<status value="active" /> <experimental value="true" /> <subjectType value="Patient" /> <date value="2026-01-20T15:05:51.993+00:00" /> <publisher value="Ontario Health & Amplify Care" /> <effectivePeriod> <start value="2025-02-03" /> </effectivePeriod> <code> <system value="http://snomed.info/sct" /> <code value="789718008" /> <display value="Cardiology service" /> </code> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="list" /> <display value="List" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="patient_header" /> <text value="Patient Information"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="group" /> <item> <linkId value="patient_surname" /> <text value="Surname:" /> <type value="string" /> <required value="true" /> </item> <item> <linkId value="patient_firstname" /> <text value="First Name:" /> <type value="string" /> <required value="true" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/entryFormat"> <valueString value="yyyy/MM/dd" /> </extension> <linkId value="patient_date_of_birth" /> <text value="DOB:" /> <type value="date" /> <required value="true" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="radio-button" /> <display value="Radio Button" /> </coding> </valueCodeableConcept> </extension> <linkId value="patient_gender" /> <text value="Gender:" /> <type value="choice" /> <required value="true" /> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/administrative-gender" /> <code value="male" /> <display value="Male" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/administrative-gender" /> <code value="female" /> <display value="Female" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/administrative-gender" /> <code value="other" /> <display value="Other" /> </valueCoding> </answerOption> </item> <item> <linkId value="patient_hc_pc" /> <text value="HN PC:" /> <type value="string" /> <maxLength value="2" /> <item> <linkId value="patient_hc_number" /> <text value="HN:" /> <type value="string" /> <maxLength value="10" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/minLength"> <valueInteger value="2" /> </extension> <linkId value="patient_hc_vc" /> <text value="HN VC:" /> <type value="string" /> </item> </item> <item> <linkId value="patient_address_line1" /> <text value="Address (Line 1):" /> <type value="string" /> <required value="true" /> <item> <linkId value="patient_address_line2" /> <text value="Address (Line 2):" /> <type value="string" /> </item> <item> <linkId value="patient_address_city" /> <text value="City:" /> <type value="string" /> <required value="true" /> </item> <item> <linkId value="patient_address_province" /> <text value="Province:" /> <type value="string" /> <required value="true" /> <maxLength value="2" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="pat-pcode" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='patient_address_postalcode').answer.all(value.matches('^(?!.*[DFIOQU])[A-VXY][0-9][A-Z] ?[0-9][A-Z][0-9]$'))" /> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid Canadian postal-code" /> </extension> </extension> <linkId value="patient_address_postalcode" /> <text value="Postal Code:" /> <type value="string" /> <required value="true" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="mobilephone" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='patient_phone_mobile').answer.all(value.matches('^(\+\d{1,2}\s?)?$?\d{3}$?[\s.-]?\d{3}[\s.-]?\d{4}$'))" /> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid phone number" /> </extension> </extension> <linkId value="patient_phone_mobile" /> <text value="Mobile #:" /> <type value="string" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="homephone" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='patient_phone_home').answer.all(value.matches('^(\+\d{1,2}\s?)?$?\d{3}$?[\s.-]?\d{3}[\s.-]?\d{4}$'))" /> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid phone number" /> </extension> </extension> <linkId value="patient_phone_home" /> <text value="Home #:" /> <type value="string" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="busphone" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='patient_phone_business').answer.all(value.matches('^(\+\d{1,2}\s?)?$?\d{3}$?[\s.-]?\d{3}[\s.-]?\d{4}$'))" /> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid phone number" /> </extension> </extension> <linkId value="patient_phone_business" /> <text value="Business #:" /> <type value="string" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="patemail" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='patient_email').answer.all(value.matches('(?:[a-z0-9!#$%&'*+/=?^_`{|}~-]+(?:\.[a-z0-9!#$%&'*+/=?^_`{|}~-]+)*|"(?:[\x01-\x08\x0b\x0c\x0e-\x1f\x21\x23-\x5b\x5d-\x7f]|\\[\x01-\x09\x0b\x0c\x0e-\x7f])*")@(?:(?:[a-z0-9](?:[a-z0-9-]*[a-z0-9])?\.)+[a-z0-9](?:[a-z0-9-]*[a-z0-9])?|\[(?:(?:(2(5[0-5]|[0-4][0-9])|1[0-9][0-9]|[1-9]?[0-9]))\.){3}(?:(2(5[0-5]|[0-4][0-9])|1[0-9][0-9]|[1-9]?[0-9])|[a-z0-9-]*[a-z0-9]:(?:[\x01-\x08\x0b\x0c\x0e-\x1f\x21-\x5a\x53-\x7f]|\\[\x01-\x09\x0b\x0c\x0e-\x7f])+)\])'))" /> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid email address" /> </extension> </extension> <linkId value="patient_email" /> <text value="Email:" /> <type value="string" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="additionalinfo_header" /> <text value="[Optional] Additional Patient Information"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="[Optional] Additional Patient Information " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="group" /> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" /> <code value="push-button" /> <display value="Push Button" /> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_sexassignedatbirth" /> <text value="Sex assigned at birth:" /> <type value="choice" /> <answerOption> <valueCoding> <system value="http://loinc.org" /> <code value="LA3-6" /> <display value="Female" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://loinc.org" /> <code value="LA2-8" /> <display value="Male" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/eforms/CodeSystem/exampleCS" /> <code value="Intersex" /> <display value="Intersex" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://loinc.org" /> <code value="LA4489-6" /> <display value="Unknown" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" /> <code value="push-button" /> <display value="Push Button" /> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_pronouns" /> <text value="Pronouns:" /> <type value="choice" /> <answerOption> <valueCoding> <system value="http://loinc.org" /> <code value="LA29519-8" /> <display value="She/Her" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://loinc.org" /> <code value="LA29518-0" /> <display value="He/Him" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://loinc.org" /> <code value="LA29519-8" /> <display value="They/Them" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="other" /> </valueCoding> </answerOption> <item> <linkId value="additionalinfo_pronouns_other" /> <text value="Other pronouns:" /> <type value="string" /> <enableWhen> <question value="additionalinfo_pronouns" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="other" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" /> <code value="push-button" /> <display value="Push Button" /> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_preferredlanguage" /> <text value="Preferred language:" /> <type value="choice" /> <required value="false" /> <answerOption> <valueCoding> <system value="urn:ietf:bcp:47" /> <code value="en" /> <display value="English" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="urn:ietf:bcp:47" /> <code value="fr" /> <display value="French" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="other" /> </valueCoding> </answerOption> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="additionalinfo_preferredlanguage_specify" /> <text value="Specify:" /> <type value="string" /> <enableWhen> <question value="additionalinfo_preferredlanguage" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="other" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="additionalinfo_preferredlanguage_translatorrequired" /> <text value="Translator required"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <enableWhen> <question value="additionalinfo_preferredlanguage" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="other" /> </answerCoding> </enableWhen> <repeats value="true" /> <answerOption> <valueString value="Translator Required" /> </answerOption> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" /> <code value="push-button" /> <display value="Push Button" /> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_bestmethodofcontact" /> <text value="Best method of contact:" /> <type value="choice" /> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/contact-point-use" /> <code value="mobile" /> <display value="Mobile" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/contact-point-use" /> <code value="home" /> <display value="Home" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/contact-point-use" /> <code value="work" /> <display value="Work" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/contact-point-system" /> <code value="email" /> <display value="Email" /> </valueCoding> </answerOption> <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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="additionalinfo_bestmethodofcontact_voicemails" /> <text value="Voicemails acceptable"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <enableWhen> <question value="additionalinfo_bestmethodofcontact" /> <operator value="=" /> <answerCoding> <system value="http://hl7.org/fhir/contact-point-use" /> <code value="mobile" /> <display value="Mobile" /> </answerCoding> </enableWhen> <enableBehavior value="any" /> <repeats value="true" /> <answerOption> <valueString value="Voicemails acceptable" /> </answerOption> </item> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="additionalinfo_preferredname_select" /> <text value="Preferred name"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <repeats value="true" /> <answerOption> <valueString value="Preferred Name" /> </answerOption> </item> <item> <linkId value="additionalinfo_preferredname" /> <text value="Prefered name String"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <enableWhen> <question value="additionalinfo_preferredname_select" /> <operator value="=" /> <answerString value="Preferred Name" /> </enableWhen> <enableBehavior value="all" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_alternatecontact_select" /> <text value="Alternate contact"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <repeats value="true" /> <answerOption> <valueString value="Alternate contact" /> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="additionalinfo_alternatecontact_name" /> <text value="Name:" /> <type value="string" /> <enableWhen> <question value="additionalinfo_alternatecontact_select" /> <operator value="=" /> <answerString value="Alternate contact" /> </enableWhen> <enableBehavior value="all" /> <required value="true" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="altphone" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='additionalinfo_alternatecontact_phone').answer.all(value.matches('^(\+\d{1,2}\s?)?$?\d{3}$?[\s.-]?\d{3}[\s.-]?\d{4}$'))" /> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid phone number" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="additionalinfo_alternatecontact_phone" /> <text value="Alternate contact phone #:" /> <type value="string" /> <enableWhen> <question value="additionalinfo_alternatecontact_select" /> <operator value="=" /> <answerString value="Alternate contact" /> </enableWhen> <enableBehavior value="all" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="additionalinfo_alternatecontact_relationship" /> <text value="Relationship:" /> <type value="string" /> <enableWhen> <question value="additionalinfo_alternatecontact_select" /> <operator value="=" /> <answerString value="Alternate contact" /> </enableWhen> <enableBehavior value="all" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="radio-button" /> <display value="Radio Button" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="additionalinfo_alternatecontact_bookingcontact" /> <text value="Is Alternate contact the appointment booking contact?:" /> <type value="choice" /> <enableWhen> <question value="additionalinfo_alternatecontact_select" /> <operator value="=" /> <answerString value="Alternate contact" /> </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> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_unsafecontacts_select" /> <text value="Unsafe contact persons (do not speak with)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <repeats value="true" /> <answerOption> <valueString value="Unsafe contact persons (do not speak with)" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="additionalinfo_unsafecontacts_speakwithpatientdirectly" /> <text value="Only speak with patient directly"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <enableWhen> <question value="additionalinfo_unsafecontacts_select" /> <operator value="=" /> <answerString value="Unsafe contact persons (do not speak with)" /> </enableWhen> <enableBehavior value="all" /> <repeats value="true" /> <answerOption> <valueString value="Only speak with patient directly" /> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="additionalinfo_unsafecontacts_donotspeakwith" /> <text value="Do not speak with:" /> <type value="string" /> <enableWhen> <question value="additionalinfo_unsafecontacts_select" /> <operator value="=" /> <answerString value="Unsafe contact persons (do not speak with)" /> </enableWhen> <enableBehavior value="all" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_accessibilityconcernsordisability_selectt" /> <text value="Accessibility concerns or disability"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <repeats value="true" /> <answerOption> <valueString value="Accessibility concerns or disability" /> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" /> <code value="push-button" /> <display value="Push Button" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="additionalinfo_accessibilityconcernsordisability" /> <text value="Accessibility concerns Options"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> </text> <type value="choice" /> <enableWhen> <question value="additionalinfo_accessibilityconcernsordisability_selectt" /> <operator value="=" /> <answerString value="Accessibility concerns or disability" /> </enableWhen> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="129839007" /> <display value="Falls risk" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="301621006" /> <display value="Patient requires lift" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="105503008" /> <display value="Wheelchair" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="15188001" /> <display value="Hearing impaired" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_specialconsiderations_select" /> <text value="Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <repeats value="true" /> <answerOption> <valueString value="Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)" /> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="additionalinfo_specialconsiderations" /> <text value="Details of special considerations:" /> <type value="text" /> <enableWhen> <question value="additionalinfo_specialconsiderations_select" /> <operator value="=" /> <answerString value="Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)" /> </enableWhen> <required value="true" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_sendcopiestoadditionalproviders" /> <text value="Send copies of reports to additional