<status value="active" /> <experimental value="true" /> <subjectType value="Patient" /> <date value="2026-08-04T09:22:28.489-04:00" /> <publisher value="Ontario Health" /> <description value="A medical imaging form that includes both English and French language text for form content" /> <effectivePeriod> <start value="2026-07-31" /> </effectivePeriod> <code> <system value="http://snomed.info/sct" /> <code value="708175003" /> <display value="Diagnostic imaging service" /> </code> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> </extension> <linkId value="medicalImaging_header_display" /> <text value="Ontario Breast Screening Program (OBSP) and Ontario Lung Screening Program (OLSP) are provincial screening programs with separate referral forms and eligibility criteria. Please refer to the program websites for details. Note: Not all imaging sites offer OBSP or OLSP exams"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="<a href="https://www.cancercareontario.ca/en/cancer-care-ontario/programs/screening-programs/ontario-breast-obsp"> Ontario Breast Screening Program (OBSP) </a> and <a href="https://www.cancercareontario.ca/en/cancer-care-ontario/programs/screening-programs/ontario-lung-screening-program"> Ontario Lung Screening Program (OLSP) </a> are provincial screening programs with separate referral forms and eligibility criteria. Please refer to the program websites for details. Note: Not all imaging sites offer OBSP or OLSP exams " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Remarques :" /> </extension> </extension> </text> <type value="display" /> </item> <item> <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="groupItems"> <valueBoolean value="false" /> </extension> </extension> <linkId value="patient_header" /> <text value="Patient Information"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Renseignements sur le patient" /> </extension> </extension> </text> <type value="group" /> <item> <linkId value="patient_surname" /> <text value="Surname:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Nom de famille :" /> </extension> </extension> </text> <type value="string" /> <required value="true" /> </item> <item> <linkId value="patient_firstname" /> <text value="First Name:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Prénom :" /> </extension> </extension> </text> <type value="string" /> <required value="true" /> </item> <item> <linkId value="patient_date_of_birth" /> <text value="DOB:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Date de naissance :" /> </extension> </extension> </text> <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> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="patient_gender" /> <text value="Gender:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Genre :" /> </extension> </extension> </text> <type value="choice" /> <required value="true" /> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/administrative-gender" /> <code value="male" /> <display value="Male"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Masculin" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/administrative-gender" /> <code value="female" /> <display value="Female"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Féminin" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/administrative-gender" /> <code value="other" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <linkId value="patient_hc_pc" /> <text value="HN PC:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Code de province (assurance-maladie) :" /> </extension> </extension> </text> <type value="string" /> <maxLength value="2" /> </item> <item> <linkId value="patient_hc_number" /> <text value="HN:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="N° d'assurance-maladie :" /> </extension> </extension> </text> <type value="string" /> <maxLength value="10" /> </item> <item> <linkId value="patient_hc_vc" /> <text value="HN VC:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Code de version (assurance-maladie) :" /> </extension> </extension> </text> <type value="string" /> </item> <item> <linkId value="patient_address_line1" /> <text value="Address (Line 1):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Adresse (ligne 1) :" /> </extension> </extension> </text> <type value="string" /> <required value="true" /> </item> <item> <linkId value="patient_address_line2" /> <text value="Address (Line 2):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Adresse (ligne 2) :" /> </extension> </extension> </text> <type value="string" /> </item> <item> <linkId value="patient_address_city" /> <text value="City:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Ville :" /> </extension> </extension> </text> <type value="string" /> <required value="true" /> </item> <item> <linkId value="patient_address_province" /> <text value="Province:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Province :" /> </extension> </extension> </text> <type value="string" /> <required value="true" /> <maxLength value="2" /> </item> <item> <linkId value="patient_address_postalcode" /> <text value="Postal Code:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Code postal :" /> </extension> </extension> </text> <type value="string" /> <required value="true" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="phone1" /> </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}$'))" /> </valueExpression> </extension> <extension url="human"> <valueString value="Please enter a valid north-american phone number. e.g. XXX-XXX-XXXX." /> </extension> </extension> <linkId value="patient_phone_mobile" /> <text value="Mobile #:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="N° de cellulaire :" /> </extension> </extension> </text> <type value="string" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="phone2" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='patient_phone_home').answer.all(value.matches('^(\+\d{1,2}\s?)?$?\d{3}$?[\s.-]?\d{3}[\s.-]?\d{4}$'))" /> </valueExpression> </extension> <extension url="human"> <valueString value="Please enter a valid north-american phone number. e.g. XXX-XXX-XXXX." /> </extension> </extension> <linkId value="patient_phone_home" /> <text value="Home #:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="N° à domicile :" /> </extension> </extension> </text> <type value="string" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="phone3" /> </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}$'))" /> </valueExpression> </extension> <extension url="human"> <valueString value="Please enter a valid north-american phone number. e.g. XXX-XXX-XXXX." /> </extension> </extension> <linkId value="patient_phone_business" /> <text value="Business #:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Téléphone professionnel :" /> </extension> </extension> </text> <type value="string" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="email1" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='patient_email').answer.all(value.matches('(?:[a-z0-9!#$%&'*+/=?^_`{|}~-]+(?:\.[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="Please enter a valid email address." /> </extension> </extension> <linkId value="patient_email" /> <text value="Email:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Courriel :" /> </extension> </extension> </text> <type value="string" /> </item> </item> <item> <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="groupItems"> <valueBoolean value="false" /> </extension> </extension> <linkId value="additionalinfo_header" /> <text value="[Optional] Additional Patient Information"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="[Facultatif] Renseignements supplémentaires sur le patient" /> </extension> </extension> </text> <type value="group" /> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="additionalinfo_preferredname" /> <text value="Preferred Name"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Nom préféré" /> </extension> </extension> </text> <type value="string" /> <enableBehavior value="all" /> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="additionalinfo_sexassignedatbirth" /> <text value="Sex assigned at birth:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sexe assigné à la naissance :" /> </extension> </extension> </text> <type value="string" /> <repeats value="false" /> <answerOption> <valueString value="Female"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Féminin" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="Male"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Masculin" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="Intersex"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Intersexe" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="Unknown"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Inconnu" /> </extension> </extension> </valueString> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </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_pronouns" /> <text value="Pronouns:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pronoms :" /> </extension> </extension> </text> <type value="choice" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21317" /> <display value="She/Her"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Elle/Elle" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21318" /> <display value="He/Him"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Il/Lui" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21319" /> <display value="They/Them"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Iel/Iel" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="additionalinfo_pronouns_other" /> <text value="Other pronouns:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autres pronoms :" /> </extension> </extension> </text> <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"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required 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://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"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Langue préférée" /> </extension> </extension> </text> <type value="choice" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="urn:ietf:bcp:47" /> <code value="en" /> <display value="English"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Anglais" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="urn:ietf:bcp:47" /> <code value="fr" /> <display value="French"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Français" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="additionalinfo_preferredlanguage_section" /> <type value="group" /> <enableWhen> <question value="additionalinfo_preferredlanguage" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </answerCoding> </enableWhen> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="additionalinfo_preferredlanguage_specify" /> <text