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value="string" /> </item> <item> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-initialExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%`var-ptLatestVal.wt`" /> </valueExpression> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Weight (kg):" /> </extension> </extension> <linkId value="item67890802" /> <text value="Weight (kg):"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Weight (kg): <br/>" /> </extension> </text> <type value="string" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="text"> <valueString value="#blank_line#" /> </extension> </extension> <linkId value="item84833268" /> <type value="display" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="style"> <valueString value="font-weight:bold;text-decoration:underline;" /> </extension> <extension url="listSeparator"> <valueString> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="<br/>" /> </extension> </valueString> </extension> </extension> <linkId value="section2763158" /> <text value="Referral Information" /> <type value="group" /> <item> <linkId value="item48807357" /> <text value="Reason for Referral:" /> <type value="text" /> <required value="true" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="listSeparator"> <valueString> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="<br/>" /> </extension> </valueString> </extension> </extension> <linkId value="section42000384" /> <text value="Pregnancy History" /> <type value="group" /> <item> <linkId value="item67762889" /> <text value="Total number of pregnancies:" /> <type value="integer" /> <required value="true" /> </item> <item> <linkId value="item91252875" /> <text value="Number of vaginal deliveries:" /> <type value="integer" /> </item> <item> <linkId value="item47328769" /> <text value="Number of C-sections:" /> <type value="integer" /> </item> <item> <linkId value="item36834119" /> <text value="Number of miscarriages/pregnancy losses/ectopic pregnancies:" /> <type value="integer" /> </item> <item> <linkId value="item29828101" /> <text value="Number of abortions/pregnancy terminations:" /> <type value="integer" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="listSeparator"> <valueString> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="<br/>" /> </extension> </valueString> </extension> </extension> <linkId value="section41623208" /> <text value="Menstrual History" /> <type value="group" /> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="<span/>" /> </extension> </valueString> </extension> </extension> <linkId value="item68062550" /> <text value="Date of Last Menstrual Period:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Date of Last Menstrual Period:<br/>" /> </extension> </text> <type value="date" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Number of days between periods:" /> </extension> </extension> <linkId value="item35661442" /> <text value="Number of days between periods:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Number of days between periods:<br/>" /> </extension> </text> <type value="integer" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Number of days period lasts:" /> </extension> </extension> <linkId value="item34464904" /> <text value="Number of days period lasts:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Number of days period lasts:<br/>" /> </extension> </text> <type value="integer" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> </extension> <linkId value="item12983596" /> <text value="Are patient's periods painful:" /> <type value="choice" /> <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://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> </extension> <linkId value="item93188178" /> <text value="Are patient's periods heavy:" /> <type value="choice" /> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="N" /> <display value="No" /> </valueCoding> </answerOption> </item> <item> <linkId value="item9542494" /> <text value="Number of pads/tampons used on the heaviest day of period:" /> <type value="integer" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="background-color:white;border-style:solid;" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="listSeparator"> <valueString> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="<br/>" /> </extension> </valueString> </extension> </extension> <linkId value="section87236956" /> <text value="Gynecologic History" /> <type value="group" /> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="item5390108" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="human"> <valueString value="Please obey rules specified in instructions" /> </extension> <extension url="expression"> <valueExpression> <description value="ScriptUtil.percentComplete( section90671878 ) != 0" /> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='section90671878').select(item.where(linkId='section95740632').exists(answer) | item.where(linkId='item27527635').exists(answer) | item.where(linkId='item5390108').exists(answer)).count() * 100 / 3 != 0" /> </valueExpression> </extension> </extension> <linkId value="section90671878" /> <type value="group" /> <item> <linkId value="item5390108" /> <text value="Select all that apply: *"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="<i>Select all that apply:</i> *" /> </extension> </text> <type value="display" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> </coding> </valueCodeableConcept> </extension> <linkId value="item27527635" /> <text value="None" /> <type value="boolean" /> </item> <item> <linkId value="section95740632" /> <type value="group" /> <enableWhen> <question value="item27527635" /> <operator value="!=" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="all" /> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> </extension> <linkId value="item97846576" /> <text value="Abnormal pap tests" /> <type value="boolean" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> </extension> <linkId value="item76524094" /> <text value="Fibroids" /> <type value="boolean" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> </extension> <linkId value="item62031353" /> <text value="Endometriosis" /> <type value="boolean" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> </extension> <linkId value="item78555427" /> <text value="Ovarian cysts" /> <type value="boolean" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> </extension> <linkId value="item86136829" /> <text value="Sexually transmitted infection(s)" /> <type value="boolean" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl"> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/questionnaire-item-control" /> <code value="drop-down" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="{{answer}}" /> </extension> </extension> <linkId value="item50977523" /> <text value="Specify:" /> <type value="choice" /> <enableWhen> <question value="item86136829" /> <operator value="=" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="all" /> <repeats value="true" /> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="1" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/dr-garvey-chilopora-_item50977523" /> <code value="Gonorrhea" /> <display value="Gonorrhea" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="2" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/dr-garvey-chilopora-_item50977523" /> <code value="Chlamydia" /> <display value="Chlamydia" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="3" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/dr-garvey-chilopora-_item50977523" /> <code value="Herpes" /> <display value="Herpes" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="4" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/dr-garvey-chilopora-_item50977523" /> <code value="Genital warts" /> <display value="Genital warts" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="5" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/dr-garvey-chilopora-_item50977523" /> <code value="Syphilis" /> <display value="Syphilis" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="0" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/dr-garvey-chilopora-_item50977523" /> <code value="Other" /> <display value="Other" /> </valueCoding> </answerOption> </item> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Date of last pap test:" /> </extension> </extension> <linkId value="item127317" /> <text value="Date of last pap test:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Date of last pap test:<br/>" /> </extension> </text> <type value="date" /> <required value="true" /> </item> <item> <linkId value="item54300787" /> <text value="Patient is sexually active:" /> <type value="choice" /> <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://ontariohealth.ca/fhir/eforms/CodeSystem/on-item-controls" /> <code value="push-button" /> </coding> </valueCodeableConcept> </extension> <linkId value="item96682694" /> <text value="With:" /> <type value="choice" 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url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="3" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/dr-garvey-chilopora-_item96682694" /> <code value="Both" /> <display value="Both" /> </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="drop-down" /> </coding> </valueCodeableConcept> </extension> <linkId value="item86913170" /> <text value="Form of birth control used:" /> <type value="choice" /> <enableWhen> <question value="item54300787" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v2-0532" /> <code value="Y" /> <display value="Yes" /> </answerCoding> </enableWhen> <enableBehavior value="all" /> <repeats value="true" /> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="1" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/dr-garvey-chilopora-_item86913170" /> <code value="Birth Control pill / patch / ring" /> <display value="Birth Control pill / patch / ring" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="2" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/dr-garvey-chilopora-_item86913170" /> <code value="Condoms" /> <display value="Condoms" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <extension url="http://hl7.org/fhir/StructureDefinition/itemWeight"> <valueDecimal value="3" /> </extension> <system value="http://ontariohealth.ca/legacy/CodeSystem/dr-garvey-chilopora-_item86913170" /> <code value="IUD (hormone)" /> <display value="IUD (hormone)" /> </valueCoding> </answerOption> <answerOption> 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</item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <description value="false" /> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> </extension> <linkId value="ax_bodySite" /> <text value="Reproductive System" /> <type value="display" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <description value="false" /> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> </extension> <linkId value="ax_v_bp" /> <text value="Dr. Chilopora eReferral Form [FINAL MAY 2022]; 2022.05.25" /> <type value="display" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <description value="false" /> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> </extension> <linkId value="ax_diagnosis" /> <text> <extension url="http://hl7.org/fhir/StructureDefinition/cqf-expression"> <valueExpression> <description value="(function() {; var descs = ""; if (item97846576.r == 'Y') {descs+='Abnormal Pap Tests' + '; ';} if (item76524094.r == 'Y') {descs+='Fibroids' + '; ';} if (item62031353.r == 'Y') {descs+='Endometriosis' + '; ';} if (item78555427.r == 'Y') {descs+='Ovarian Cysts' + '; ';} if (item86136829.r == 'Y') {descs+='Sexually transmitted infection(s)' + '; ';} return descs.substring(0, (descs.length-2)); })()" /> <language value="text/fhirpath" /> <expression value="(iif(%resource.repeat(item).where(linkId='item97846576').answer.exists(value = 'Y'),'Abnormal Pap Tests' + '; ') | iif(%resource.repeat(item).where(linkId='item76524094').answer.exists(value = 'Y'),'Fibroids' + '; ') | iif(%resource.repeat(item).where(linkId='item62031353').answer.exists(value = 'Y'),'Endometriosis' + '; ') | iif(%resource.repeat(item).where(linkId='item78555427').answer.exists(value = 'Y'),'Ovarian Cysts' + '; ') | iif(%resource.repeat(item).where(linkId='item86136829').answer.exists(value = 'Y'),'Sexually transmitted infection(s)' + '; ')).aggregate($total & $this, '')" /> </valueExpression> </extension> </text> <type value="display" /> </item> </item> </item> </Questionnaire>