providers"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <repeats value="true" /> <answerOption> <valueString value="Send copies of reports to additional providers" /> </answerOption> </item> <item> <linkId value="additionalinfo_sendcopiestoadditionalproviders_names" /> <text value="Name(s):" /> <type value="string" /> <enableWhen> <question value="additionalinfo_sendcopiestoadditionalproviders" /> <operator value="=" /> <answerString value="Send copies of reports to additional providers" /> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <item> <linkId value="additionalinfo_sendcopiestoadditionalproviders_contactinfo" /> <text value="Contact information:" /> <type value="string" /> <enableWhen> <question value="additionalinfo_sendcopiestoadditionalproviders" /> <operator value="=" /> <answerString value="Send copies of reports to additional providers" /> </enableWhen> <enableBehavior value="all" /> <required value="true" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="additionalinfo_sendcopiestoadditionalproviders_ispcp" /> <text value="This is the Primary Care Provider"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <enableWhen> <question value="additionalinfo_sendcopiestoadditionalproviders" /> <operator value="=" /> <answerString value="Send copies of reports to additional providers" /> </enableWhen> <enableBehavior value="all" /> <repeats value="true" /> <answerOption> <valueString value="This is the Primary Care Provider" /> </answerOption> </item> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="sortIndex"> <valuePositiveInt value="1" /> </extension> <extension url="text"> <valueString value="Referral Details"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" Referral Details " /> </extension> </valueString> </extension> <extension url="style"> <valueString value="font-weight:bold;text-decoration:underline;" /> </extension> <extension url="groupItems"> <valueBoolean value="false" /> </extension> </extension> <linkId value="102173268919" /> <text value="Referral Details"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Referral Details " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;color:#202035;" /> </extension> </text> <type value="group" /> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="true" /> </valueExpression> </extension> <extension url="sortIndex"> <valuePositiveInt value="1" /> </extension> <extension url="text"> <valueString value="Triage Considerations" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> </extension> <linkId value="cardio_triagecons" /> <text value="Triage Considerations"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Triage Considerations " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="group" /> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" /> <code value="push-button" /> <display value="Push Button" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sortIndex"> <valuePositiveInt value="1" /> </extension> <extension url="text"> <valueString value="Requested Priority:" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#EE6B00;" /> </extension> </extension> <linkId value="referral_requestedpriority" /> <text value="Requested Priority:" /> <type value="choice" /> <required value="true" /> <answerOption> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/option-note-info"> <extension url="text"> <valueString value="Routine" /> </extension> <extension url="style"> <valueString value="font-weight:bold;color:#EE6B00;" /> </extension> </extension> <valueCoding> <system value="http://hl7.org/fhir/request-priority" /> <code value="routine" /> <display value="Routine" /> </valueCoding> <initialSelected value="true" /> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/request-priority" /> <code value="urgent" /> <display value="Urgent" /> </valueCoding> </answerOption> <item> <linkId value="referral_requestedpriority_urgentreason" /> <text value="Reason for urgent triage" /> <type value="string" /> <enableWhen> <question value="referral_requestedpriority" /> <operator value="=" /> <answerCoding> <system value="http://hl7.org/fhir/request-priority" /> <code value="urgent" /> <display value="Urgent" /> </answerCoding> </enableWhen> <required value="true" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sortIndex"> <valuePositiveInt value="2" /> </extension> <extension url="text"> <valueString value="Second Opinion" /> </extension> </extension> <linkId value="referral_secondopinion" /> <text value="Second Opinion"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="77406008" /> <display value="Second or third medical opinion" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="referral_secondopinion_reason" /> <text value="Reason for second opinion:" /> <type value="text" /> <enableWhen> <question value="referral_secondopinion" /> <operator value="=" /> <answerCoding> <system value="http://snomed.info/sct" /> <code value="77406008" /> <display value="Second or third medical opinion" /> </answerCoding> </enableWhen> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="sortIndex"> <valuePositiveInt value="2" /> </extension> <extension url="text"> <valueString value="Service(s) Requested" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> </extension> <linkId value="695991571585" /> <text value="Service(s) Requested Select all that apply:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Service(s) Requested Select all that apply: " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="color:Gray20;" /> </extension> </text> <type value="group" /> <required value="true" /> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression"> <valueExpression> <description value="Calculates HSC services based on selected checkboxes for cardiac testing and cardiology consult" /> <language value="text/fhirpath" /> <expression value="iif(%resource.item.where(linkId='223886162384').answer.value.exists(), 'CARDIOLOGY_SERVICES', '') + iif(%resource.item.where(linkId='223886162384').answer.value.exists() and %resource.item.where(linkId='785727177547').answer.value.exists(), '|', '') + iif(%resource.item.where(linkId='785727177547').answer.value.exists(), 'CARDIOLOGY', '')" /> </valueExpression> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="HSCs Assigned:" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true" /> </extension> <linkId value="referralService" /> <text value="HSCs Assigned:" /> <type value="string" /> <readOnly value="true" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="223886162384" /> <text value="Cardiac Testing"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20001" /> <display value="Cardiac Testing" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="660331267409" /> <text value="Exam(s) Requested"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Exam(s) Requested " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="color:Gray20;font-weight:bold;" /> </extension> </text> <type value="group" /> <enableWhen> <question value="223886162384" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20001" /> <display value="Cardiac Testing" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="720409326878" /> <text value="24 Hour Ambulatory Blood Pressure Monitoring (Not OHIP Covered)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20003" /> <display value="24 Hour Ambulatory Blood Pressure Monitoring (Not OHIP Covered)" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="960455115596" /> <text value="Coronary Angiogram"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20004" /> <display value="Coronary Angiogram" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="297634898828" /> <text value="Echocardiogram - Resting"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20005" /> <display value="Echocardiogram - Resting" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="443484577720" /> <text value="sub Echocardiogram - Resting"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="group" /> <enableWhen> <question value="297634898828" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20005" /> <display value="Echocardiogram - Resting" /> </answerCoding> </enableWhen> <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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="165530569567" /> <text value="Echocardiogram (2D)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20012" /> <display value="Echocardiogram (2D)" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="286552421895" /> <text value="Echocardiogram with Contrast"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20013" /> <display value="Echocardiogram with Contrast" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="910527687300" /> <text value="Echocardiogram with Saline (Bubble)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20014" /> <display value="Echocardiogram with Saline (Bubble)" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="657824763133" /> <text value="Pediatric Echocardiogram"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20015" /> <display value="Pediatric Echocardiogram" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="992743200182" /> <text value="Transesophageal Echocardiogram (TEE)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20016" /> <display value="Transesophageal Echocardiogram (TEE)" /> </valueCoding> </answerOption> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="894277763438" /> <text value="Electrocardiogram (ECG)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20006" /> <display value="Electrocardiogram (ECG)" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="279226023495" /> <text value="Holter Monitoring"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20007" /> <display value="Holter Monitoring" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="440449731882" /> <text value="sub holter monitoring"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="group" /> <enableWhen> <question value="279226023495" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20007" /> <display value="Holter Monitoring" 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</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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="423992261841" /> <text value="48 Hours"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20018" /> <display value="48 Hours" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="419924239187" /> <text value="72 Hours"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20019" /> <display value="72 Hours" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="731054417270" /> <text value="7 Days"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20020" /> <display value="7 Days" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="235876421044" /> <text value="14 Days"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20021" /> <display value="14 Days" /> </valueCoding> </answerOption> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="374742834400" /> <text value="Loop / Event Monitor"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20008" /> <display value="Loop / Event Monitor" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="159161544747" /> <text value="Cardiovascular stress testing"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code 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<extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="814218498309" /> <text value="ECG - Exercise Stress Test"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20022" /> <display value="ECG - Exercise Stress Test" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="307107493993" /> <text value="ECG - Dobutamine/Persantine Stress Test"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20023" /> <display value="ECG - Dobutamine/Persantine Stress Test" /> </valueCoding> </answerOption> </item> <item> <extension 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</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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="193586908489" /> <text value="Echocardiogram - Dobutamine/Persantine Stress Test"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code 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</answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="892165959617" /> <text value="Myocardial perfusion scan"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20028" /> <display value="MIBI Scans / 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<text value="Tilt Table Testing"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20011" /> <display value="Tilt Table Testing" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="cardiology_referral_services_cardiactesting_other" /> <text value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="other" /> </valueCoding> </answerOption> </item> <item> <linkId value="cardiology_referral_services_cardiactesting_other_specify" /> <text value="Specify" /> <type value="text" /> <enableWhen> <question value="cardiology_referral_services_cardiactesting_other" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="other" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="785727177547" /> <text value="Cardiology Consultation"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20002" /> <display value="Cardiology Consultation" /> </valueCoding> </answerOption> </item> </item> <item> <linkId value="186952778859" /> <text value="Concern(s) / Indication(s) Triggering Referral Select all that apply:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Concern(s) / Indication(s) Triggering Referral Select all that apply: " /> </extension> </text> <type value="group" /> <required value="true" /> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="219569805461" /> <text value="Arrhythmias or Palpitations"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="698247007" /> <display value="Arrhythmias or Palpitations" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="571934328499" /> <text value="Cardiovascular Risk Assessment"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20033" /> <display value="Cardiovascular Risk Assessment" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="459737733395" /> <text value="Chest Pain or Angina"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20034" /> <display value="Chest Pain or Angina" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="929919815516" /> <text value="Congenital Heart Disease"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20035" /> <display value="Congenital Heart Disease" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="832263816528" /> <text value="Congestive Heart Failure"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20036" /> <display value="Congestive Heart Failure" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="803760213460" /> <text value="Coronary Artery Disease"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20037" /> <display value="Coronary Artery Disease" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="129767162379" /> <text value="Dyspnea"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20038" /> <display value="Dyspnea" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="116150628533" /> <text value="Hypertension"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20039" /> <display value="Hypertension" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="513825527027" /> <text value="Murmur"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20040" /> <display value="Murmur" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="975075898688" /> <text value="Pericardial Disease"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20041" /> <display value="Pericardial Disease" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="704148928571" /> <text