value="Specify language and considerations:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser la langue et les considérations :" /> </extension> </extension> </text> <type value="string" /> <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://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="additionalinfo_preferredlanguage_interpreterrequired" /> <text value="Interpreter Required"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Interprète requis" /> </extension> </extension> </text> <type value="string" /> <repeats value="false" /> <answerOption> <valueString value="Interpreter Required"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Interprète requis" /> </extension> </extension> </valueString> </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://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:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Meilleur moyen de communication :" /> </extension> </extension> </text> <type value="choice" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/contact-point-use" /> <code value="mobile" /> <display value="Mobile"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cellulaire" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/contact-point-use" /> <code value="home" /> <display value="Home"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Domicile" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/contact-point-use" /> <code value="work" /> <display value="Work"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Travail" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/contact-point-system" /> <code value="email" /> <display value="Email"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Courriel" /> </extension> </extension> </display> </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://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="additionalinfo_bestmethodofcontact_voicemails" /> <text value="Voicemails acceptable"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Messages vocaux acceptés" /> </extension> </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"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cellulaire" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="additionalinfo_bestmethodofcontact" /> <operator value="=" /> <answerCoding> <system value="http://hl7.org/fhir/contact-point-use" /> <code value="home" /> <display value="Home"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Domicile" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="additionalinfo_bestmethodofcontact" /> <operator value="=" /> <answerCoding> <system value="http://hl7.org/fhir/contact-point-use" /> <code value="work" /> <display value="Work"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Travail" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="any" /> <repeats value="true" /> <answerOption> <valueString value="Voicemails acceptable"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Messages vocaux acceptés" /> </extension> </extension> </valueString> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Patient prefers SMS/text if available" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </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="additionalinfo_bestmethodofcontact_prefersms" /> <text value="Prefer SMS/Text if available"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préférence pour les SMS/textos, si possible" /> </extension> </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"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cellulaire" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="any" /> <repeats value="true" /> <answerOption> <valueString value="Prefer SMS/Text if available"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préférence pour les SMS/textos, si possible" /> </extension> </extension> </valueString> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </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="additionalinfo_parentguardianSDM" /> <text value="Identify parent/guardian, care contact, or Substitute Decision Maker (SDM)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Indiquer le parent/tuteur, la personne-ressource pour les soins ou le décideur substitut (SDM)" /> </extension> </extension> </text> <type value="string" /> <repeats value="false" /> <answerOption> <valueString value="Identify parent/guardian, care contact, or Substitute Decision Maker"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Indiquer le parent/tuteur, la personne-ressource pour les soins ou le décideur substitut" /> </extension> </extension> </valueString> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="additionalinfo_parentguardianSDM_section" /> <type value="group" /> <enableWhen> <question value="additionalinfo_parentguardianSDM" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="additionalinfo_parentguardianSDM_firstcontact_name" /> <text value="First Contact name:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Nom de la première personne-ressource :" /> </extension> </extension> </text> <type value="string" /> <required value="true" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="additionalinfo_parentguardianSDM_firstcontact_phone" /> <text value="Phone (if different than pt):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Téléphone (s'il diffère de celui du patient) :" /> </extension> </extension> </text> <type value="string" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="additionalinfo_parentguardianSDM_firstcontact_email" /> <text value="Email (if different than pt):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Courriel (s'il diffère de celui du patient) :" /> </extension> </extension> </text> <type value="string" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="additionalinfo_parentguardianSDM_firstcontact_relation" /> <text value="Relationship (incl. SDM):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Lien (y compris décideur substitut) :" /> </extension> </extension> </text> <type value="string" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </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_parentguardianSDM_firstcontact_apptbookcontact" /> <text value="Is this person an appointment booking contact?"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cette personne est-elle une personne-ressource pour la prise de rendez-vous?" /> </extension> </extension> </text> <type value="string" /> <required value="true" /> <answerOption> <valueString value="Yes"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Oui" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="No"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Non" /> </extension> </extension> </valueString> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="additionalinfo_parentguardianSDM_secondcontact_name" /> <text value="Second Contact name:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Nom de la deuxième personne-ressource :" /> </extension> </extension> </text> <type value="string" /> <required value="false" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="additionalinfo_parentguardianSDM_secondcontact_phone" /> <text value="Phone (if different than pt):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Téléphone (s'il diffère de celui du patient) :" /> </extension> </extension> </text> <type value="string" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="additionalinfo_parentguardianSDM_secondcontact_email" /> <text value="Email (if different than pt):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Courriel (s'il diffère de celui du patient) :" /> </extension> </extension> </text> <type value="string" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="additionalinfo_parentguardianSDM_secondcontact_relation" /> <text value="Relationship (incl. SDM):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Lien (y compris décideur substitut) :" /> </extension> </extension> </text> <type value="string" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </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_parentguardianSDM_secondcontact_apptbookcontact" /> <text value="Is this person an appointment booking contact?"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cette personne est-elle une personne-ressource pour la prise de rendez-vous?" /> </extension> </extension> </text> <type value="string" /> <required value="false" /> <repeats value="false" /> <answerOption> <valueString value="Yes"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Oui" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="No"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Non" /> </extension> </extension> </valueString> </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://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="additionalinfo_unsafecontactsprivacy_select" /> <text value="Do not contact (e.g. safety, privacy)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display: none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Ne pas communiquer (p. ex. sécurité, confidentialité)" /> </extension> </extension> </text> <type value="string" /> <repeats value="true" /> <answerOption> <valueString value="Do not contact (e.g. safety, privacy)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Ne pas communiquer (p. ex. sécurité, confidentialité)" /> </extension> </extension> </valueString> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="additionalinfo_unsafecontactsprivacy_section" /> <type value="group" /> <enableWhen> <question value="additionalinfo_unsafecontactsprivacy_select" /> <operator value="exists" /> <answerBoolean value="true" /> </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://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="additionalinfo_unsafecontacts_speakwithpatientdirectly" /> <text value="Only contact patient directly"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display: none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Communiquer uniquement avec le patient directement" /> </extension> </extension> </text> <type value="string" /> <repeats value="true" /> <answerOption> <valueString value="Only contact patient directly"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Communiquer uniquement avec le patient directement" /> </extension> </extension> </valueString> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="additionalinfo_unsafecontacts_donotspeakwith" /> <text value="Do not speak with:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Ne pas parler avec :" /> </extension> </extension> </text> <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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="additionalinfo_accessibilityconcernsordisability_select" /> <text value="Accessibility concerns or disability"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préoccupations liées à l'accessibilité