhen> <question value="item7249653" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <item> <linkId value="item68139337" /> <text value="Based on your response, this program is not suitable for the client’s needs."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Based on your response, this program is not suitable for the client’s needs.<br/>" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="display" /> </item> <item> <linkId value="item46110349" /> <text value="You can receive medication management through your Primary Care Practitioner (Nurse practitioner, family doctor, etc.) or have your PCP refer you to a psychiatrist who can oversee medication management." /> <type value="display" /> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> <extension url="negativeStyle"> <valueString value="font-weight:bold;color:#008800;" /> </extension> </extension> <linkId value="item92961042" /> <text value="The client has moderate to severe impairment of cognitive function (e.g., dementia); or moderate to severe impairment due to a developmental disability or learning disability:" /> <type value="choice" /> <required value="true" /> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="item20569774" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="human"> <valueString value="Please obey rules specified in instructions" /> </extension> <extension url="expression"> <valueExpression> <description value="item92961042.r == 'N'" /> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='item92961042').answer.exists(value = 'N')" /> </valueExpression> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="section6252983" /> <text value="STOP" /> <type value="group" /> <enableWhen> <question value="item92961042" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <item> <linkId value="item20569774" /> <text value="Based on your response, this program is not suitable for the client’s needs."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Based on your response, this program is not suitable for the client’s needs.<br/>" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="display" /> </item> <item> <linkId value="item83790660" /> <text value="Connex Ontario (https://www.connexontario.ca/en-ca/; 1-866-531-2600) can help you find services that are a better fit for your concerns, age group, and geographical area. An organization that provides services across Ontario is: Developmental Services Ontario at 1-855-277-2121. If you live in York Region, you may wish to refer to York Support Services Network at https://yssn.ca/case-management-children-and-adults If you live in North York, you may wish to refer to Surrey Place at https://www.surreyplace.ca/directory/developmental-services-ontario-toronto-region/#1621272376201-e833bfa6-b680."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Connex Ontario (https://www.connexontario.ca/en-ca/; 1-866-531-2600) can help you find services that are a better fit for your concerns, age group, and geographical area. <br/>An organization that provides services across Ontario is: Developmental Services Ontario at 1-855-277-2121.<br/>If you live in York Region, you may wish to refer to York Support Services Network at https://yssn.ca/case-management-children-and-adults<br/>If you live in North York, you may wish to refer to Surrey Place at https://www.surreyplace.ca/directory/developmental-services-ontario-toronto-region/#1621272376201-e833bfa6-b680." /> </extension> </text> <type value="display" /> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> <extension url="negativeStyle"> <valueString value="font-weight:bold;color:#008800;" /> </extension> </extension> <linkId value="item67161689" /> <text value="The client currently has problematic substance use or has had problematic substance use in the past three months that would seriously impact their ability to actively participate in CBT (e.g., the client is unable to attend scheduled session, or unable to attempt assigned work required between sessions):" /> <type value="choice" /> <required value="true" /> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="item28837504" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="human"> <valueString value="Please obey rules specified in instructions" /> </extension> <extension url="expression"> <valueExpression> <description value="item67161689.r == 'N'" /> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='item67161689').answer.exists(value = 'N')" /> </valueExpression> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="section54876940" /> <text value="STOP" /> <type value="group" /> <enableWhen> <question value="item67161689" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <item> <linkId value="item28837504" /> <text value="Based on your response, this program is not suitable for the client’s needs."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Based on your response, this program is not suitable for the client’s needs.<br/>" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="display" /> </item> <item> <linkId value="item18871507" /> <text value="If you live in York Region, you may wish to refer to a Rapid Access to Addictions Management Clinic (RAAM) at Major Mackenzie Health Hospital (Richmond Hill), Oak Valley Health (Markham) or Southlake Regional Health Centre (Newmarket) 289-221-4839 or 1-888-399-8342. You may also refer to Connex Ontario at 1-866-531-2600. If you live in North York, you may wish to refer to Rapid Access to Addictions Management Clinic (RAAM) at 289-221-4839 OR Toll Free:1- 888-399-8342 or North York General Hospital Addiction Program 416-756-6919 or Connex Ontario at 1-866-531-2600 If you live in North Etobicoke, Malton or West Woodbridge, you may wish to refer to Etobicoke General Hospital Addiction Counselling Service 905-494-2120 ext 29385, Vitanova Foundation Outpatient Counselling at 416-744-8940 ext. 232 or Connex Ontario at 1-866-531-2600."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="If you live in York Region, you may wish to refer to a Rapid Access to Addictions Management Clinic (RAAM) at Major Mackenzie Health Hospital (Richmond Hill), Oak Valley Health (Markham) or Southlake Regional Health Centre (Newmarket) 289-221-4839 or 1-888-399-8342. You may also refer to Connex Ontario at 1-866-531-2600.<br/>If you live in North York, you may wish to refer to Rapid Access to Addictions Management Clinic (RAAM) at 289-221-4839 OR Toll Free:1- 888-399-8342 or North York General Hospital Addiction Program 416-756-6919 or Connex Ontario at 1-866-531-2600<br/>If you live in North Etobicoke, Malton or West Woodbridge, you may wish to refer to Etobicoke General Hospital Addiction Counselling Service 905-494-2120 ext 29385, Vitanova Foundation Outpatient Counselling at 416-744-8940 ext. 232 or Connex Ontario at 1-866-531-2600." /> </extension> </text> <type value="display" /> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> <extension url="negativeStyle"> <valueString value="font-weight:bold;color:#008800;" /> </extension> </extension> <linkId value="item23443648" /> <text value="Client requires specialized concurrent disorders treatment:" /> <type value="choice" /> <required value="true" /> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="item67181026" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="human"> <valueString value="Please obey rules specified in instructions" /> </extension> <extension url="expression"> <valueExpression> <description value="item23443648.r == 'N'" /> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='item23443648').answer.exists(value = 'N')" /> </valueExpression> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="section19600218" /> <text value="STOP" /> <type value="group" /> <enableWhen> <question value="item23443648" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <item> <linkId value="item67181026" /> <text value="Based on your response, this program is not suitable for the client’s needs."