value="Peripheral Edema"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20042" /> <display value="Peripheral Edema" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="886489617115" /> <text value="Post-Myocardial Infarction"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20043" /> <display value="Post-Myocardial Infarction" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="621745958993" /> <text value="Pre-operative Consultation"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20044" /> <display value="Pre-operative Consultation" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="873024527134" /> <code> <system value="http://snomed.info/sct" /> <code value="439272007" /> <display value="Date of procedure" /> </code> <text value="Procedure Date (if known)" /> <type value="date" /> <enableWhen> <question value="621745958993" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20044" /> <display value="Pre-operative Consultation" /> </answerCoding> </enableWhen> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="197975129599" /> <text value="Syncope"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20045" /> <display value="Syncope" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="675849150752" /> <text value="Valvular Heart Disease or Prosthetic Heart Valve"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="368009" /> <display value="Valvular Heart Disease or Prosthetic Heart Valve" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="721982740516" /> <text value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="other" /> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="720594942482" /> <text value="Specify" /> <type value="text" /> <enableWhen> <question value="721982740516" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="other" /> </answerCoding> </enableWhen> <required value="true" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="Descriptionofclinicalquestion" /> <text value="Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="text" /> <required value="true" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="cpp_header" /> <text value="Cumulative Patient Profile Please delete any sensitive information you do not intend to share from the CPP"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Cumulative Patient Profile Please delete any sensitive information you do not intend to share from the CPP" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="cpp_separate" /> <text value="CPP attached separately (if not entered below)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <repeats value="true" /> <answerOption> <valueString value="CPP attached separately (if not entered below)" /> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="cpp_currentprob" /> <code> <system value="http://snomed.info/sct" /> <code value="55607006" /> <display value="Problem" /> </code> <text value="Current Problem List:" /> <type value="text" /> <enableWhen> <question value="cpp_separate" /> <operator value="exists" /> <answerBoolean value="false" /> </enableWhen> <enableBehavior value="all" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="cpp_pastmedicalhistory" /> <code> <system value="http://snomed.info/sct" /> <code value="417662000" /> <display value="History of clinical finding in subject" /> </code> <text value="Past Medical History:" /> <type value="text" /> <enableWhen> <question value="cpp_separate" /> <operator value="exists" /> <answerBoolean value="false" /> </enableWhen> <enableBehavior value="all" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="cpp_currentmedications" /> <code> <system value="http://snomed.info/sct" /> <code value="129019007" /> <display value="Taking medication" /> </code> <text value="Current Medications :" /> <type value="text" /> <enableWhen> <question value="cpp_separate" /> <operator value="exists" /> <answerBoolean value="false" /> </enableWhen> <enableBehavior value="all" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="cpp_familyhistory" /> <code> <system value="http://snomed.info/sct" /> <code value="57177007" /> <display value="Family history with explicit context" /> </code> <text value="Family History:" /> <type value="text" /> <enableWhen> <question value="cpp_separate" /> <operator value="exists" /> <answerBoolean value="false" /> </enableWhen> <enableBehavior value="all" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="cpp_allergies" /> <code> <system value="http://snomed.info/sct" /> <code value="609328004" /> <display value="Allergic disposition" /> </code> <text value="Allergies:" /> <type value="text" /> <enableWhen> <question value="cpp_separate" /> <operator value="exists" /> <answerBoolean value="false" /> </enableWhen> <enableBehavior value="all" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="preferredconsultlocation_header" /> <text value="Preferred Consultant or Location All patients will be triaged to the shortest wait time unless a preferred consultant or location is entered."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Preferred Consultant or Location All patients will be triaged to the shortest wait time unless a preferred consultant or location is entered." /> </extension> </text> <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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="preferredconsultlocation_selector" /> <text value="Preferred consultant or location"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <repeats value="true" /> <answerOption> <valueString value="Preferred consultant or location" /> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="preferredconsultlocation_specify" /> <text value="Please specify either a preferred consultant or location"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Please specify either a preferred consultant or location" /> </extension> </text> <type value="group" /> <enableWhen> <question value="preferredconsultlocation_selector" /> <operator value="=" /> <answerString value="Preferred consultant or location" /> </enableWhen> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="preferredconsultlocation_consultant" /> <text value="Consultant:" /> <type value="string" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="preferredconsultlocation_location" /> <text value="Location:" /> <type value="string" /> </item> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="preferredconsultlocation_willingtotravel" /> <text value="Patient willing to travel for shorter wait time"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <repeats value="true" /> <answerOption> <valueString value="Patient willing to travel for shorter wait time" /> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <linkId value="preferredconsultlocation_otherconsiderations" /> <text value="Other considerations:" /> <type value="string" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="supportingdocumentation_header" /> <text value="Supporting Documentation Please attach all relevant laboratory and diagnostic investigations."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Supporting Documentation Please attach all relevant laboratory and diagnostic investigations. " /> </extension> </text> <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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="supportingdocumentation_details" /> <text value="Personal Health Information that is medically relevant has not been disclosed at the request of the patient."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="string" /> <repeats value="true" /> <answerOption> <valueString value="Personal Health Information that is medically relevant has not been disclosed at the request of the patient." /> </answerOption> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="application/pdf" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="image/gif" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="image/bmp" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="application/vnd.openxmlformats-officedocument.spreadsheetml.sheet" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="video/mp4" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="text/csv" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="image/jpeg" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="application/msword" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="image/png" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="application/vnd.openxmlformats-officedocument.wordprocessingml.document" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="application/vnd.ms-excel" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="text/plain" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="audio/mp4" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="audio/mpeg" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="image/tiff" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/maxSize"> <valueDecimal value="5000000" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="positiveText"> <valueString value="Attachment Provided" /> </extension> </extension> <linkId value="supportingdocumentation_attachment" /> <text value="Add Attachments" /> <type value="attachment" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="feedbacksurvey_cardiology" /> <text value="Click here to provide feedback on this form"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="<a href="https://www.surveymonkey.com/r/cardioSRF" rel="noopener noreferrer" target="_blank">Click here to provide feedback on this form</a> " /> </extension> </text> <type value="display" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:grey;border-style:solid;" /> </extension> <linkId value="referrer_header" /> <text value="Referrer's Information"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="group" /> <item> <linkId value="referrer_sitename" /> <text value="Site Name:" /> <type value="string" /> </item> <item> <linkId value="referrer_address_line1" /> <text value="Address (Line 1):" /> <type value="string" /> <required value="true" /> <item> <linkId value="referrer_address_line2" /> <text value="Address (Line 2):" /> <type value="string" /> </item> <item> <linkId value="referrer_address_city" /> <text value="City:" /> <type value="string" /> <required value="true" /> </item> <item> <linkId value="referrer_address_province" /> <text value="Province:" /> <type value="string" /> <required value="true" /> <maxLength value="2" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="ref-pcode" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='referrer_address_postalcode').answer.all(value.matches('^(?!.*[DFIOQU])[A-VXY][0-9][A-Z] ?[0-9][A-Z][0-9]$'))" /> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid Canadian postal-code" /> </extension> </extension> <linkId value="referrer_address_postalcode" /> <text value="Postal Code:" /> <type value="string" /> <required value="true" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="refphone" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='referrer_phone').answer.all(value.matches('^(\+\d{1,2}\s?)?$?\d{3}$?[\s.-]?\d{3}[\s.-]?\d{4}$'))" /> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid phone number" /> </extension> </extension> <linkId value="referrer_phone" /> <text value="Phone #:" /> <type value="string" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="reffax" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='referrer_fax').answer.all(value.matches('^(\+\d{1,2}\s?)?$?\d{3}$?[\s.-]?\d{3}[\s.-]?\d{4}$'))" /> </valueExpression> </extension> <extension url="human"> <valueString value="Must be a valid phone number" /> </extension> </extension> <linkId value="referrer_fax" /> <text value="Fax #:" /> <type value="string" /> </item> <item> <linkId value="referrer_billing" /> <text value="Billing Number:" /> <type value="integer" /> </item> <item> <linkId value="referrer_professionalid" /> <text value="Professional ID:" /> <type value="integer" /> </item> <item> <linkId value="referrer_signature" /> <text value="Signed:" /> <type value="text" /> <required value="true" /> </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" /> <display value="Drop down" /> </coding> </valueCodeableConcept> </extension> <linkId value="referrer_role" /> <text value="Role:" /> <type value="choice" /> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="309398001" /> <display value="Allied Health Professional" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="62247001" /> <display value="Family Physician" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="449161006" /> <display value="Physician Assistant" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="398130009" /> <display value="Medical Student" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="106292003" /> <display value="Nurse" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="224571005" /> <display value="Nurse Practitioner" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="405277009" /> <display value="Resident" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="69280009" /> <display value="Specialist" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="other" /> </valueCoding> </answerOption> </item> </item> </Questionnaire>


  
    
      
      
    
  
  
    
  
  
    
      
    
  
  
  
  
  <status value="active" />
  <experimental value="true" />
  <subjectType value="Patient" />
  <date value="2026-01-20T15:05:51.993+00:00" />
  <publisher value="Ontario Health & Amplify Care" />
  <effectivePeriod>
    <start value="2025-02-03" />
  </effectivePeriod>
  <code>
    <system value="http://snomed.info/sct" />
    <code value="789718008" />
    <display value="Cardiology service" />
  </code>
  <item>
    <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl">
      <valueCodeableConcept>
        <coding>
          <system value="http://hl7.org/fhir/questionnaire-item-control" />
          <code value="list" />
          <display value="List" />
        </coding>
      </valueCodeableConcept>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
      <valueString value="background-color:grey;border-style:solid;" />
    </extension>
    <linkId value="patient_header" />
    <text value="Patient Information">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="font-weight:bold;" />
      </extension>
    </text>
    <type value="group" />
    <item>
      <linkId value="patient_surname" />
      <text value="Surname:" />
      <type value="string" />
      <required value="true" />
    </item>
    <item>
      <linkId value="patient_firstname" />
      <text value="First Name:" />
      <type value="string" />
      <required value="true" />
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/entryFormat">
        <valueString value="yyyy/MM/dd" />
      </extension>
      <linkId value="patient_date_of_birth" />
      <text value="DOB:" />
      <type value="date" />
      <required value="true" />
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl">
        <valueCodeableConcept>
          <coding>
            <system value="http://hl7.org/fhir/questionnaire-item-control" />
            <code value="radio-button" />
            <display value="Radio Button" />
          </coding>
        </valueCodeableConcept>
      </extension>
      <linkId value="patient_gender" />
      <text value="Gender:" />
      <type value="choice" />
      <required value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://hl7.org/fhir/administrative-gender" />
          <code value="male" />
          <display value="Male" />
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://hl7.org/fhir/administrative-gender" />
          <code value="female" />
          <display value="Female" />