ou incapacité" /> </extension> </extension> </text> <type value="string" /> <repeats value="false" /> <answerOption> <valueString value="Accessibility concerns or disability"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préoccupations liées à l'accessibilité ou incapacité" /> </extension> </extension> </valueString> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="additionalinfo_accessibilityconcernsordisability_section" /> <type value="group" /> <enableWhen> <question value="additionalinfo_accessibilityconcernsordisability_select" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <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_accessibilityconcernsordisability" /> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21269" /> <display value="Cognitively impaired"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Déficience cognitive" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21270" /> <display value="Falls risk"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Risque de chute" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21271" /> <display value="Hearing impaired"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Malentendant" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21272" /> <display value="Patient requires lift"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Le patient nécessite un lève-personne" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21273" /> <display value="Vision impaired"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Malvoyant" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21274" /> <display value="Wheelchair"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Fauteuil roulant" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <linkId value="additionalinfo_accessibilityconcernsordisability_specify" /> <text value="Specify"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser" /> </extension> </extension> </text> <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="additionalinfo_specialconsiderations_select" /> <text value="Special considerations"> <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="false" /> <answerOption> <valueString value="Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, requires escort, current location)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Considérations particulières (p. ex. obstacles, conseils pour la prestation des soins, assurance d'un tiers, accompagnateur requis, lieu actuel)" /> </extension> </extension> </valueString> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="additionalinfo_specialconsiderations_group" /> <type value="group" /> <enableWhen> <question value="additionalinfo_specialconsiderations_select" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <item> <linkId value="additionalinfo_specialconsiderations" /> <text value="Details of special considerations:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Détails des considérations particulières :" /> </extension> </extension> </text> <type value="text" /> <enableWhen> <question value="additionalinfo_specialconsiderations_select" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <required value="true" /> </item> </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://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </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"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Envoyer des copies des comptes rendus à d'autres fournisseurs de soins" /> </extension> </extension> </valueString> </answerOption> </item> <item> <linkId value="additionalinfo_sendcopiestoadditionalproviders_group" /> <type value="group" /> <enableWhen> <question value="additionalinfo_sendcopiestoadditionalproviders" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="all" /> <item> <linkId value="additionalinfo_sendcopiestoadditionalproviders_names" /> <text value="Name(s):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Nom(s) :" /> </extension> </extension> </text> <type value="string" /> <required value="true" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="additionalinfo_sendcopiestoadditionalproviders_contactinfo" /> <text value="Contact information:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Coordonnées :" /> </extension> </extension> </text> <type value="string" /> <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" /> <enableBehavior value="all" /> <repeats value="false" /> <answerOption> <valueString value="This is the Primary Care Provider"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Il s'agit du fournisseur de soins primaires" /> </extension> </extension> </valueString> </answerOption> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </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="medicalImaging_payerType" /> <text value="Payer Type"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Type de payeur" /> </extension> </extension> </text> <type value="string" /> <repeats value="false" /> <answerOption> <valueString value="OHIP"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="OHIP" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="WSIB Case"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Dossier WSIB" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="DND"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="DND" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="IFH"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="IFH" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="RAMQ"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="RAMQ" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </valueString> </answerOption> </item> <item> <linkId value="medicalImaging_payerType_other" /> <text value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_payerType" /> <operator value="=" /> <answerString value="Other" /> </enableWhen> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="repeat(item).answer.exists()" /> </valueExpression> </extension> <extension url="text"> <valueString value="Exam(s) Requested" /> </extension> <extension url="style"> <valueString value="font-weight:bold;text-decoration:underline;" /> </extension> <extension url="groupItems"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="847648250958" /> <text value="Select Exam Request"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sélectionner la demande d'examen" /> </extension> </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="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest" /> <text> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> </text> <type value="choice" /> <required value="true" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20390" /> <display value="CT Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande de TDM" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20391" /> <display value="MRI Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'IRM" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20392" /> <display value="X-Ray Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande de radiographie" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20393" /> <display value="Ultrasound Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'échographie" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20394" /> <display value="Bone Mineral Density Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'ostéodensitométrie" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="iif(%resource.item.repeat(item).where(linkId='medicalImaging_examRequest').answer.where(valueCoding.code = '20391').exists(), 'MRI_HEIGHT_WEIGHT_REQUIRED', iif(%resource.item.repeat(item).where(linkId='medicalImaging_examRequest').answer.where(valueCoding.code = '20390').exists(), 'CT_WEIGHT_REQUIRED', iif(%resource.item.repeat(item).where(linkId='medicalImaging_examRequest').answer.where(valueCoding.code = '20394').exists(), 'BMD_HEIGHT_WEIGHT_OPTIONAL', 'HIDE')))" /> </valueExpression> </extension> <linkId value="medicalImaging_weightHeightRequirement" /> <text value="Weight/height requirement"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Exigence de poids/taille" /> </extension> </extension> </text> <type value="string" /> <readOnly value="true" /> </item> </item> <item> <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="groupItems"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_referral_triageconsiderations" /> <text value="Triage Considerations"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Considérations de triage" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="all" /> <item> <linkId value="medicalImaging_referral_triageconsiderations_display" /> <text value="If the patient requires emergent attention, do not submit this form. Please contact your nearest imaging facility directly."> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Si le patient nécessite des soins urgents, ne pas soumettre ce formulaire. Veuillez communiquer directement avec l'établissement d'imagerie le plus proche." /> </extension> </extension> </text> <type value="display" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> <valueString value="font-weight:bold;color:#EE6B00;" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </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="medicalImaging_examRequest_triage" /> <text value="Requested Triage Priority"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Priorité de triage demandée" /> </extension> </extension> </text> <type value="string" /> <repeats value="false" /> <answerOption> <valueString value="Routine"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="De routine" /> </extension> </extension> </valueString> <initialSelected value="true" /> </answerOption> <answerOption> <valueString value="Urgent"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Urgent" /> </extension> </extension> </valueString> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_triage_urgentReason" /> <text value="Reason for urgent triage:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Motif du triage urgent :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_triage" /> <operator value="=" /> <answerString value="Urgent" /> </enableWhen> <required value="true" /> <repeats value="false" /> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> <extension url="groupItems"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_referral_cds" /> <text value="Clinical Decision Support"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Aide à la décision clinique" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20390" /> <display value="CT Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande de TDM" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20391" /> <display value="MRI Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'IRM" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20392" /> <display