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Based on your response, this program is not suitable for the client’s needs.<br/>" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="display" /> </item> <item> <linkId value="item2488452" /> <text value="You may wish to refer to Connex Ontario at www.connexontario.ca or 1-866-531-2600 for alternate services." /> <type value="display" /> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> <extension url="negativeStyle"> <valueString value="font-weight:bold;color:#008800;" /> </extension> </extension> <linkId value="item29163757" /> <text value="Client has a severe eating disorder that would impact their ability to actively participate in CBT for anxiety or depression:" /> <type value="choice" /> <required value="true" /> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="item88646779" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="human"> <valueString value="Please obey rules specified in instructions" /> </extension> <extension url="expression"> <valueExpression> <description value="item29163757.r == 'N'" /> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='item29163757').answer.exists(value = 'N')" /> </valueExpression> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="section55142452" /> <text value="STOP" /> <type value="group" /> <enableWhen> <question value="item29163757" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <item> <linkId value="item88646779" /> <text value="Based on your response, this program is not suitable for the client’s needs."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Based on your response, this program is not suitable for the client’s needs.<br/>" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="display" /> </item> <item> <linkId value="item12955452" /> <text value="If you live in York Region, you may wish to refer to Southlake Regional Health Centre at 905-895-4521, ext. 2825; Ontario Shores Eating Disorder Clinic at 1.877.767.9642; or Connex Ontario at 1-866-531-2600. If you live in North York, you may wish to refer to the Centre of Addictions and Mental Health (CAMH) at 416 535-8501, option 2; Sheena’s Place at 416 927-8900; or Connex Ontario at 1-866-531-2600. If you live in North Etobicoke, Malton or West Woodbridge, you can find additional support through Peel Memorial Hospital Eating Disorder Clinic at 905-494-2120 ext. 56709 ; or Connex Ontario at 1-866-531-2600."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="If you live in York Region, you may wish to refer to Southlake Regional Health Centre at 905-895-4521, ext. 2825; Ontario Shores Eating Disorder Clinic at 1.877.767.9642; or Connex Ontario at 1-866-531-2600.<br/>If you live in North York, you may wish to refer to the Centre of Addictions and Mental Health (CAMH) at 416 535-8501, option 2; Sheena’s Place at 416 927-8900; or Connex Ontario at 1-866-531-2600.<br/>If you live in North Etobicoke, Malton or West Woodbridge, you can find additional support through Peel Memorial Hospital Eating Disorder Clinic at 905-494-2120 ext. 56709 ; or Connex Ontario at 1-866-531-2600. <br/> <br/>" /> </extension> </text> <type value="display" /> </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="item53407338" /> <type value="display" /> </item> </item> <item> <linkId value="section44914524" /> <type value="group" /> <enableWhen> <question value="item1967164" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </answerCoding> </enableWhen> <enableWhen> <question value="item49714327" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </answerCoding> </enableWhen> <enableWhen> <question value="item76121425" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </answerCoding> </enableWhen> <enableWhen> <question value="item1990858" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </answerCoding> </enableWhen> <enableWhen> <question value="item456132" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </answerCoding> </enableWhen> <enableWhen> <question value="item85478952" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </answerCoding> </enableWhen> <enableWhen> <question value="item35961598" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </answerCoding> </enableWhen> <enableWhen> <question value="item4954473" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </answerCoding> </enableWhen> <enableWhen> <question value="item7249653" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </answerCoding> </enableWhen> <enableWhen> <question value="item92961042" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </answerCoding> </enableWhen> <enableWhen> <question value="item67161689" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </answerCoding> </enableWhen> <enableWhen> <question value="item23443648" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </answerCoding> </enableWhen> <enableWhen> <question value="item23443648" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </answerCoding> </enableWhen> <enableWhen> <question value="item29163757" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <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 url="listSeparator"> <valueString> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="<br/>" /> </extension> </valueString> </extension> </extension> <linkId value="section33974133" /> <text value="Client Information" /> <type value="group" /> <item> <linkId value="item9696892" /> <text value="As emailed materials are an essential component of program, please note that referrals without email addresses may result in considerably longer wait time to access service."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-style:italic;" /> </extension> </text> <type value="display" /> </item> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%`var-ptEmail`" /> </valueExpression> </extension> <linkId value="item7989770" /> <text value="Email:" /> <type value="string" /> <enableWhen> <question value="item29976128" /> <operator value="!=" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="all" /> <required value="true" /> </item> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-enableWhenExpression"> <valueExpression> <description value="item7989770.r == ''" /> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='item7989770').answer.empty()" /> </valueExpression> </extension> <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="item29976128" /> <text value="Patient does not have an email address" /> <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="drop-down" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#0000AA;" /> </extension> </extension> <linkId value="ptnt_cntctPrfrnc" /> <text value="Preferred method of contact:" /> <type value="choice" /> <required value="true" /> <repeats value="true" /> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="1" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_ptnt_cntctPrfrnc" /> <code value="Mobile" /> <display value="Mobile" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="2" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_ptnt_cntctPrfrnc" /> <code value="Home" /> <display value="Home" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="3" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_ptnt_cntctPrfrnc" /> <code value="Work" /> <display value="Work" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="0" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_ptnt_cntctPrfrnc" /> <code value="Email" /> <display value="Email" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="0" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_ptnt_cntctPrfrnc" /> <code