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://hl7.org/fhir/administrative-gender" />
          <code value="other" />
          <display value="Other" />
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <linkId value="patient_hc_pc" />
      <text value="HN PC:" />
      <type value="string" />
      <maxLength value="2" />
      <item>
        <linkId value="patient_hc_number" />
        <text value="HN:" />
        <type value="string" />
        <maxLength value="10" />
      </item>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/minLength">
          <valueInteger value="2" />
        </extension>
        <linkId value="patient_hc_vc" />
        <text value="HN VC:" />
        <type value="string" />
      </item>
    </item>
    <item>
      <linkId value="patient_address_line1" />
      <text value="Address (Line 1):" />
      <type value="string" />
      <required value="true" />
      <item>
        <linkId value="patient_address_line2" />
        <text value="Address (Line 2):" />
        <type value="string" />
      </item>
      <item>
        <linkId value="patient_address_city" />
        <text value="City:" />
        <type value="string" />
        <required value="true" />
      </item>
      <item>
        <linkId value="patient_address_province" />
        <text value="Province:" />
        <type value="string" />
        <required value="true" />
        <maxLength value="2" />
      </item>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint">
          <extension url="key">
            <valueId value="pat-pcode" />
          </extension>
          <extension url="severity">
            <valueCode value="error" />
          </extension>
          <extension url="expression">
            <valueExpression>
              <language value="text/fhirpath" />
              <expression value="%resource.repeat(item).where(linkId='patient_address_postalcode').answer.all(value.matches('^(?!.*[DFIOQU])[A-VXY][0-9][A-Z] ?[0-9][A-Z][0-9]$'))" />
            </valueExpression>
          </extension>
          <extension url="human">
            <valueString value="Must be a valid Canadian postal-code" />
          </extension>
        </extension>
        <linkId value="patient_address_postalcode" />
        <text value="Postal Code:" />
        <type value="string" />
        <required value="true" />
      </item>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint">
        <extension url="key">
          <valueId value="mobilephone" />
        </extension>
        <extension url="severity">
          <valueCode value="error" />
        </extension>
        <extension url="expression">
          <valueExpression>
            <language value="text/fhirpath" />
            <expression value="%resource.repeat(item).where(linkId='patient_phone_mobile').answer.all(value.matches('^(\+\d{1,2}\s?)?\(?\d{3}\)?[\s.-]?\d{3}[\s.-]?\d{4}$'))" />
          </valueExpression>
        </extension>
        <extension url="human">
          <valueString value="Must be a valid phone number" />
        </extension>
      </extension>
      <linkId value="patient_phone_mobile" />
      <text value="Mobile #:" />
      <type value="string" />
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint">
        <extension url="key">
          <valueId value="homephone" />
        </extension>
        <extension url="severity">
          <valueCode value="error" />
        </extension>
        <extension url="expression">
          <valueExpression>
            <language value="text/fhirpath" />
            <expression value="%resource.repeat(item).where(linkId='patient_phone_home').answer.all(value.matches('^(\+\d{1,2}\s?)?\(?\d{3}\)?[\s.-]?\d{3}[\s.-]?\d{4}$'))" />
          </valueExpression>
        </extension>
        <extension url="human">
          <valueString value="Must be a valid phone number" />
        </extension>
      </extension>
      <linkId value="patient_phone_home" />
      <text value="Home #:" />
      <type value="string" />
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint">
        <extension url="key">
          <valueId value="busphone" />
        </extension>
        <extension url="severity">
          <valueCode value="error" />
        </extension>
        <extension url="expression">
          <valueExpression>
            <language value="text/fhirpath" />
            <expression value="%resource.repeat(item).where(linkId='patient_phone_business').answer.all(value.matches('^(\+\d{1,2}\s?)?\(?\d{3}\)?[\s.-]?\d{3}[\s.-]?\d{4}$'))" />
          </valueExpression>
        </extension>
        <extension url="human">
          <valueString value="Must be a valid phone number" />
        </extension>
      </extension>
      <linkId value="patient_phone_business" />
      <text value="Business #:" />
      <type value="string" />
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint">
        <extension url="key">
          <valueId value="patemail" />
        </extension>
        <extension url="severity">
          <valueCode value="error" />
        </extension>
        <extension url="expression">
          <valueExpression>
            <language value="text/fhirpath" />
            <expression value="%resource.repeat(item).where(linkId='patient_email').answer.all(value.matches('(?:[a-z0-9!#$%&'*+/=?^_`{|}~-]+(?:\.[a-z0-9!#$%&'*+/=?^_`{|}~-]+)*|"(?:[\x01-\x08\x0b\x0c\x0e-\x1f\x21\x23-\x5b\x5d-\x7f]|\\[\x01-\x09\x0b\x0c\x0e-\x7f])*")@(?:(?:[a-z0-9](?:[a-z0-9-]*[a-z0-9])?\.)+[a-z0-9](?:[a-z0-9-]*[a-z0-9])?|\[(?:(?:(2(5[0-5]|[0-4][0-9])|1[0-9][0-9]|[1-9]?[0-9]))\.){3}(?:(2(5[0-5]|[0-4][0-9])|1[0-9][0-9]|[1-9]?[0-9])|[a-z0-9-]*[a-z0-9]:(?:[\x01-\x08\x0b\x0c\x0e-\x1f\x21-\x5a\x53-\x7f]|\\[\x01-\x09\x0b\x0c\x0e-\x7f])+)\])'))" />
          </valueExpression>
        </extension>
        <extension url="human">
          <valueString value="Must be a valid email address" />
        </extension>
      </extension>
      <linkId value="patient_email" />
      <text value="Email:" />
      <type value="string" />
    </item>
  </item>
  <item>
    <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
      <valueString value="background-color:grey;border-style:solid;" />
    </extension>
    <linkId value="additionalinfo_header" />
    <text value="[Optional] Additional Patient Information">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
        <valueString value="[Optional]&#xa0;Additional&#xa0;Patient&#xa0;Information<br/>" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="font-weight:bold;" />
      </extension>
    </text>
    <type value="group" />
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
        <valueCode value="horizontal" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl">
        <valueCodeableConcept>
          <coding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
            <code value="push-button" />
            <display value="Push Button" />
          </coding>
        </valueCodeableConcept>
      </extension>
      <linkId value="additionalinfo_sexassignedatbirth" />
      <text value="Sex assigned at birth:" />
      <type value="choice" />
      <answerOption>
        <valueCoding>
          <system value="http://loinc.org" />
          <code value="LA3-6" />
          <display value="Female" />
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://loinc.org" />
          <code value="LA2-8" />
          <display value="Male" />
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/eforms/CodeSystem/exampleCS" />
          <code value="Intersex" />
          <display value="Intersex" />
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://loinc.org" />
          <code value="LA4489-6" />
          <display value="Unknown" />
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl">
        <valueCodeableConcept>
          <coding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
            <code value="push-button" />
            <display value="Push Button" />
          </coding>
        </valueCodeableConcept>
      </extension>
      <linkId value="additionalinfo_pronouns" />
      <text value="Pronouns:" />
      <type value="choice" />
      <answerOption>
        <valueCoding>
          <system value="http://loinc.org" />
          <code value="LA29519-8" />
          <display value="She/Her" />
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://loinc.org" />
          <code value="LA29518-0" />
          <display value="He/Him" />
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://loinc.org" />
          <code value="LA29519-8" />
          <display value="They/Them" />
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
          <code value="OTH" />
          <display value="other" />
        </valueCoding>
      </answerOption>
      <item>
        <linkId value="additionalinfo_pronouns_other" />
        <text value="Other pronouns:" />
        <type value="string" />
        <enableWhen>
          <question value="additionalinfo_pronouns" />
          <operator value="=" />
          <answerCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="other" />
          </answerCoding>
        </enableWhen>
        <enableBehavior value="all" />
        <required value="true" />
      </item>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
        <valueCode value="horizontal" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl">
        <valueCodeableConcept>
          <coding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
            <code value="push-button" />
            <display value="Push Button" />
          </coding>
        </valueCodeableConcept>
      </extension>
      <linkId value="additionalinfo_preferredlanguage" />
      <text value="Preferred language:" />
      <type value="choice" />
      <required value="false" />
      <answerOption>
        <valueCoding>
          <system value="urn:ietf:bcp:47" />
          <code value="en" />
          <display value="English" />
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="urn:ietf:bcp:47" />
          <code value="fr" />
          <display value="French" />
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
          <code value="OTH" />
          <display value="other" />
        </valueCoding>
      </answerOption>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="background-color:white;border-style:solid;" />
        </extension>
        <linkId value="additionalinfo_preferredlanguage_specify" />
        <text value="Specify:" />
        <type value="string" />
        <enableWhen>
          <question value="additionalinfo_preferredlanguage" />
          <operator value="=" />
          <answerCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="other" />
          </answerCoding>
        </enableWhen>
        <enableBehavior value="all" />
        <required value="true" />
      </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" />
              <display value="Check-box" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="background-color:white;border-style:solid;" />
        </extension>
        <linkId value="additionalinfo_preferredlanguage_translatorrequired" />
        <text value="Translator required">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<br/>" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="additionalinfo_preferredlanguage" />
          <operator value="=" />
          <answerCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="other" />
          </answerCoding>
        </enableWhen>
        <repeats value="true" />
        <answerOption>
          <valueString value="Translator Required" />
        </answerOption>
      </item>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl">
        <valueCodeableConcept>
          <coding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
            <code value="push-button" />
            <display value="Push Button" />
          </coding>
        </valueCodeableConcept>
      </extension>
      <linkId value="additionalinfo_bestmethodofcontact" />
      <text value="Best method of contact:" />
      <type value="choice" />
      <answerOption>
        <valueCoding>
          <system value="http://hl7.org/fhir/contact-point-use" />
          <code value="mobile" />
          <display value="Mobile" />
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://hl7.org/fhir/contact-point-use" />
          <code value="home" />
          <display value="Home" />
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://hl7.org/fhir/contact-point-use" />
          <code value="work" />
          <display value="Work" />
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://hl7.org/fhir/contact-point-system" />
          <code value="email" />
          <display value="Email" />
        </valueCoding>
      </answerOption>
      <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" />
              <display value="Check-box" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="background-color:white;border-style:solid;" />
        </extension>
        <linkId value="additionalinfo_bestmethodofcontact_voicemails" />
        <text value="Voicemails acceptable">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<br/>" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="additionalinfo_bestmethodofcontact" />
          <operator value="=" />
          <answerCoding>
            <system value="http://hl7.org/fhir/contact-point-use" />
            <code value="mobile" />
            <display value="Mobile" />
          </answerCoding>
        </enableWhen>
        <enableBehavior value="any" />
        <repeats value="true" />
        <answerOption>
          <valueString value="Voicemails acceptable" />
        </answerOption>
      </item>
    </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" />
            <display value="Check-box" />
          </coding>
        </valueCodeableConcept>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="background-color:white;border-style:solid;" />
      </extension>
      <linkId value="additionalinfo_preferredname_select" />
      <text value="Preferred name">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
          <valueString value="<br/>" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
      </text>
      <type value="string" />
      <repeats value="true" />
      <answerOption>
        <valueString value="Preferred Name" />
      </answerOption>
    </item>
    <item>
      <linkId value="additionalinfo_preferredname" />
      <text value="Prefered name String">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
          <valueString value="<br/>" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
      </text>
      <type value="string" />
      <enableWhen>
        <question value="additionalinfo_preferredname_select" />
        <operator value="=" />
        <answerString value="Preferred Name" />
      </enableWhen>
      <enableBehavior value="all" />
    </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" />
            <display value="Check-box" />
          </coding>
        </valueCodeableConcept>
      </extension>
      <linkId value="additionalinfo_alternatecontact_select" />
      <text value="Alternate contact">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
          <valueString value="<br/>" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
      </text>
      <type value="string" />
      <repeats value="true" />
      <answerOption>
        <valueString value="Alternate contact" />
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="background-color:white;border-style:solid;" />
      </extension>
      <linkId value="additionalinfo_alternatecontact_name" />
      <text value="Name:" />
      <type value="string" />
      <enableWhen>