value="X-Ray Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande de radiographie" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20394" /> <display value="Bone Mineral Density Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'ostéodensitométrie" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="any" /> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </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="medicalImaging_examRequest_cds" /> <text value="Display Clinical Decision Support (CDS)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Afficher l'aide à la décision clinique (ADC)" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20390" /> <display value="CT Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande de TDM" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20391" /> <display value="MRI Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'IRM" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20392" /> <display value="X-Ray Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande de radiographie" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20394" /> <display value="Bone Mineral Density Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'ostéodensitométrie" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="any" /> <repeats value="false" /> <answerOption> <valueString value="Hide"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Masquer" /> </extension> </extension> </valueString> <initialSelected value="true" /> </answerOption> <answerOption> <valueString value="Show"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Afficher" /> </extension> </extension> </valueString> </answerOption> <item> <linkId value="medicalImaging_examRequest_CT_cds_show" /> <text value="CDS will show for selections below where available. Click 'Hide' to remove."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" CDS will show for selections below where available. Click 'Hide' to remove. "> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value=" L'ADC s'affichera pour les sélections ci-dessous lorsque c'est possible. Cliquez sur « Masquer » pour la retirer. " /> </extension> </extension> </valueString> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Afficher" /> </extension> </extension> </text> <type value="display" /> <enableWhen> <question value="medicalImaging_examRequest_cds" /> <operator value="=" /> <answerString value="Show" /> </enableWhen> <enableBehavior value="all" /> </item> <item> <linkId value="medicalImaging_examRequest_CT_cds_hide" /> <text value="CDS is hidden for selections below. Click 'Show' to display where available."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" CDS is hidden for selections below. Click 'Show' to display where available. "> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value=" L'ADC est masquée pour les sélections ci-dessous. Cliquez sur « Afficher » pour l'afficher lorsque c'est possible. " /> </extension> </extension> </valueString> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Masquer" /> </extension> </extension> </text> <type value="display" /> <enableWhen> <question value="medicalImaging_examRequest_cds" /> <operator value="=" /> <answerString value="Hide" /> </enableWhen> <enableBehavior value="all" /> </item> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="text"> <valueString value="CT Exam/Region(s) of Interest:" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="style"> <valueString value="font-weight:bold;text-decoration:underline;" /> </extension> <extension url="groupItems"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_group" /> <text value="Select CT Exam/Region(s) of Interest:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sélectionner l'examen/la ou les régions de TDM d'intérêt :" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20390" /> <display value="CT Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande de TDM" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_head" /> <text value="Head"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tête" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20395" /> <display value="Head"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tête" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_head_group" /> <prefix value="Head"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tête" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_CT_head" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_CT_head_specificarea" /> <text value="Specific area of interest (optional)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Région d'intérêt précise (facultatif)" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20406" /> <display value="Brain"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cerveau" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20408" /> <display value="Facial bones"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Os de la face" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20447" /> <display value="Head angiography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie de la tête" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20456" /> <display value="Head venography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Phlébographie de la tête" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20409" /> <display value="Internal auditory canals"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Conduits auditifs internes" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20410" /> <display value="Orbits"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Orbites" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20411" /> <display value="Sinuses"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sinus" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20412" /> <display value="Temporal bones"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Os temporaux" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_CT_head_specificarea_other" /> <text value="Specify:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_CT_head_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_neck" /> <text value="Neck"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cou" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20396" /> <display value="Neck"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cou" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_neck_group" /> <prefix value="Neck"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cou" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_CT_neck" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_CT_neck_specificarea" /> <text value="Specific area of interest (optional)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Région d'intérêt précise (facultatif)" /> </extension> </extension> </text> <type value="choice" /> <enableBehavior value="any" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20448" /> <display value="Neck angiography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie du cou" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20414" /> <display value="Soft Tissue Neck"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tissus mous du cou" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_CT_neck_specificarea_other" /> <text value="Specify:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_CT_neck_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_spine" /> <text value="Spine"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Colonne vertébrale" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20397" /> <display value="Spine"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Colonne vertébrale" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_spine_group" /> <prefix value="Spine"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Colonne vertébrale" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_CT_spine" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_CT_spine_specificarea" /> <text value="Specific area of interest (optional)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Région d'intérêt précise (facultatif)" /> </extension> </extension> </text> <type value="choice" /> <required value="true" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20415" /> <display value="Cervical Spine"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Colonne cervicale" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20416" /> <display value="Thoracic Spine"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Colonne thoracique" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20417" /> <display value="Lumbar Spine"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Colonne lombaire" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20418" /> <display value="Sacrum/Coccyx"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sacrum / coccyx" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20419" /> <display value="Sacroiliac Joints"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Articulations sacro-iliaques" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="CT_CDS_lowbackpain" /> <text value="Low Back Pain - Quality Standards People with acute low back pain do not receive diagnostic imaging tests unless they present with red flags that suggest serious pathological disease. Red flag signs or symptoms include: Neurological disorders: diffuse or substantial motor/sensory loss, progressive neurological deficits, cauda equina syndrome Infection: fever, history of IV drug use, immunosuppression Fracture: trauma, osteoporosis risk/fragility fracture Tumour: history of cancer, unexplained weight loss, significant unexpected night pain, severe fatigue Inflammation: chronic low back pain for more than 3 months, age of onset less than 45 years, morning stiffness for more than 30 minutes, improvement with exercise, disproportionate night pain. Source: Health Quality Ontario. Quality Standards – Low Back Pain: Care for Adults with Acute Low Back Pain; 2019."