value="Text" /> <display value="Text" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/on-item-controls" /> <code value="push-button" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#0000AA;" /> </extension> <extension url="negativeStyle"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> </extension> <linkId value="item32218804" /> <text value="Permission to leave a voicemail:" /> <type value="choice" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="1" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_item32218804" /> <code value="No" /> <display value="No" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="2" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_item32218804" /> <code value="Yes" /> <display value="Yes" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/on-item-controls" /> <code value="push-button" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> 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value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_item40054684" /> <code value="Any" /> <display value="Any" /> </valueCoding> </answerOption> </item> <item> <linkId value="item46487425" /> <text value="Does the client require an interpreter:" /> <type value="choice" /> <required value="true" /> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%`var-ptLanguage`" /> </valueExpression> </extension> <linkId value="item97047215" /> <text value="Language:" /> <type value="string" /> <enableWhen> 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</answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="item95061810" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="human"> <valueString value="Please obey rules specified in instructions" /> </extension> <extension url="expression"> <valueExpression> <description value="ScriptUtil.percentComplete( section22204334 ) != 0" /> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='section22204334').select(item.where(linkId='item35282384').exists(answer) | item.where(linkId='item95061810').exists(answer) | item.where(linkId='section52454146').exists(answer)).count() * 100 / 3 != 0" /> </valueExpression> </extension> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="text"> <valueString value="Support Organizations" /> </extension> <extension 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</extension> </extension> <linkId value="section41558688" /> <text value="Primary Care Provider" /> <type value="group" /> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="positiveText"> <valueString value="Referring provider is Primary Care Provider" /> </extension> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#008800;" /> </extension> <extension url="negativeText"> <valueString value="Referring provider is NOT Primary Care Provider" /> </extension> <extension url="negativeStyle"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> </extension> <linkId value="item30583415" /> <text value="Referring provider is Primary Care Provider:" /> <type value="choice" /> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </valueCoding> <initialSelected value="true" /> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </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="check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Client does not have a primary care provider (PCP)" /> </extension> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> </extension> <linkId value="item73714162" /> <text value="Client does not have a Primary Care Provider (PCP)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Client does not have a Primary Care Provider (PCP)<br/>" /> </extension> </text> <type value="boolean" /> <enableWhen> <question value="item30583415" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="style"> <valueString value="text-decoration:underline;" /> </extension> </extension> <linkId value="section60358726" /> <type value="group" /> <enableWhen> <question value="item73714162" /> <operator value="!=" /> <answerBoolean value="true" /> </enableWhen> <enableWhen> <question value="item30583415" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </answerCoding> </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-ptFamilyDoc`" /> </valueExpression> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="PCP Name:" /> </extension> </extension> <linkId value="item86194914" /> <text value="PCP Name:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="PCP Name:<br/>" /> </extension> </text> <type value="string" /> <required value="true" /> </item> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%`var-ptFamilyDoc`" /> </valueExpression> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Email:" /> </extension> </extension> <linkId value="item93996427" /> <text value="Email:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Email:<br/>" /> </extension> </text> <type value="string" /> </item> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%`var-ptFamilyDoc`" /> </valueExpression> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Professional ID:" /> </extension> </extension> <linkId value="item31723932" /> <text value="Professional ID:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Professional ID:<br/>" /> </extension> </text> <type value="string" /> </item> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%`var-ptFamilyDoc`" /> </valueExpression> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="OHIP Billing #:" /> </extension> </extension> <linkId value="item34994179" /> <text value="OHIP Billing #:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="OHIP Billing #:<br/>" /> </extension> </text> <type value="string" /> </item> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%`var-ptFamilyDoc`" /> </valueExpression> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Clinic Name:" /> </extension> </extension> <linkId value="item58543877" /> <text value="Clinic Name:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Clinic Name:<br/>" /> </extension> </text> <type value="string" /> </item> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%`var-ptFamilyDoc`" /> </valueExpression> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Address:" /> </extension> </extension> <linkId value="item91721567" /> <text value="Address:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Address:<br/>" /> </extension> </text> <type value="string" /> </item> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%`var-ptFamilyDoc`" /> </valueExpression> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Address Line 2:" /> </extension> </extension> <linkId value="item35304545" /> <text value="Address Line 2:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Address Line 2:<br/>" /> </extension> </text> <type value="string" /> </item> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%`var-ptFamilyDoc`" /> </valueExpression> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="City:" /> </extension> </extension> <linkId value="item1621758" /> <text value="City:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="City:<br/>" /> </extension> </text> <type value="string" /> </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" /> </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="PCPProvince" /> <definition value="urn:uri:ontariolegacy:province" /> <text value="Province:" /> <type value="choice" /> <repeats value="false" /> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="1" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_PCPProvince" /> <code value="AB" /> <display value="AB" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="2" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_PCPProvince" /> <code value="BC" /> <display