        <question value="additionalinfo_alternatecontact_select" />
        <operator value="=" />
        <answerString value="Alternate contact" />
      </enableWhen>
      <enableBehavior value="all" />
      <required value="true" />
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint">
        <extension url="key">
          <valueId value="altphone" />
        </extension>
        <extension url="severity">
          <valueCode value="error" />
        </extension>
        <extension url="expression">
          <valueExpression>
            <language value="text/fhirpath" />
            <expression value="%resource.repeat(item).where(linkId='additionalinfo_alternatecontact_phone').answer.all(value.matches('^(\+\d{1,2}\s?)?\(?\d{3}\)?[\s.-]?\d{3}[\s.-]?\d{4}$'))" />
          </valueExpression>
        </extension>
        <extension url="human">
          <valueString value="Must be a valid phone number" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="background-color:white;border-style:solid;" />
      </extension>
      <linkId value="additionalinfo_alternatecontact_phone" />
      <text value="Alternate contact phone #:" />
      <type value="string" />
      <enableWhen>
        <question value="additionalinfo_alternatecontact_select" />
        <operator value="=" />
        <answerString value="Alternate contact" />
      </enableWhen>
      <enableBehavior value="all" />
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="background-color:white;border-style:solid;" />
      </extension>
      <linkId value="additionalinfo_alternatecontact_relationship" />
      <text value="Relationship:" />
      <type value="string" />
      <enableWhen>
        <question value="additionalinfo_alternatecontact_select" />
        <operator value="=" />
        <answerString value="Alternate contact" />
      </enableWhen>
      <enableBehavior value="all" />
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl">
        <valueCodeableConcept>
          <coding>
            <system value="http://hl7.org/fhir/questionnaire-item-control" />
            <code value="radio-button" />
            <display value="Radio Button" />
          </coding>
        </valueCodeableConcept>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
        <valueCode value="horizontal" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="background-color:white;border-style:solid;" />
      </extension>
      <linkId value="additionalinfo_alternatecontact_bookingcontact" />
      <text value="Is Alternate contact the appointment booking contact?:" />
      <type value="choice" />
      <enableWhen>
        <question value="additionalinfo_alternatecontact_select" />
        <operator value="=" />
        <answerString value="Alternate contact" />
      </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>
    </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" />
            <display value="Check-box" />
          </coding>
        </valueCodeableConcept>
      </extension>
      <linkId value="additionalinfo_unsafecontacts_select" />
      <text value="Unsafe contact persons (do not speak with)">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
          <valueString value="<br/>" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
      </text>
      <type value="string" />
      <repeats value="true" />
      <answerOption>
        <valueString value="Unsafe contact persons (do not speak with)" />
      </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" />
            <display value="Check-box" />
          </coding>
        </valueCodeableConcept>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="background-color:white;border-style:solid;" />
      </extension>
      <linkId value="additionalinfo_unsafecontacts_speakwithpatientdirectly" />
      <text value="Only speak with patient directly">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
          <valueString value="<br/>" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
      </text>
      <type value="string" />
      <enableWhen>
        <question value="additionalinfo_unsafecontacts_select" />
        <operator value="=" />
        <answerString value="Unsafe contact persons (do not speak with)" />
      </enableWhen>
      <enableBehavior value="all" />
      <repeats value="true" />
      <answerOption>
        <valueString value="Only speak with patient directly" />
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="background-color:white;border-style:solid;" />
      </extension>
      <linkId value="additionalinfo_unsafecontacts_donotspeakwith" />
      <text value="Do not speak with:" />
      <type value="string" />
      <enableWhen>
        <question value="additionalinfo_unsafecontacts_select" />
        <operator value="=" />
        <answerString value="Unsafe contact persons (do not speak with)" />
      </enableWhen>
      <enableBehavior value="all" />
    </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" />
            <display value="Check-box" />
          </coding>
        </valueCodeableConcept>
      </extension>
      <linkId value="additionalinfo_accessibilityconcernsordisability_selectt" />
      <text value="Accessibility concerns or disability">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
          <valueString value="<br/>" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
      </text>
      <type value="string" />
      <repeats value="true" />
      <answerOption>
        <valueString value="Accessibility concerns or disability" />
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
        <valueCode value="horizontal" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl">
        <valueCodeableConcept>
          <coding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
            <code value="push-button" />
            <display value="Push Button" />
          </coding>
        </valueCodeableConcept>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="background-color:white;border-style:solid;" />
      </extension>
      <linkId value="additionalinfo_accessibilityconcernsordisability" />
      <text value="Accessibility concerns Options">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
          <valueString value="<br/>" />
        </extension>
      </text>
      <type value="choice" />
      <enableWhen>
        <question value="additionalinfo_accessibilityconcernsordisability_selectt" />
        <operator value="=" />
        <answerString value="Accessibility concerns or disability" />
      </enableWhen>
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://snomed.info/sct" />
          <code value="129839007" />
          <display value="Falls risk" />
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://snomed.info/sct" />
          <code value="301621006" />
          <display value="Patient requires lift" />
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://snomed.info/sct" />
          <code value="105503008" />
          <display value="Wheelchair" />
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://snomed.info/sct" />
          <code value="15188001" />
          <display value="Hearing impaired" />
        </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" />
            <display value="Check-box" />
          </coding>
        </valueCodeableConcept>
      </extension>
      <linkId value="additionalinfo_specialconsiderations_select" />
      <text value="Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
          <valueString value="<br/>" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
      </text>
      <type value="string" />
      <repeats value="true" />
      <answerOption>
        <valueString value="Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)" />
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="background-color:white;border-style:solid;" />
      </extension>
      <linkId value="additionalinfo_specialconsiderations" />
      <text value="Details of special considerations:" />
      <type value="text" />
      <enableWhen>
        <question value="additionalinfo_specialconsiderations_select" />
        <operator value="=" />
        <answerString value="Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)" />
      </enableWhen>
      <required value="true" />
    </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" />
            <display value="Check-box" />
          </coding>
        </valueCodeableConcept>
      </extension>
      <linkId value="additionalinfo_sendcopiestoadditionalproviders" />
      <text value="Send copies of reports to additional providers">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
          <valueString value="<br/>" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
      </text>
      <type value="string" />
      <repeats value="true" />
      <answerOption>
        <valueString value="Send copies of reports to additional providers" />
      </answerOption>
    </item>
    <item>
      <linkId value="additionalinfo_sendcopiestoadditionalproviders_names" />
      <text value="Name(s):" />
      <type value="string" />
      <enableWhen>
        <question value="additionalinfo_sendcopiestoadditionalproviders" />
        <operator value="=" />
        <answerString value="Send copies of reports to additional providers" />
      </enableWhen>
      <enableBehavior value="all" />
      <required value="true" />
      <item>
        <linkId value="additionalinfo_sendcopiestoadditionalproviders_contactinfo" />
        <text value="Contact information:" />
        <type value="string" />
        <enableWhen>
          <question value="additionalinfo_sendcopiestoadditionalproviders" />
          <operator value="=" />
          <answerString value="Send copies of reports to additional providers" />
        </enableWhen>
        <enableBehavior value="all" />
        <required value="true" />
      </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" />
              <display value="Check-box" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <linkId value="additionalinfo_sendcopiestoadditionalproviders_ispcp" />
        <text value="This is the Primary Care Provider">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<br/>" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="additionalinfo_sendcopiestoadditionalproviders" />
          <operator value="=" />
          <answerString value="Send copies of reports to additional providers" />
        </enableWhen>
        <enableBehavior value="all" />
        <repeats value="true" />
        <answerOption>
          <valueString value="This is the Primary Care Provider" />
        </answerOption>
      </item>
    </item>
  </item>
  <item>
    <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
      <valueString value="background-color:grey;border-style:solid;" />
    </extension>
    <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info">
      <extension url="sortIndex">
        <valuePositiveInt value="1" />
      </extension>
      <extension url="text">
        <valueString value="Referral Details">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<br/>Referral Details<br/>" />
          </extension>
        </valueString>
      </extension>
      <extension url="style">
        <valueString value="font-weight:bold;text-decoration:underline;" />
      </extension>
      <extension url="groupItems">
        <valueBoolean value="false" />
      </extension>
    </extension>
    <linkId value="102173268919" />
    <text value="Referral Details">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
        <valueString value="Referral&#xa0;Details<br/>" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="font-weight:bold;color:#202035;" />
      </extension>
    </text>
    <type value="group" />
    <item>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info">
        <extension url="enableWhenExpression">
          <valueExpression>
            <language value="text/fhirpath" />
            <expression value="true" />
          </valueExpression>
        </extension>
        <extension url="sortIndex">
          <valuePositiveInt value="1" />
        </extension>
        <extension url="text">
          <valueString value="Triage Considerations" />
        </extension>
        <extension url="style">
          <valueString value="font-weight:bold;" />
        </extension>
      </extension>
      <linkId value="cardio_triagecons" />
      <text value="Triage Considerations">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
          <valueString value="Triage&#xa0;Considerations<br/><br/>" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="font-weight:bold;" />
        </extension>
      </text>
      <type value="group" />
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl">
          <valueCodeableConcept>
            <coding>
              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
              <code value="push-button" />
              <display value="Push Button" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="sortIndex">
            <valuePositiveInt value="1" />
          </extension>
          <extension url="text">
            <valueString value="Requested Priority:" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="answerStyle">
            <valueString value="font-weight:bold;color:#EE6B00;" />
          </extension>
        </extension>
        <linkId value="referral_requestedpriority" />
        <text value="Requested Priority:" />
        <type value="choice" />
        <required value="true" />
        <answerOption>
          <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/option-note-info">
            <extension url="text">
              <valueString value="Routine" />
            </extension>
            <extension url="style">
              <valueString value="font-weight:bold;color:#EE6B00;" />
            </extension>
          </extension>
          <valueCoding>
            <system value="http://hl7.org/fhir/request-priority" />
            <code value="routine" />
            <display value="Routine" />
          </valueCoding>
          <initialSelected value="true" />
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://hl7.org/fhir/request-priority" />
            <code value="urgent" />
            <display value="Urgent" />
          </valueCoding>
        </answerOption>
        <item>
          <linkId value="referral_requestedpriority_urgentreason" />
          <text value="Reason for urgent triage" />
          <type value="string" />
          <enableWhen>
            <question value="referral_requestedpriority" />
            <operator value="=" />
            <answerCoding>
              <system value="http://hl7.org/fhir/request-priority" />
              <code value="urgent" />
              <display value="Urgent" />
            </answerCoding>
          </enableWhen>
          <required value="true" />
        </item>
      </item>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
        </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" />
              <display value="Check-box" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="sortIndex">
            <valuePositiveInt value="2" />
          </extension>
          <extension url="text">
            <valueString value="Second Opinion" />
          </extension>
        </extension>
        <linkId value="referral_secondopinion" />
        <text value="Second Opinion">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<br/>" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://snomed.info/sct" />
            <code value="77406008" />
            <display value="Second or third medical opinion" />