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Low Back Pain - Quality Standards People with acute low back pain do not receive diagnostic imaging tests unless they present with red flags that suggest serious pathological disease. Red flag signs or symptoms include: <li> Neurological disorders: diffuse or substantial motor/sensory loss, progressive neurological deficits, cauda equina syndrome </li> <li> Infection: fever, history of IV drug use, immunosuppression </li> <li> Fracture: trauma, osteoporosis risk/fragility fracture </li> <li> Tumour: history of cancer, unexplained weight loss, significant unexpected night pain, severe fatigue </li> <li> Inflammation: chronic low back pain for more than 3 months, age of onset less than 45 years, morning stiffness for more than 30 minutes, improvement with exercise, disproportionate night pain. </li> Source: Health Quality Ontario. Quality Standards – Low Back Pain: Care for Adults with Acute Low Back Pain; 2019. " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Lombalgie – Normes de qualité" /> </extension> </extension> </text> <type value="display" /> <enableWhen> <question value="medicalImaging_examRequest_CT_spine_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20579" /> <display value="Lumbar"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Lombaire" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest_cds" /> <operator value="=" /> <answerString value="Show" /> </enableWhen> <enableBehavior value="all" /> </item> <item> <extension 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/> <display value="Chest Low-Dose"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Thorax à faible dose" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20449" /> <display value="Chest Angiography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie du thorax" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20423" /> <display value="Pulmonary Embolism"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Embolie pulmonaire" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20425" /> <display value="Thoracic Outlet"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Défilé thoracobrachial" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20426" /> <display value="Chest Abdomen Pelvis"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Thorax, abdomen et pelvis" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_CT_thorax_specificarea_other" /> <text value="Specify:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_CT_thorax_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </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="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_abdomenpelvis" /> <text value="Abdomen Pelvis"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Abdomen et pelvis" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20399" /> <display value="Abdomen Pelvis"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Abdomen et pelvis" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_abdomenpelvis_group" /> <prefix value="Abdomen Pelvis"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Abdomen et pelvis" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_CT_abdomenpelvis" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_CT_abdomenpelvis_specificarea" /> <text value="Specific area of interest (optional)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Région d'intérêt précise (facultatif)" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20399" /> <display value="Abdomen Pelvis"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Abdomen et pelvis" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20452" /> <display value="Abdomen Pelvis Angiography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie de l'abdomen et du pelvis" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20426" /> <display value="Chest Abdomen Pelvis"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Thorax, abdomen et pelvis" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20427" /> <display value="Abdomen only"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Abdomen seulement" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20428" /> <display value="Pelvis only"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pelvis seulement" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20430" /> <display value="Colonography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Coloscopie virtuelle" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20431" /> <display value="Enterography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Entérographie" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20432" /> <display value="Renal Colic"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Colique néphrétique" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20433" /> <display value="Urography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Urographie" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_CT_abdomenpelvis_specificarea_other" /> <text value="Specify:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_CT_abdomenpelvis_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_musculoskeletal" /> <text value="Musculoskeletal"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Musculosquelettique" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20400" /> <display value="Musculoskeletal"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Musculosquelettique" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_musculoskeletal_group" /> <prefix value="Musculoskeletal"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Musculosquelettique" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_CT_musculoskeletal" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="true" /> </extension> </extension> <linkId value="medicalImaging_examRequest_CT_musculoskeletal_specificarea" /> <text value="Specific area of interest"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Région d'intérêt précise" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20434" /> <display value="Shoulder"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Épaule" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20435" /> <display value="Humerus"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Humérus" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20436" /> <display value="Elbow"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Coude" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20437" /> <display value="Forearm"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Avant-bras" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20438" /> <display value="Wrist"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poignet" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20439" /> <display value="Hand"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Main" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20440" /> <display value="Bony Pelvis"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bassin osseux" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20441" /> <display value="Hip"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Hanche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20442" /> <display value="Femur"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Fémur" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20443" /> <display value="Knee"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Genou" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20444" /> <display value="Tibia and Fibula"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tibia et fibula" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20445" /> <display value="Ankle"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cheville" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20446" /> <display value="Foot"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pied" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_musculoskeletal_shoulder" /> <text value="Shoulder:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Épaule :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_CT_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20434" /> <display value="Shoulder"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Épaule" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_musculoskeletal_humerus" /> <text value="Humerus:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Humérus :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_CT_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20435" /> <display value="Humerus"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Humérus" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_musculoskeletal_elbow" /> <text value="Elbow:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Coude :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_CT_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20436" /> <display value="Elbow"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Coude" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_musculoskeletal_forearm" /> <text value="Forearm:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Avant-bras :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_CT_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20437" /> <display value="Forearm"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Avant-bras" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_musculoskeletal_wrist" /> <text value="Wrist:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poignet :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_CT_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20438" /> <display value="Wrist"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poignet" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_musculoskeletal_hand" /> <text value="Hand:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Main :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_CT_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20439" /> <display value="Hand"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Main" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_musculoskeletal_hip" /> <text value="Hip:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Hanche :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_CT_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20441" /> <display value="Hip"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Hanche" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_musculoskeletal_femur" /> <text value="Femur:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Fémur :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_CT_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20442" /> <display value="Femur"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Fémur" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_musculoskeletal_knee" /> <text value="Knee:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Genou :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_CT_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20443" /> <display value="Knee"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Genou" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_musculoskeletal_tibia" /> <text value="Tibia and Fibula:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tibia et fibula :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_CT_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20444" /> <display value="Tibia and Fibula"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tibia et fibula" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_musculoskeletal_ankle" /> <text value="Ankle:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cheville :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_CT_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20445" /> <display value="Ankle"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cheville" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_musculoskeletal_foot" /> <text value="Foot:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pied :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_CT_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20446" /> <display value="Foot"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pied" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%resource.item.repeat(item).where(linkId = 'medicalImaging_examRequest_CT_musculoskeletal_specificarea').answer.valueCoding.code.where($this = '20441' or $this = '20443' or $this = '20438' or $this = '20434').exists() and %resource.item.repeat(item).where(linkId = 'medicalImaging_examRequest_cds').answer.valueString.where($this = 'Show').exists()" /> </valueExpression> </extension> <linkId value="medicalImaging_CT_CDS_Osteoarthritis_enabled" /> <text value="CT osteoarthritis CDS display condition" /> <type value="boolean" /> <readOnly value="true" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="CT_CDS_Osteoarthritis" /> <text value="Osteoarthritis - Quality Standards People who have persistent, atraumatic, movement related joint pain or aching, and/or morning stiffness lasting less than 30 minutes, are diagnosed with osteoarthritis based on clinical assessment. Radiological imaging is not required to make a diagnosis in people aged 40 years or older if their symptoms are typical of osteoarthritis Symptoms typical of osteoarthritis: Persistent atraumatic movement-related joint pain, aching, stiffness, and/or swelling. Morning stiffness lasting less than 30 minutes may or may not be present. Symptoms may affect one or a few joints. Atypical features: A recent history of injury, joint locking, prolonged morning joint-related stiffness, rapid onset of symptoms, the presence of a hot swollen joint, fever, chills, sweats, or feeling generally unwell. Atypical features usually indicate the need for further investigations to identify possible additional or alternative diagnoses, including loose body, meniscal injury, gout, or other inflammatory arthritides, such as rheumatoid arthritis, septic arthritis, and malignancy (if bone or soft tissue pain are present). Source: Ontario Health. Quality Standards – Osteoarthritis: Care for Adults with Osteoarthritis of the Knee, Hip, Hands, or Shoulder; 2024."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Osteoarthritis - Quality Standards People who have persistent, atraumatic, movement related joint pain or aching, and/or morning stiffness lasting less than 30 minutes, are diagnosed with osteoarthritis based on clinical assessment. Radiological imaging is not required to make a diagnosis in people aged 40 years or older if their symptoms are typical of osteoarthritis Symptoms typical of osteoarthritis: Persistent atraumatic movement-related joint pain, aching, stiffness, and/or swelling. Morning stiffness lasting less than 30 minutes may or may not be present. Symptoms may affect one or a few joints. Atypical features: A recent history of injury, joint locking, prolonged morning joint-related stiffness, rapid onset of symptoms, the presence of a hot swollen joint, fever, chills, sweats, or feeling generally unwell. Atypical features usually indicate the need for further investigations to identify possible additional or alternative diagnoses, including loose body, meniscal injury, gout, or other inflammatory arthritides, such as rheumatoid arthritis, septic arthritis, and malignancy (if bone or soft tissue pain are present). Source: Ontario Health. Quality Standards – Osteoarthritis: Care for Adults with Osteoarthritis of the Knee, Hip, Hands, or Shoulder; 2024." /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Arthrose – Normes de qualité" /> </extension> </extension> </text> <type value="display" /> <enableWhen> <question value="medicalImaging_CT_CDS_Osteoarthritis_enabled" /> <operator value="=" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="all" /> </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="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_angiographyarterial" /> <text value="CT Angiography"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie par TDM" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20401" /> <display value="Angiography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_angiographyarterial_group" /> <prefix value="Angiography Arterial"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie artérielle" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_CT_angiographyarterial" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_CT_angiographyarterial_specificarea" /> <text value="Specific area of interest"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Région d'intérêt précise" /> </extension> </extension> </text> <type value="choice" /> <required value="true" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20447" /> <display value="Head Angiography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie de la tête" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20448" /> <display value="Neck Angiography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie du cou" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20449" /> <display value="Chest Angiography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie du thorax" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20450" /> <display value="Chest Abdomen Pelvis Angiography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie du thorax, de l'abdomen et du pelvis" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20451" /> <display value="Abdomen Angiography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie de l'abdomen" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20452" /> <display value="Abdomen Pelvis Angiography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie de l'abdomen et du pelvis" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20453" /> <display value="Pelvis Angiography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie du pelvis" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20454" /> <display value="Upper Extremity Angiography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie des membres supérieurs" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20455" /> <display value="Lower Extremity Angiography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie des membres inférieurs" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_CT_angiographyarterial_specificarea_other" /> <text value="Specify:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_CT_angiographyarterial_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required 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://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" /> <code value="push-button" /> <display value="Push Button" /> </coding> </valueCodeableConcept> </extension> <linkId value="medicalImaging_examRequest_CT_angiographyarterial_specificarea_upper_specify" /> <text value="Specify Upper Extremity Angiography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser l'angiographie des membres supérieurs" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_CT_angiographyarterial_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20454" /> <display value="Upper Extremity Angiography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie des membres supérieurs" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" /> <code value="push-button" /> <display value="Push Button" /> </coding> </valueCodeableConcept> </extension> <linkId value="medicalImaging_examRequest_CT_angiographyarterial_specificarea_lower_specify" /> <text value="Specify Lower Extremity Angiography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser l'angiographie des membres inférieurs" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_CT_angiographyarterial_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20455" /> <display value="Lower Extremity Angiography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie des membres inférieurs" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_myeloma" /> <text value="Whole-Body Low-Dose (Myeloma)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Corps entier à faible dose (myélome)" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20403" /> <display value="Whole-Body Low-Dose (Myeloma)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Corps entier à faible dose (myélome)" /> </extension> </extension> </display> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_cardiac" /> <text value="Cardiac"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cardiaque" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20404" /> <display value="Cardiac"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cardiaque" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_cardiac_group" /> <prefix value="Cardiac"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cardiaque" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_CT_cardiac" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_CT_cardiac_specificarea" /> <text value="Cardiac"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cardiaque" /> </extension> </extension> </text> <type value="choice" /> <required value="true" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20465" /> <display value="Coronary Angiography (CCTA)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie coronarienne par TDM (CCTA)" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20466" /> <display value="Cardiac Calcium Score"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Score calcique coronarien" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20464" /> <display value="Cardiac CT"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="TDM cardiaque" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <linkId value="medicalImaging_examRequest_CT_cardiac_display" /> <text value="Please provide any relevant consult notes or prior testing results, either as an attachment or in the Clinical History text field."> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Veuillez fournir toute note de consultation ou tout résultat d'examen antérieur pertinent, soit en pièce jointe, soit dans le champ des antécédents cliniques." /> </extension> </extension> </text> <type value="display" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="CT_CDS_Cardiac" /> <text value="CCTA Patient Selection Guidance Patients appropriate for CCTA: Symptomatic patients with no known coronary artery disease (CAD) and no prior testingSymptomatic patients with no known CAD and with prior CAD testing showing results that are incongruent with clinical impression.Suspected anomalous coronary anatomy Patients not appropriate for CCTA History of CADAtrial fibrillation (depending on scanner)Contraindication to nitratesContraindication to heart rate modifying medicationsContraindications to radiationContraindication to contrastInability to comply with breath-hold and breath-hold instructionsSource: Ontario Health. Ontario Clinical Guidance on Patient Selection and Prioritization for Coronary Computed Tomography Angiography (CCTA); 2024."