value="BC" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="3" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_PCPProvince" /> <code value="NB" /> <display value="NB" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="4" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_PCPProvince" /> <code value="MB" /> <display value="MB" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="5" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_PCPProvince" /> <code value="NL" /> <display value="NL" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="6" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_PCPProvince" /> <code value="NT" /> <display value="NT" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="7" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_PCPProvince" /> <code value="NS" /> <display value="NS" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="8" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_PCPProvince" /> <code value="NU" /> <display value="NU" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="9" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_PCPProvince" /> <code value="ON" /> <display value="ON" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="10" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_PCPProvince" /> <code value="PE" /> <display value="PE" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="11" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_PCPProvince" /> <code value="QC" /> <display value="QC" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="12" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_PCPProvince" /> <code value="SK" /> <display value="SK" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="13" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_PCPProvince" /> <code value="YT" /> <display value="YT" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%`var-ptFamilyDoc`" /> </valueExpression> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Postal Code:" /> </extension> </extension> <linkId value="item91112457" /> <text value="Postal Code:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Postal Code:<br/>" /> </extension> </text> <type value="string" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Phone Number:" /> </extension> </extension> <linkId value="item26155675" /> <text value="Phone Number:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Phone Number:<br/>" /> </extension> </text> <type value="integer" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Fax Number:" /> </extension> </extension> <linkId value="item82276690" /> <text value="Fax Number:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Fax Number:<br/>" /> </extension> </text> <type value="integer" /> </item> <item> <linkId value="item25608239" /> <text value="Other Information:" /> <type value="text" /> </item> </item> <item> <linkId value="item40132366" /> <text value="Has the client provided consent to share information with the Primary Care Provider:" /> <type value="choice" /> <enableWhen> <question value="item73714162" /> <operator value="!=" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="all" /> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/legacy/CodeSystem/unknown" /> <code value="NotSure" /> <display value="Not sure" /> </valueCoding> </answerOption> </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="item14509730" /> <type value="display" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true" /> </extension> <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="section85250608" /> <text value="PHQ-9" /> <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/question-note-info"> <extension url="text"> <valueString value="PHQ-9 Score: {{answer}}" /> </extension> </extension> <linkId value="item65955818" /> <text value="Please enter the Client's / Patient's most recent PHQ-9 score:" /> <type value="string" /> <required value="true" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true" /> </extension> <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="item720500" /> <text value="If there is no available PHQ-9 score, please click here to complete PHQ-9" /> <type value="boolean" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="listSeparator"> <valueString> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="<br/>" /> </extension> </valueString> </extension> </extension> <linkId value="patient_health_quest" /> <type value="group" /> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="text"> <valueString value="Over the last two weeks:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Over the last two weeks:<br/>" /> </extension> </valueString> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="listSeparator"> <valueString> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="<br/>" /> </extension> </valueString> </extension> <extension url="quoteAnswers"> <valueBoolean value="true" /> </extension> </extension> <linkId value="phq9Q" /> <text value="Ask the Client: "Over the last two weeks, how often have you been bothered by any of the following symptoms?"" /> <type value="group" /> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/on-item-controls" /> <code value="push-button" /> </coding> </valueCodeableConcept> </extension> <linkId value="q1" /> <text value="1. Little interest or pleasure in doing things" /> <type value="choice" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="0" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q1" /> <code value="Not at all" /> <display value="Not at all" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="1" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q1" /> <code value="Several days" /> <display value="Several days" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="2" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q1" /> <code value="More than half the days" /> <display value="More than half the days" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="3" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q1" /> <code value="Nearly every day" /> <display value="Nearly every day" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/on-item-controls" /> <code value="push-button" /> </coding> </valueCodeableConcept> </extension> <linkId value="q2" /> <text value="2. Feeling down, depressed, or hopeless" /> <type value="choice" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="0" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q2" /> <code value="Not at all" /> <display value="Not at all" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="1" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q2" /> <code value="Several days" /> <display value="Several days" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="2" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q2" /> <code value="More than half the days" /> <display value="More than half the days" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="3" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q2" /> <code value="Nearly every day" /> <display value="Nearly every day" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/on-item-controls" /> <code value="push-button" /> </coding> </valueCodeableConcept> </extension> <linkId value="q3" /> <text value="3. Trouble falling or staying asleep, or sleeping too much" /> <type value="choice" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="0" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q3" /> <code value="Not at all" /> <display value="Not at all" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="1" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q3" /> <code value="Several days" /> <display value="Several days" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="2" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q3" /> <code