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="background-color:white;border-style:solid;" />
        </extension>
        <linkId value="referral_secondopinion_reason" />
        <text value="Reason for second opinion:" />
        <type value="text" />
        <enableWhen>
          <question value="referral_secondopinion" />
          <operator value="=" />
          <answerCoding>
            <system value="http://snomed.info/sct" />
            <code value="77406008" />
            <display value="Second or third medical opinion" />
          </answerCoding>
        </enableWhen>
      </item>
    </item>
    <item>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info">
        <extension url="sortIndex">
          <valuePositiveInt value="2" />
        </extension>
        <extension url="text">
          <valueString value="Service(s) Requested" />
        </extension>
        <extension url="style">
          <valueString value="font-weight:bold;" />
        </extension>
      </extension>
      <linkId value="695991571585" />
      <text value="Service(s) Requested Select all that apply:">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
          <valueString value="<b>Service(s)&#xa0;Requested</b><br/><i>Select&#xa0;all&#xa0;that&#xa0;apply:</i><br/><br/>" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="color:Gray20;" />
        </extension>
      </text>
      <type value="group" />
      <required value="true" />
      <item>
        <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression">
          <valueExpression>
            <description value="Calculates HSC services based on selected checkboxes for cardiac testing and cardiology consult" />
            <language value="text/fhirpath" />
            <expression value="iif(%resource.item.where(linkId='223886162384').answer.value.exists(), 'CARDIOLOGY_SERVICES', '') + iif(%resource.item.where(linkId='223886162384').answer.value.exists() and %resource.item.where(linkId='785727177547').answer.value.exists(), '|', '') + iif(%resource.item.where(linkId='785727177547').answer.value.exists(), 'CARDIOLOGY', '')" />
          </valueExpression>
        </extension>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="HSCs Assigned:" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden">
          <valueBoolean value="true" />
        </extension>
        <linkId value="referralService" />
        <text value="HSCs Assigned:" />
        <type value="string" />
        <readOnly value="true" />
      </item>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
        </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" />
              <display value="Check-box" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <linkId value="223886162384" />
        <text value="Cardiac Testing">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<br/>" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20001" />
            <display value="Cardiac Testing" />
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="background-color:white;border-style:solid;" />
        </extension>
        <linkId value="660331267409" />
        <text value="Exam(s) Requested">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="Exam(s)&#xa0;Requested<br/><br/>" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="color:Gray20;font-weight:bold;" />
          </extension>
        </text>
        <type value="group" />
        <enableWhen>
          <question value="223886162384" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20001" />
            <display value="Cardiac Testing" />
          </answerCoding>
        </enableWhen>
        <enableBehavior value="all" />
        <item>
          <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
            <valueCode value="horizontal" />
          </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" />
                <display value="Check-box" />
              </coding>
            </valueCodeableConcept>
          </extension>
          <linkId value="720409326878" />
          <text value="24 Hour Ambulatory Blood Pressure Monitoring (Not OHIP Covered)">
            <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
              <valueString value="<br/>" />
            </extension>
            <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
              <valueString value="display:none;" />
            </extension>
          </text>
          <type value="choice" />
          <repeats value="true" />
          <answerOption>
            <valueCoding>
              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
              <code value="20003" />
              <display value="24 Hour Ambulatory Blood Pressure Monitoring (Not OHIP Covered)" />
            </valueCoding>
          </answerOption>
        </item>
        <item>
          <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
            <valueCode value="horizontal" />
          </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" />
                <display value="Check-box" />
              </coding>
            </valueCodeableConcept>
          </extension>
          <linkId value="960455115596" />
          <text value="Coronary Angiogram">
            <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
              <valueString value="<br/>" />
            </extension>
            <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
              <valueString value="display:none;" />
            </extension>
          </text>
          <type value="choice" />
          <repeats value="true" />
          <answerOption>
            <valueCoding>
              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
              <code value="20004" />
              <display value="Coronary Angiogram" />
            </valueCoding>
          </answerOption>
        </item>
        <item>
          <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
            <valueCode value="horizontal" />
          </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" />
                <display value="Check-box" />
              </coding>
            </valueCodeableConcept>
          </extension>
          <linkId value="297634898828" />
          <text value="Echocardiogram - Resting">
            <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
              <valueString value="<br/>" />
            </extension>
            <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
              <valueString value="display:none;" />
            </extension>
          </text>
          <type value="choice" />
          <repeats value="true" />
          <answerOption>
            <valueCoding>
              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
              <code value="20005" />
              <display value="Echocardiogram - Resting" />
            </valueCoding>
          </answerOption>
        </item>
        <item>
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="background-color:grey;border-style:solid;" />
          </extension>
          <linkId value="443484577720" />
          <text value="sub Echocardiogram - Resting">
            <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
              <valueString value="<br/>" />
            </extension>
            <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
              <valueString value="display:none;" />
            </extension>
          </text>
          <type value="group" />
          <enableWhen>
            <question value="297634898828" />
            <operator value="=" />
            <answerCoding>
              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
              <code value="20005" />
              <display value="Echocardiogram - Resting" />
            </answerCoding>
          </enableWhen>
          <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" />
                  <display value="Check-box" />
                </coding>
              </valueCodeableConcept>
            </extension>
            <linkId value="165530569567" />
            <text value="Echocardiogram (2D)">
              <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
                <valueString value="<br/>" />
              </extension>
              <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
                <valueString value="display:none;" />
              </extension>
            </text>
            <type value="choice" />
            <repeats value="true" />
            <answerOption>
              <valueCoding>
                <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
                <code value="20012" />
                <display value="Echocardiogram (2D)" />
              </valueCoding>
            </answerOption>
          </item>
          <item>
            <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
              <valueCode value="horizontal" />
            </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" />
                  <display value="Check-box" />
                </coding>
              </valueCodeableConcept>
            </extension>
            <linkId value="286552421895" />
            <text value="Echocardiogram with Contrast">
              <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
                <valueString value="<br/>" />
              </extension>
              <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
                <valueString value="display:none;" />
              </extension>
            </text>
            <type value="choice" />
            <repeats value="true" />
            <answerOption>
              <valueCoding>
                <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
                <code value="20013" />
                <display value="Echocardiogram with Contrast" />
              </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" />
                  <display value="Check-box" />
                </coding>
              </valueCodeableConcept>
            </extension>
            <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
              <valueCode value="horizontal" />
            </extension>
            <linkId value="910527687300" />
            <text value="Echocardiogram with Saline (Bubble)">
              <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
                <valueString value="<br/>" />
              </extension>
              <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
                <valueString value="display:none;" />
              </extension>
            </text>
            <type value="choice" />
            <repeats value="true" />
            <answerOption>
              <valueCoding>
                <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
                <code value="20014" />
                <display value="Echocardiogram with Saline (Bubble)" />
              </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" />
                  <display value="Check-box" />
                </coding>
              </valueCodeableConcept>
            </extension>
            <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
              <valueCode value="horizontal" />
            </extension>
            <linkId value="657824763133" />
            <text value="Pediatric Echocardiogram">
              <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
                <valueString value="<br/>" />
              </extension>
              <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
                <valueString value="display:none;" />
              </extension>
            </text>
            <type value="choice" />
            <repeats value="true" />
            <answerOption>
              <valueCoding>
                <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
                <code value="20015" />
                <display value="Pediatric Echocardiogram" />
              </valueCoding>
            </answerOption>
          </item>
          <item>
            <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
              <valueCode value="horizontal" />
            </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" />
                  <display value="Check-box" />
                </coding>
              </valueCodeableConcept>
            </extension>
            <linkId value="992743200182" />
            <text value="Transesophageal Echocardiogram (TEE)">
              <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
                <valueString value="<br/>" />
              </extension>
              <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
                <valueString value="display:none;" />
              </extension>
            </text>
            <type value="choice" />
            <repeats value="true" />
            <answerOption>
              <valueCoding>
                <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
                <code value="20016" />
                <display value="Transesophageal Echocardiogram (TEE)" />
              </valueCoding>
            </answerOption>
          </item>
        </item>
        <item>
          <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
            <valueCode value="horizontal" />
          </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" />
                <display value="Check-box" />
              </coding>
            </valueCodeableConcept>
          </extension>
          <linkId value="894277763438" />
          <text value="Electrocardiogram (ECG)">
            <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
              <valueString value="<br/>" />
            </extension>
            <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
              <valueString value="display:none;" />
            </extension>
          </text>
          <type value="choice" />
          <repeats value="true" />
          <answerOption>
            <valueCoding>
              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
              <code value="20006" />
              <display value="Electrocardiogram (ECG)" />
            </valueCoding>
          </answerOption>
        </item>
        <item>
          <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
            <valueCode value="horizontal" />
          </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" />
                <display value="Check-box" />
              </coding>
            </valueCodeableConcept>
          </extension>
          <linkId value="279226023495" />
          <text value="Holter Monitoring">
            <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
              <valueString value="<br/>" />
            </extension>
            <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
              <valueString value="display:none;" />
            </extension>
          </text>
          <type value="choice" />
          <repeats value="true" />
          <answerOption>
            <valueCoding>
              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
              <code value="20007" />
              <display value="Holter Monitoring" />
            </valueCoding>
          </answerOption>
        </item>
        <item>
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="background-color:grey;border-style:solid;" />
          </extension>
          <linkId value="440449731882" />
          <text value="sub holter monitoring">
            <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
              <valueString value="<br/>" />
            </extension>
            <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