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="CCTA Patient Selection Guidance Patients appropriate for CCTA: <li>Symptomatic patients with no known coronary artery disease (CAD) and no prior testing</li><li>Symptomatic patients with no known CAD and with prior CAD testing showing results that are incongruent with clinical impression.</li><li>Suspected anomalous coronary anatomy</li> Patients not appropriate for CCTA <li>History of CAD</li><li>Atrial fibrillation (depending on scanner)</li><li>Contraindication to nitrates</li><li>Contraindication to heart rate modifying medications</li><li>Contraindications to radiation</li><li>Contraindication to contrast</li><li>Inability to comply with breath-hold and breath-hold instructions</li>Source: Ontario Health. Ontario Clinical Guidance on Patient Selection and Prioritization for Coronary Computed Tomography Angiography (CCTA); 2024." /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Directives cardiaques" /> </extension> </extension> </text> <type value="display" /> <enableWhen> <question value="medicalImaging_examRequest_CT_cardiac_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20465" /> <display value="Coronary Angiography (CCTA)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie coronarienne par TDM (CCTA)" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest_cds" /> <operator value="=" /> <answerString value="Show" /> </enableWhen> <enableBehavior value="all" /> </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="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_biopsy" /> <text value="Biopsy"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Biopsie" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20405" /> <display value="Biopsy"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Biopsie" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_biopsy_group" /> <prefix value="Biopsy"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Biopsie" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_CT_biopsy" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_CT_biopsy_specificarea" /> <text value="Specify area of interest:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser la région d'intérêt :" /> </extension> </extension> </text> <type value="choice" /> <required value="true" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21366" /> <display value="Adrenals"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Surrénales" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21367" /> <display value="Bone"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Os" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21368" /> <display value="Kidneys"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Reins" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21369" /> <display value="Liver"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Foie" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21370" /> <display value="Lung"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poumon" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21371" /> <display value="Lymph nodes"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Ganglions lymphatiques" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21372" /> <display value="Mediastinal mass"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Masse médiastinale" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21373" /> <display value="Pancreas"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pancréas" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21374" /> <display value="Pelvis"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pelvis" /> </extension> </extension> </display> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_other" /> <text value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </text> <type value="choice" /> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_CT_other_specify" /> <text value="Specify:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_CT_other" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="all" /> <required value="true" /> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="groupItems"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_CT_clinicalindication_CTrefnote" /> <text value="CT Request: Clinical History / Indication"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande de TDM : antécédents cliniques / indication" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20390" /> <display value="CT Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande de TDM" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <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=" " /> </extension> </valueString> </extension> </extension> <linkId value="medicalImaging_CT_clinicalindication_text" /> <text value="Reason for exam (please also include presenting symptom(s), relevant underlying diagnosis and therapies, where applicable)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Motif de l'examen (veuillez aussi indiquer le ou les symptômes présents, le diagnostic sous-jacent pertinent et les traitements, le cas échéant)" /> </extension> </extension> </text> <type value="text" /> <required value="true" /> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="text"> <valueString value="MRI Exam/Region(s) of Interest:" /> </extension> <extension url="style"> <valueString value="font-weight:bold;text-decoration:underline;" /> </extension> <extension url="groupItems"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_group_MRIrefnote" /> <text value="Select MRI Exam/Region(s) of Interest:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sélectionner l'examen/la ou les régions d'IRM d'intérêt :" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20391" /> <display value="MRI Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'IRM" /> </extension> </extension> </display> </answerCoding> </enableWhen> <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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_head" /> <text value="Head"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tête" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20467" /> <display value="Head"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tête" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_head_group" /> <prefix value="Head"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tête" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_head" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_MRI_head_specificarea" /> <text value="Specific area of interest (optional)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Région d'intérêt précise (facultatif)" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20478" /> <display value="Brain"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cerveau" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20540" /> <display value="Head angiography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie de la tête" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20480" /> <display value="Internal auditory canals"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Conduits auditifs internes" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20481" /> <display value="Orbits"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Orbites" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20482" /> <display value="Pituitary / Sella"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Hypophyse / selle turcique" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20483" /> <display value="Sinuses"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sinus" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20484" /> <display value="Temporomandibular joints"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Articulations temporomandibulaires" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20485" /> <display value="Trigeminal nerve"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Nerf trijumeau" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_MRI_head_specificarea_other" /> <text value="Specify Other"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser (autre)" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_head_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_neck" /> <text value="Neck"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cou" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20468" /> <display value="Neck"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cou" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_neck_group" /> <prefix value="Neck"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cou" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_neck" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_MRI_neck_specificarea" /> <text value="Specific area of interest (optional)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Région d'intérêt précise (facultatif)" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20541" /> <display value="Neck angiography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie du cou" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20487" /> <display value="Soft Tissue Neck"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tissus mous du cou" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20488" /> <display value="Brachial plexus"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Plexus brachial" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_MRI_neck_specificarea_other" /> <text value="Specify Other"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser (autre)" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_neck_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> </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> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="medicalImaging_examRequest_MRI_neck_specificarea_brachial" /> <text value="Brachial Plexus:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Plexus brachial :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_neck_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20488" /> <display value="Brachial plexus"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Plexus brachial" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_spine" /> <text value="Spine"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Colonne