value="More than half the days" /> <display value="More than half the days" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="3" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q3" /> <code value="Nearly every day" /> <display value="Nearly every day" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/on-item-controls" /> <code value="push-button" /> </coding> </valueCodeableConcept> </extension> <linkId value="q4" /> <text value="4. Feeling tired or having little energy" /> <type value="choice" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="0" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q4" /> <code value="Not at all" /> <display value="Not at all" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="1" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q4" /> <code value="Several days" /> <display value="Several days" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="2" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q4" /> <code value="More than half the days" /> <display value="More than half the days" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="3" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q4" /> <code value="Nearly every day" /> <display value="Nearly every day" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/on-item-controls" /> <code value="push-button" /> </coding> </valueCodeableConcept> </extension> <linkId value="q5" /> <text value="5. Poor appetite or overeating" /> <type value="choice" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="0" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q5" /> <code value="Not at all" /> <display value="Not at all" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="1" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q5" /> <code value="Several days" /> <display value="Several days" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="2" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q5" /> <code value="More than half the days" /> <display value="More than half the days" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="3" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q5" /> <code value="Nearly every day" /> <display value="Nearly every day" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/on-item-controls" /> <code value="push-button" /> </coding> </valueCodeableConcept> </extension> <linkId value="q6" /> <text value="6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down" /> <type value="choice" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="0" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q6" /> <code value="Not at all" /> <display value="Not at all" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="1" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q6" /> <code value="Several days" /> <display value="Several days" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="2" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q6" /> <code value="More than half the days" /> <display value="More than half the days" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="3" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q6" /> <code value="Nearly every day" /> <display value="Nearly every day" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/on-item-controls" /> <code value="push-button" /> </coding> </valueCodeableConcept> </extension> <linkId value="q7" /> <text value="7. Trouble concentrating on things, such as reading the newspaper or watching television" /> <type value="choice" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="0" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q7" /> <code value="Not at all" /> <display value="Not at all" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="1" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q7" /> <code value="Several days" /> <display value="Several days" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="2" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q7" /> <code value="More than half the days" /> <display value="More than half the days" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="3" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q7" /> <code value="Nearly every day" /> <display value="Nearly every day" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/on-item-controls" /> <code value="push-button" /> </coding> </valueCodeableConcept> </extension> <linkId value="q8" /> <text value="8. Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual" /> <type value="choice" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="0" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q8" /> <code value="Not at all" /> <display value="Not at all" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="1" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q8" /> <code value="Several days" /> <display value="Several days" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="2" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q8" /> <code value="More than half the days" /> <display value="More than half the days" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="3" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q8" /> <code value="Nearly every day" /> <display value="Nearly every day" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/on-item-controls" /> <code value="push-button" /> </coding> </valueCodeableConcept> </extension> <linkId value="q9" /> <text value="9. Thoughts that you would be better off dead, or of hurting yourself in some way" /> <type value="choice" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="0" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q9" /> <code value="Not at all" /> <display value="Not at all" /> </valueCoding> </answerOption> <answerOption> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/option-note-info"> <extension url="style"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> </extension> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="1" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q9" /> <code value="Several days" /> <display value="Several days" /> </valueCoding> </answerOption> <answerOption> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/option-note-info"> <extension url="style"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> </extension> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="2" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q9" /> <code value="More than half the days" /> <display value="More than half the days" /> </valueCoding> </answerOption> <answerOption> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/option-note-info"> <extension url="style"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> </extension> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="3" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q9" /> <code value="Nearly every day" /> <display value="Nearly every day" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/on-item-controls" /> <code value="push-button" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="quoteAnswer"> <valueBoolean value="true" /> </extension> </extension> <linkId value="q10" /> <text value="10. If you indicated any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people" /> <type value="choice" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="0" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q10" /> <code value="Not difficult at all" /> <display value="Not difficult at all" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="1" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q10" /> <code value="Somewhat difficult" /> <display value="Somewhat difficult" /> </valueCoding> </answerOption> <answerOption> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/option-note-info"> <extension