              <valueString value="display:none;" />
            </extension>
          </text>
          <type value="group" />
          <enableWhen>
            <question value="279226023495" />
            <operator value="=" />
            <answerCoding>
              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
              <code value="20007" />
              <display value="Holter Monitoring" />
            </answerCoding>
          </enableWhen>
          <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" />
                  <display value="Check-box" />
                </coding>
              </valueCodeableConcept>
            </extension>
            <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
              <valueCode value="horizontal" />
            </extension>
            <linkId value="671328703851" />
            <text value="24 Hours">
              <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
                <valueString value="<br/>" />
              </extension>
              <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
                <valueString value="display:none;" />
              </extension>
            </text>
            <type value="choice" />
            <repeats value="true" />
            <answerOption>
              <valueCoding>
                <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
                <code value="20017" />
                <display value="24 Hours" />
              </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" />
                  <display value="Check-box" />
                </coding>
              </valueCodeableConcept>
            </extension>
            <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
              <valueCode value="horizontal" />
            </extension>
            <linkId value="423992261841" />
            <text value="48 Hours">
              <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
                <valueString value="<br/>" />
              </extension>
              <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
                <valueString value="display:none;" />
              </extension>
            </text>
            <type value="choice" />
            <repeats value="true" />
            <answerOption>
              <valueCoding>
                <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
                <code value="20018" />
                <display value="48 Hours" />
              </valueCoding>
            </answerOption>
          </item>
          <item>
            <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl">
              <valueCodeableConcept>
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        </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" />
              <display value="Check-box" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <linkId value="785727177547" />
        <text value="Cardiology Consultation">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<br/>" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20002" />
            <display value="Cardiology Consultation" />
          </valueCoding>
        </answerOption>
      </item>
    </item>
    <item>
      <linkId value="186952778859" />
      <text value="Concern(s) / Indication(s) Triggering Referral Select all that apply:">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
          <valueString value="<b>Concern(s)&#xa0;/&#xa0;Indication(s)&#xa0;Triggering&#xa0;Referral</b><br/><i>Select&#xa0;all&#xa0;that&#xa0;apply:</i><br/>" />
        </extension>
      </text>
      <type value="group" />
      <required value="true" />
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl">
          <valueCodeableConcept>
            <coding>
              <system value="http://hl7.org/fhir/questionnaire-item-control" />
              <code value="check-box" />
              <display value="Check-box" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <linkId value="219569805461" />
        <text value="Arrhythmias or Palpitations">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<br/>" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://snomed.info/sct" />
            <code value="698247007" />
            <display value="Arrhythmias or Palpitations" />
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl">
          <valueCodeableConcept>
            <coding>
              <system value="http://hl7.org/fhir/questionnaire-item-control" />
              <code value="check-box" />
              <display value="Check-box" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <linkId value="571934328499" />
        <text value="Cardiovascular Risk Assessment">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<br/>" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20033" />
            <display value="Cardiovascular Risk Assessment" />
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl">
          <valueCodeableConcept>
            <coding>
              <system value="http://hl7.org/fhir/questionnaire-item-control" />
              <code value="check-box" />
              <display value="Check-box" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <linkId value="459737733395" />
        <text value="Chest Pain or Angina">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<br/>" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20034" />
            <display value="Chest Pain or Angina" />
          </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" />
              <display value="Check-box" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
        </extension>
        <linkId value="929919815516" />
        <text value="Congenital Heart Disease">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<br/>" />
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          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
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        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20035" />
            <display value="Congenital Heart Disease" />
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl">
          <valueCodeableConcept>
            <coding>
              <system value="http://hl7.org/fhir/questionnaire-item-control" />
              <code value="check-box" />
              <display value="Check-box" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <linkId value="832263816528" />
        <text value="Congestive Heart Failure">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<br/>" />
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          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
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        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20036" />
            <display value="Congestive Heart Failure" />
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl">
          <valueCodeableConcept>
            <coding>
              <system value="http://hl7.org/fhir/questionnaire-item-control" />
              <code value="check-box" />
              <display value="Check-box" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <linkId value="803760213460" />
        <text value="Coronary Artery Disease">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<br/>" />
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          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20037" />
            <display value="Coronary Artery Disease" />
          </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" />
              <display value="Check-box" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
        </extension>
        <linkId value="129767162379" />
        <text value="Dyspnea">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<br/>" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20038" />
            <display value="Dyspnea" />
          </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" />
              <display value="Check-box" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
        </extension>
        <linkId value="116150628533" />
        <text value="Hypertension">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<br/>" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20039" />
            <display value="Hypertension" />
          </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" />
              <display value="Check-box" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
        </extension>
        <linkId value="513825527027" />
        <text value="Murmur">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<br/>" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20040" />
            <display value="Murmur" />
          </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" />
              <display value="Check-box" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
        </extension>
        <linkId value="975075898688" />
        <text value="Pericardial Disease">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<br/>" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
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        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20041" />
            <display value="Pericardial Disease" />
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl">
          <valueCodeableConcept>
            <coding>
              <system value="http://hl7.org/fhir/questionnaire-item-control" />
              <code value="check-box" />
              <display value="Check-box" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <linkId value="704148928571" />
        <text value="Peripheral Edema">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<br/>" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20042" />
            <display value="Peripheral Edema" />
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
        </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" />
              <display value="Check-box" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <linkId value="886489617115" />
        <text value="Post-Myocardial Infarction">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<br/>" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20043" />
            <display value="Post-Myocardial Infarction" />
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl">
          <valueCodeableConcept>
            <coding>
              <system value="http://hl7.org/fhir/questionnaire-item-control" />
              <code value="check-box" />
              <display value="Check-box" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <linkId value="621745958993" />
        <text value="Pre-operative Consultation">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<br/>" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20044" />
            <display value="Pre-operative Consultation" />
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="background-color:white;border-style:solid;" />
        </extension>
        <linkId value="873024527134" />
        <code>
          <system value="http://snomed.info/sct" />
          <code value="439272007" />
          <display value="Date of procedure" />
        </code>
        <text value="Procedure Date (if known)" />
        <type value="date" />
        <enableWhen>
          <question value="621745958993" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20044" />
            <display value="Pre-operative Consultation" />
          </answerCoding>
        </enableWhen>
      </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" />
              <display value="Check-box" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
        </extension>
        <linkId value="197975129599" />
        <text value="Syncope">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<br/>" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20045" />
            <display value="Syncope" />
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl">
          <valueCodeableConcept>
            <coding>
              <system value="http://hl7.org/fhir/questionnaire-item-control" />
              <code value="check-box" />
              <display value="Check-box" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <linkId value="675849150752" />
        <text value="Valvular Heart Disease or Prosthetic Heart Valve">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<br/>" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://snomed.info/sct" />
            <code value="368009" />
            <display value="Valvular Heart Disease or Prosthetic Heart Valve" />
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
        </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" />
              <display value="Check-box" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <linkId value="721982740516" />
        <text value="Other">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<br/>" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
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        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="other" />
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="background-color:white;border-style:solid;" />
        </extension>
        <linkId value="720594942482" />
        <text value="Specify" />
        <type value="text" />
        <enableWhen>
          <question value="721982740516" />
          <operator value="=" />
          <answerCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="other" />
          </answerCoding>
        </enableWhen>
        <required value="true" />
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    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="background-color:white;border-style:solid;" />
      </extension>
      <linkId value="Descriptionofclinicalquestion" />
      <text value="Clinical Question / Goal(s) of Referral with Relevant History, Management and Investigations">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
          <valueString value="Clinical&#xa0;Question&#xa0;/&#xa0;Goal(s)&#xa0;of&#xa0;Referral&#xa0;with&#xa0;Relevant&#xa0;History,&#xa0;Management&#xa0;and&#xa0;Investigations<br/>" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="font-weight:bold;" />
        </extension>
      </text>
      <type value="text" />
      <required value="true" />
    </item>
  </item>
  <item>
    <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
      <valueString value="background-color:grey;border-style:solid;" />
    </extension>
    <linkId value="cpp_header" />
    <text value="Cumulative Patient Profile Please delete any sensitive information you do not intend to share from the CPP">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
        <valueString value="Cumulative Patient Profile<br/><br/><i>Please delete any sensitive information you do not intend to share from the CPP</i>" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="font-weight:bold;" />
      </extension>
    </text>
    <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" />
            <display value="Check-box" />
          </coding>
        </valueCodeableConcept>
      </extension>
      <linkId value="cpp_separate" />
      <text value="CPP attached separately (if not entered below)">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
          <valueString value="<br/>" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
      </text>
      <type value="string" />
      <repeats value="true" />
      <answerOption>
        <valueString value="CPP attached separately (if not entered below)" />
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="background-color:white;border-style:solid;" />