url="style"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> </extension> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="2" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q10" /> <code value="Very difficult" /> <display value="Very difficult" /> </valueCoding> </answerOption> <answerOption> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/option-note-info"> <extension url="style"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> </extension> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="3" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_q10" /> <code value="Extremely difficult" /> <display value="Extremely difficult" /> </valueCoding> </answerOption> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="text"> <valueString value="PHQ-9 Score: {{answer}}" /> </extension> </extension> <linkId value="phq9SS" /> <text> <extension url="http://hl7.org/fhir/StructureDefinition/cqf-expression"> <valueExpression> <description value="q1.p + q2.p + q3.p + q4.p + q5.p + q6.p + q7.p + q8.p + q9.p" /> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='q1').answer.value.weight() + %resource.repeat(item).where(linkId='q2').answer.value.weight() + %resource.repeat(item).where(linkId='q3').answer.value.weight() + %resource.repeat(item).where(linkId='q4').answer.value.weight() + %resource.repeat(item).where(linkId='q5').answer.value.weight() + %resource.repeat(item).where(linkId='q6').answer.value.weight() + %resource.repeat(item).where(linkId='q7').answer.value.weight() + %resource.repeat(item).where(linkId='q8').answer.value.weight() + %resource.repeat(item).where(linkId='q9').answer.value.weight()" /> </valueExpression> </extension> </text> <type value="display" /> </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="item83238507" /> <type value="display" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true" /> </extension> <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="section702092" /> <text value="GAD-7" /> <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/question-note-info"> <extension url="text"> <valueString value="GAD-7 Score:" /> </extension> </extension> <linkId value="item10370323" /> <text value="Please enter the Client's / Patient's most recent GAD-7 score:" /> <type value="string" /> <required value="true" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true" /> </extension> <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="item83970870" /> <text value="If there is no available GAD-7 score, please click here to complete GAD-7" /> <type value="boolean" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> </extension> <linkId value="gad_7" /> <type value="group" /> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="text"> <valueString value="Over the last 2 weeks:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Over the last 2 weeks:<br/>" /> </extension> </valueString> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="quoteAnswers"> <valueBoolean value="true" /> </extension> </extension> <linkId value="gad7Qs" /> <text value="Ask the Client: "Over the last 2 weeks, how often have you been bothered by the following problems?"" /> <type value="group" /> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/on-item-controls" /> <code value="push-button" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="quoteAnswer"> <valueBoolean value="true" /> </extension> </extension> <linkId value="gad7q1" /> <text value="1. Feeling nervous, anxious, or on edge" /> <type value="choice" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="0" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q1" /> <code value="Not at all" /> <display value="Not at all" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="1" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q1" /> <code value="Several days" /> <display value="Several days" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="2" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q1" /> <code value="Over half the days" /> <display value="Over half the days" /> </valueCoding> </answerOption> <answerOption> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/option-note-info"> <extension url="style"> <valueString value="font-weight:bold;color:#A6A900;" /> </extension> </extension> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="3" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q1" /> <code value="Nearly every day" /> <display value="Nearly every day" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/on-item-controls" /> <code value="push-button" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="quoteAnswer"> <valueBoolean value="true" /> </extension> </extension> <linkId value="gad7q2" /> <text value="2. Not being able to stop or control worrying" /> <type value="choice" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="0" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q2" /> <code value="Not at all" /> <display value="Not at all" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="1" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q2" /> <code value="Several days" /> <display value="Several days" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="2" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q2" /> <code value="Over half the days" /> <display value="Over half the days" /> </valueCoding> </answerOption> <answerOption> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/option-note-info"> <extension url="style"> <valueString value="font-weight:bold;color:#A6A900;" /> </extension> </extension> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="3" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q2" /> <code value="Nearly every day" /> <display value="Nearly every day" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/on-item-controls" /> <code value="push-button" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="quoteAnswer"> <valueBoolean value="true" /> </extension> </extension> <linkId value="gad7q3" /> <text value="3. Worrying too much about different things" /> <type value="choice" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="0" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q3" /> <code value="Not at all" /> <display value="Not at all" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="1" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q3" /> <code value="Several days" /> <display value="Several days" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="2" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q3" /> <code value="Over half the days" /> <display value="Over half the days" /> </valueCoding> </answerOption> <answerOption> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/option-note-info"> <extension url="style"> <valueString value="font-weight:bold;color:#A6A900;" /> </extension> </extension> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="3" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q3" /> <code value="Nearly every day" /> <display value="Nearly every day" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/on-item-controls" /> <code value="push-button" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="quoteAnswer"> <valueBoolean value="true" /> </extension> </extension> <linkId value="gad7q4" /> <text value="4. Trouble relaxing" /> <type value="choice" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="0" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q4" /> <code value="Not at all" /> <display value="Not at all" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="1" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q4" /> <code value="Several days" /> <display value="Several days" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="2" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q4" /> <code value="Over half the days" /> <display value="Over half the days" /> </valueCoding> </answerOption> <answerOption> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/option-note-info"> <extension url="style"> <valueString value="font-weight:bold;color:#A6A900;" /> </extension> </extension> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="3" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q4" /> <code value="Nearly every day" /> <display value="Nearly every day" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/on-item-controls" /> <code value="push-button" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="quoteAnswer"> <valueBoolean value="true" /> </extension> </extension> <linkId value="gad7q5" /> <text value="5. Being so restless that it's hard to sit still" /> <type value="choice" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="0" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q5" /> <code value="Not at all" /> <display value="Not at all" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="1" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q5" /> <code value="Several days" /> <display value="Several days" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="2" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q5" /> <code value="Over half the days" /> <display value="Over half the days" /> </valueCoding> </answerOption> <answerOption> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/option-note-info"> <extension url="style"> <valueString value="font-weight:bold;color:#A6A900;" /> </extension> </extension> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="3" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q5" /> <code value="Nearly every day" /> <display value="Nearly every day" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/on-item-controls" /> <code value="push-button" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="quoteAnswer"> <valueBoolean value="true" /> </extension> </extension> <linkId value="gad7q6" /> <text value="6. Becoming easily annoyed or irritable" /> <type value="choice" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="0" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q6" /> <code value="Not at all" /> <display value="Not at all" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="1" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q6" /> <code value="Several days" /> <display value="Several days" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="2" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q6" /> <code value="Over half the days" /> <display value="Over half the days" /> </valueCoding> </answerOption> <answerOption> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/option-note-info"> <extension url="style"> <valueString value="font-weight:bold;color:#A6A900;" /> </extension> </extension> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="3" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q6" /> <code value="Nearly every day" /> <display value="Nearly every day" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/on-item-controls" /> <code value="push-button" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="quoteAnswer"> <valueBoolean value="true" /> </extension> </extension> <linkId value="gad7q7" /> <text value="7. Feeling afraid as if something awful might happen" /> <type value="choice" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="0" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q7" /> <code value="Not at all" /> <display value="Not at all" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="1" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q7" /> <code value="Several days" /> <display value="Several days" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="2" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q7" /> <code value="Over half the days" /> <display value="Over half the days" /> </valueCoding> </answerOption> <answerOption> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/option-note-info"> <extension url="style"> <valueString value="font-weight:bold;color:#A6A900;" /> </extension> </extension> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="3" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_gad7q7" /> <code value="Nearly every day" /> <display value="Nearly every day" /> </valueCoding> </answerOption> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/on-item-controls" /> <code value="push-button" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="true" /> </extension> </extension> <linkId value="item37281656" /> <text value="8. If you indicated any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people" /> <type value="choice" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="0" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_item37281656" /> <code value="Not difficult at all" /> <display value="Not difficult at all" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="1" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_item37281656" /> <code value="Somewhat difficult" /> <display value="Somewhat difficult" /> </valueCoding> </answerOption> <answerOption> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/option-note-info"> <extension url="style"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> </extension> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="2" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_item37281656" /> <code value="Very difficult" /> <display value="Very difficult" /> </valueCoding> </answerOption> <answerOption> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/option-note-info"> <extension url="style"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> </extension> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="3" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/cmha-york-region-ont8365_item37281656" /> <code value="Extremely difficult" /> <display value="Extremely difficult" /> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="text"> <valueString value="GAD-7 Score: {{answer}}" /> </extension> </extension> <linkId value="gad7Score" /> <text> <extension url="http://hl7.org/fhir/StructureDefinition/cqf-expression"> <valueExpression> <description value="gad7q1.p + gad7q2.p + gad7q3.p + gad7q4.p + gad7q5.p + gad7q6.p + gad7q7.p" /> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='gad7q1').answer.value.weight() + %resource.repeat(item).where(linkId='gad7q2').answer.value.weight() + %resource.repeat(item).where(linkId='gad7q3').answer.value.weight() + %resource.repeat(item).where(linkId='gad7q4').answer.value.weight() + %resource.repeat(item).where(linkId='gad7q5').answer.value.weight() + %resource.repeat(item).where(linkId='gad7q6').answer.value.weight() + %resource.repeat(item).where(linkId='gad7q7').answer.value.weight()" /> </valueExpression> </extension> </text> <type value="display" /> </item> </item> </item> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-enableWhenExpression"> <valueExpression> <description value="prob.r != '' || pmhx.r != '' || fhx.r != '' || rx.r != '' || allg.r != '' || tx.r != '' || soc.r != ''" /> <language value="text/fhirpath" /> <expression value="%context.repeat(item).where(linkId='prob').answer.exists() or %context.repeat(item).where(linkId='pmhx').answer.exists() or %context.repeat(item).where(linkId='fhx').answer.exists() or %context.repeat(item).where(linkId='rx').answer.exists() or %context.repeat(item).where(linkId='allg').answer.exists() or %context.repeat(item).where(linkId='tx').answer.exists() or %context.repeat(item).where(linkId='soc').answer.exists()" /> </valueExpression> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="section13142135" /> <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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="<span/>" /> </extension> </valueString> </extension> </extension> <linkId