      </extension>
      <linkId value="cpp_currentprob" />
      <code>
        <system value="http://snomed.info/sct" />
        <code value="55607006" />
        <display value="Problem" />
      </code>
      <text value="Current Problem List:" />
      <type value="text" />
      <enableWhen>
        <question value="cpp_separate" />
        <operator value="exists" />
        <answerBoolean value="false" />
      </enableWhen>
      <enableBehavior value="all" />
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="background-color:white;border-style:solid;" />
      </extension>
      <linkId value="cpp_pastmedicalhistory" />
      <code>
        <system value="http://snomed.info/sct" />
        <code value="417662000" />
        <display value="History of clinical finding in subject" />
      </code>
      <text value="Past Medical History:" />
      <type value="text" />
      <enableWhen>
        <question value="cpp_separate" />
        <operator value="exists" />
        <answerBoolean value="false" />
      </enableWhen>
      <enableBehavior value="all" />
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="background-color:white;border-style:solid;" />
      </extension>
      <linkId value="cpp_currentmedications" />
      <code>
        <system value="http://snomed.info/sct" />
        <code value="129019007" />
        <display value="Taking medication" />
      </code>
      <text value="Current Medications :" />
      <type value="text" />
      <enableWhen>
        <question value="cpp_separate" />
        <operator value="exists" />
        <answerBoolean value="false" />
      </enableWhen>
      <enableBehavior value="all" />
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="background-color:white;border-style:solid;" />
      </extension>
      <linkId value="cpp_familyhistory" />
      <code>
        <system value="http://snomed.info/sct" />
        <code value="57177007" />
        <display value="Family history with explicit context" />
      </code>
      <text value="Family History:" />
      <type value="text" />
      <enableWhen>
        <question value="cpp_separate" />
        <operator value="exists" />
        <answerBoolean value="false" />
      </enableWhen>
      <enableBehavior value="all" />
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="background-color:white;border-style:solid;" />
      </extension>
      <linkId value="cpp_allergies" />
      <code>
        <system value="http://snomed.info/sct" />
        <code value="609328004" />
        <display value="Allergic disposition" />
      </code>
      <text value="Allergies:" />
      <type value="text" />
      <enableWhen>
        <question value="cpp_separate" />
        <operator value="exists" />
        <answerBoolean value="false" />
      </enableWhen>
      <enableBehavior value="all" />
    </item>
  </item>
  <item>
    <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
      <valueString value="background-color:grey;border-style:solid;" />
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    <linkId value="preferredconsultlocation_header" />
    <text value="Preferred Consultant or Location All patients will be triaged to the shortest wait time unless a preferred consultant or location is entered.">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
        <valueString value="<b>Preferred Consultant or Location</b><br/><br/>All patients will be triaged to the shortest wait time unless a preferred consultant or location is entered." />
      </extension>
    </text>
    <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" />
            <display value="Check-box" />
          </coding>
        </valueCodeableConcept>
      </extension>
      <linkId value="preferredconsultlocation_selector" />
      <text value="Preferred consultant or location">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
          <valueString value="<br/>" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
      </text>
      <type value="string" />
      <repeats value="true" />
      <answerOption>
        <valueString value="Preferred consultant or location" />
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="background-color:white;border-style:solid;" />
      </extension>
      <linkId value="preferredconsultlocation_specify" />
      <text value="Please specify either a preferred consultant or location">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
          <valueString value="Please specify either a <b>preferred</b> consultant or location" />
        </extension>
      </text>
      <type value="group" />
      <enableWhen>
        <question value="preferredconsultlocation_selector" />
        <operator value="=" />
        <answerString value="Preferred consultant or location" />
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      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
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        <linkId value="preferredconsultlocation_consultant" />
        <text value="Consultant:" />
        <type value="string" />
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      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </extension>
        <linkId value="preferredconsultlocation_location" />
        <text value="Location:" />
        <type value="string" />
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    <item>
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            <system value="http://hl7.org/fhir/questionnaire-item-control" />
            <code value="check-box" />
            <display value="Check-box" />
          </coding>
        </valueCodeableConcept>
      </extension>
      <linkId value="preferredconsultlocation_willingtotravel" />
      <text value="Patient willing to travel for shorter wait time">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
          <valueString value="<br/>" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
      </text>
      <type value="string" />
      <repeats value="true" />
      <answerOption>
        <valueString value="Patient willing to travel for shorter wait time" />
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    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="background-color:white;border-style:solid;" />
      </extension>
      <linkId value="preferredconsultlocation_otherconsiderations" />
      <text value="Other considerations:" />
      <type value="string" />
    </item>
  </item>
  <item>
    <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
      <valueString value="background-color:grey;border-style:solid;" />
    </extension>
    <linkId value="supportingdocumentation_header" />
    <text value="Supporting Documentation Please attach all relevant laboratory and diagnostic investigations.">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
        <valueString value="<b>Supporting&#xa0;Documentation</b><br/>Please&#xa0;attach&#xa0;all&#xa0;<b><span style="text-decoration: underline">relevant</span></b>&#xa0;laboratory&#xa0;and&#xa0;diagnostic&#xa0;investigations.<br/>" />
      </extension>
    </text>
    <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" />
            <display value="Check-box" />
          </coding>
        </valueCodeableConcept>
      </extension>
      <linkId value="supportingdocumentation_details" />
      <text value="Personal Health Information that is medically relevant has not been disclosed at the request of the patient.">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
          <valueString value="<br/>" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
      </text>
      <type value="string" />
      <repeats value="true" />
      <answerOption>
        <valueString value="Personal Health Information that is medically relevant has not been disclosed at the request of the patient." />
      </answerOption>
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  </item>
  <item>
    <extension url="http://hl7.org/fhir/StructureDefinition/mimeType">
      <valueCode value="application/pdf" />
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/mimeType">
      <valueCode value="image/gif" />
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    <extension url="http://hl7.org/fhir/StructureDefinition/mimeType">
      <valueCode value="image/bmp" />
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    <extension url="http://hl7.org/fhir/StructureDefinition/mimeType">
      <valueCode value="application/vnd.openxmlformats-officedocument.spreadsheetml.sheet" />
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/mimeType">
      <valueCode value="video/mp4" />
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/mimeType">
      <valueCode value="text/csv" />
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    <extension url="http://hl7.org/fhir/StructureDefinition/mimeType">
      <valueCode value="image/jpeg" />
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    <extension url="http://hl7.org/fhir/StructureDefinition/mimeType">
      <valueCode value="application/msword" />
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      <valueCode value="image/png" />
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    <extension url="http://hl7.org/fhir/StructureDefinition/mimeType">
      <valueCode value="application/vnd.openxmlformats-officedocument.wordprocessingml.document" />
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    <extension url="http://hl7.org/fhir/StructureDefinition/mimeType">
      <valueCode value="application/vnd.ms-excel" />
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    <extension url="http://hl7.org/fhir/StructureDefinition/mimeType">
      <valueCode value="text/plain" />
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    <extension url="http://hl7.org/fhir/StructureDefinition/mimeType">
      <valueCode value="audio/mp4" />
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    <extension url="http://hl7.org/fhir/StructureDefinition/mimeType">
      <valueCode value="audio/mpeg" />
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      <valueCode value="image/tiff" />
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      <valueDecimal value="5000000" />
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      <valueString value="background-color:grey;border-style:solid;" />
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    <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
      <extension url="positiveText">
        <valueString value="Attachment Provided" />
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    </extension>
    <linkId value="supportingdocumentation_attachment" />
    <text value="Add Attachments" />
    <type value="attachment" />
  </item>
  <item>
    <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
      <valueString value="background-color:grey;border-style:solid;" />
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    <linkId value="feedbacksurvey_cardiology" />
    <text value="Click here to provide feedback on this form">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
        <valueString value="<a href="https://www.surveymonkey.com/r/cardioSRF" rel="noopener noreferrer" target="_blank">Click&#xa0;here&#xa0;to&#xa0;provide&#xa0;feedback&#xa0;on&#xa0;this&#xa0;form</a><br/>" />
      </extension>
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    <type value="display" />
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  <item>
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      <valueString value="background-color:grey;border-style:solid;" />
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    <text value="Referrer's Information">
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        <valueString value="font-weight:bold;" />
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      <type value="string" />
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      <type value="string" />
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      <item>
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        <type value="string" />
        <required value="true" />
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      <item>
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              <expression value="%resource.repeat(item).where(linkId='referrer_address_postalcode').answer.all(value.matches('^(?!.*[DFIOQU])[A-VXY][0-9][A-Z] ?[0-9][A-Z][0-9]$'))" />
            </valueExpression>
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          <extension url="human">
            <valueString value="Must be a valid Canadian postal-code" />
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        <linkId value="referrer_address_postalcode" />
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    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint">
        <extension url="key">
          <valueId value="refphone" />
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          <valueCode value="error" />
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        <extension url="expression">
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            <language value="text/fhirpath" />
            <expression value="%resource.repeat(item).where(linkId='referrer_phone').answer.all(value.matches('^(\+\d{1,2}\s?)?\(?\d{3}\)?[\s.-]?\d{3}[\s.-]?\d{4}$'))" />
          </valueExpression>
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        <extension url="human">
          <valueString value="Must be a valid phone number" />
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    <item>
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          <valueCode value="error" />
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            <expression value="%resource.repeat(item).where(linkId='referrer_fax').answer.all(value.matches('^(\+\d{1,2}\s?)?\(?\d{3}\)?[\s.-]?\d{3}[\s.-]?\d{4}$'))" />
          </valueExpression>
        </extension>
        <extension url="human">
          <valueString value="Must be a valid phone number" />
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      <type value="string" />
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    <item>
      <linkId value="referrer_billing" />
      <text value="Billing Number:" />
      <type value="integer" />
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    <item>
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          <display value="Allied Health Professional" />
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
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      <answerOption>
        <valueCoding>
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      <answerOption>
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          <display value="Nurse" />
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      <answerOption>
        <valueCoding>
          <system value="http://snomed.info/sct" />
          <code value="224571005" />
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      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://snomed.info/sct" />
          <code value="405277009" />
          <display value="Resident" />
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      <answerOption>
        <valueCoding>
          <system value="http://snomed.info/sct" />
          <code value="69280009" />
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      <answerOption>
        <valueCoding>
          <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
          <code value="OTH" />
          <display value="other" />
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</Questionnaire>