value="includeCPP" /> <text value="Include CPP" /> <type value="boolean" /> <enableWhen> <question value="prob" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <enableWhen> <question value="pmhx" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <enableWhen> <question value="fhx" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <enableWhen> <question value="rx" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <enableWhen> <question value="allg" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <enableWhen> <question value="tx" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <enableWhen> <question value="soc" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="any" /> </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="CPP" /> </extension> <extension url="style"> <valueString value="font-weight:bold;text-decoration:underline;" /> </extension> </extension> <linkId value="s__section" /> <type value="group" /> <enableWhen> <question value="includeCPP" /> <operator value="=" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="all" /> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-enableWhenExpression"> <valueExpression> <description value="prob.r != ''" /> <language value="text/fhirpath" /> <expression value="%context.item.where(linkId='prob').answer.exists()" /> </valueExpression> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> </extension> <linkId value="i_ncurrent_problems_n" /> <text value="Current Problems:" /> <type value="group" /> <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" /> <type value="text" /> </item> </item> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-enableWhenExpression"> <valueExpression> <description value="pmhx.r != ''" /> <language value="text/fhirpath" /> <expression value="%context.item.where(linkId='pmhx').answer.exists()" /> </valueExpression> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> </extension> <linkId value="i_npast_medical_histo" /> <text value="Past Medical History:" /> <type value="group" /> <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" /> <type value="text" /> </item> </item> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-enableWhenExpression"> <valueExpression> <description value="fhx.r != ''" /> <language value="text/fhirpath" /> <expression value="%context.item.where(linkId='fhx').answer.exists()" /> </valueExpression> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> </extension> <linkId value="i_nfamily_history_n" /> <text value="Family History:" /> <type value="group" /> <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="fhx" /> <type value="text" /> </item> </item> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-enableWhenExpression"> <valueExpression> <description value="rx.r != ''" /> <language value="text/fhirpath" /> <expression value="%context.item.where(linkId='rx').answer.exists()" /> </valueExpression> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> </extension> <linkId value="i_nmedications_n" /> <text value="Medications:" /> <type value="group" /> <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" /> <type value="text" /> </item> </item> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-enableWhenExpression"> <valueExpression> <description value="allg.r != ''" /> <language value="text/fhirpath" /> <expression value="%context.item.where(linkId='allg').answer.exists()" /> </valueExpression> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> </extension> <linkId value="allergies" /> <text value="Allergies:" /> <type value="group" /> <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="allg" /> <type value="text" /> </item> </item> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-enableWhenExpression"> <valueExpression> <description value="tx.r != ''" /> <language value="text/fhirpath" /> <expression value="%context.item.where(linkId='tx').answer.exists()" /> </valueExpression> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="text"> <valueString value="Treatments"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Treatments<br/>" /> </extension> </valueString> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> </extension> <linkId value="i_ntreatments_n" /> <text value="Treatments:" /> <type value="group" /> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%`var-ptCpp.tx`" /> </valueExpression> </extension> <linkId value="tx" /> <type value="text" /> </item> </item> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-enableWhenExpression"> <valueExpression> <description value="soc.r != ''" /> <language value="text/fhirpath" /> <expression value="%context.item.where(linkId='soc').answer.exists()" /> </valueExpression> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> </extension> <linkId value="i_nsocial_history_n" /> <text value="Social History:" /> <type value="group" /> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%`var-ptCpp.soc`" /> </valueExpression> </extension> <linkId value="soc" /> <type value="text" /> </item> </item> </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="section41290342" /> <text value="Thank you for completing this referral to the Ontario Structured Psychotherapy (OSP) program." /> <type value="group" /> <item> <linkId value="item29241412" /> <text value="Next Steps: Please note that an email with subject title "OSP Referral Follow up – Information Required" will be sent to the email address provided within the next 72 hours. If no email is received beyond that time and you have checked your Junk Mail or Spam folder for the message, please call 1-866-345-0224 ext 1343 to follow-up."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Next Steps:<br/> <br/>Please note that an email with subject title "OSP Referral Follow up – Information Required" will be sent to the email address provided within the next 72 hours. If no email is received beyond that time and you have checked your Junk Mail or Spam folder for the message, please call 1-866-345-0224 ext 1343 to follow-up." /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="display" /> </item> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="section98670638" /> <type value="group" /> <item> <linkId value="item7654630" /> <text value="See image"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="<img src="#img-1" alt="untitled" />" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/referencesContained"> <valueReference> <reference value="#img-1" /> </valueReference> </extension> </text> <type value="display" /> </item> <item> <linkId value="item45542220" /> <text value="See image"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="<img src="#img-2" alt="untitled" />" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/referencesContained"> <valueReference> <reference value="#img-2" /> </valueReference> </extension> </text> <type value="display" /> </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> <linkId value="section98896179" /> <text value="Export Analytics" /> <type value="group" /> <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="referralService" /> <text value="MENTAL_HEALTH_ASSESSMENT_AND_REFERRAL" /> <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="referralDescription" /> <text value="Ontario Structured Psychotherapy Program" /> <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 value="Ontario Structured Psychotherapy Program" /> <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_diagnosis" /> <text> <extension url="http://hl7.org/fhir/StructureDefinition/cqf-expression"> <valueExpression> <description value="(function() {; 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