vertébrale" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20469" /> <display value="Spine"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Colonne vertébrale" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_spine_group" /> <prefix value="Spine"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Colonne vertébrale" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_spine" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_MRI_spine_specificarea" /> <text value="Specific area of interest"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Région d'intérêt précise" /> </extension> </extension> </text> <type value="choice" /> <required value="true" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20489" /> <display value="Whole Spine"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Colonne vertébrale entière" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20490" /> <display value="Cervical Spine"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Colonne cervicale" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20491" /> <display value="Thoracic Spine"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Colonne thoracique" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20492" /> <display value="Lumbar Spine"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Colonne lombaire" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20493" /> <display value="Sacrum/Coccyx"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sacrum / coccyx" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20494" /> <display value="Sacroiliac Joints"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Articulations sacro-iliaques" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="MRI_CDS_lowbackpain" /> <text value="Low Back Pain - Quality Standards People with acute low back pain do not receive diagnostic imaging tests unless they present with red flags that suggest serious pathological disease. Red flag signs or symptoms include: Neurological disorders: diffuse or substantial motor/sensory loss, progressive neurological deficits, cauda equina syndrome Infection: fever, history of IV drug use, immunosuppression Fracture: trauma, osteoporosis risk/fragility fracture Tumour: history of cancer, unexplained weight loss, significant unexpected night pain, severe fatigue Inflammation: chronic low back pain for more than 3 months, age of onset less than 45 years, morning stiffness for more than 30 minutes, improvement with exercise, disproportionate night pain Source: Health Quality Ontario. Quality Standards – Low Back Pain: Care for Adults with Acute Low Back Pain; 2019."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Low Back Pain - Quality Standards People with acute low back pain do not receive diagnostic imaging tests unless they present with red flags that suggest serious pathological disease. Red flag signs or symptoms include: <li> Neurological disorders: diffuse or substantial motor/sensory loss, progressive neurological deficits, cauda equina syndrome </li> <li> Infection: fever, history of IV drug use, immunosuppression </li> <li> Fracture: trauma, osteoporosis risk/fragility fracture </li> <li> Tumour: history of cancer, unexplained weight loss, significant unexpected night pain, severe fatigue </li> <li> Inflammation: chronic low back pain for more than 3 months, age of onset less than 45 years, morning stiffness for more than 30 minutes, improvement with exercise, disproportionate night pain </li> Source: Health Quality Ontario. Quality Standards – Low Back Pain: Care for Adults with Acute Low Back Pain; 2019. " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Lombalgie – Normes de qualité" /> </extension> </extension> </text> <type value="display" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_spine_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20579" /> <display value="Lumbar"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Lombaire" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest_cds" /> <operator value="=" /> <answerString value="Show" /> </enableWhen> <enableBehavior value="all" /> </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="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_thorax" /> <text value="Thorax"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Thorax" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20470" /> <display value="Thorax"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Thorax" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_thorax_group" /> <prefix value="Thorax"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Thorax" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_thorax" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_MRI_thorax_specificarea" /> <text value="Specific area of interest (optional)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Région d'intérêt précise (facultatif)" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20495" /> <display value="Chest"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Thorax" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20496" /> <display value="Chest wall"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Paroi thoracique" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20497" /> <display value="Pulmonary arteries"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Artères pulmonaires" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20498" /> <display value="Sternoclavicular joints"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Articulations sternoclaviculaires" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20499" /> <display value="Sternum"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sternum" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20542" /> <display value="Chest Angiography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie du thorax" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20501" /> <display value="Thoracic Outlet"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Défilé thoracobrachial" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_MRI_thorax_specificarea_other" /> <text value="Specify Other"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser (autre)" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_thorax_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_abdomen" /> <text value="Abdomen"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Abdomen" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20471" /> <display value="Abdomen"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Abdomen" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_abdomen_group" /> <prefix value="Abdomen"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Abdomen" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_abdomen" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_MRI_abdomen_specificarea" /> <text value="Specific area of interest (optional)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Région d'intérêt précise (facultatif)" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21398" /> <display value="Abdomen Pelvis Angiography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie de l'abdomen et du pelvis" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20503" /> <display value="Abdominal wall"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Paroi abdominale" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20504" /> <display value="Adrenal glands"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Glandes surrénales" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20505" /> <display value="Biliary and pancreatic ducts"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Voies biliaires et pancréatiques" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20506" /> <display value="Enterography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Entérographie" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20507" /> <display value="Kidneys"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Reins" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20508" /> <display value="Liver"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Foie" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20509" /> <display value="Pancreas"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pancréas" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20510" /> <display value="Renal artery"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Artère rénale" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20511" /> <display value="Urography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Urographie" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_MRI_abdomen_specificarea_other" /> <text value="Specify Other"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser (autre)" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_abdomen_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_pelvis" /> <text value="Pelvis"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pelvis" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20472" /> <display value="Pelvis"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pelvis" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_pelvis_group" /> <prefix value="Pelvis"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pelvis" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_pelvis" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_MRI_pelvis_specificarea" /> <text value="Specific area of interest (optional)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Région d'intérêt précise (facultatif)" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20512" /> <display value="Bladder"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Vessie" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20513" /> <display value="Gynecology (Uterus/ Ovaries/ Adnexal)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gynécologie (utérus / ovaires / annexes)" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20514" /> <display value="Iliac arteries"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Artères iliaques" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20515" /> <display value="Piriformis"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Piriforme" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20516" /> <display value="Prostate"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Prostate" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20517" /> <display value="Rectum/ Anal"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Rectum / anus" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20518" /> <display value="Urogenital (Testicular/ Penile)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Urogénital (testiculaire / pénien)" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_MRI_pelvis_specificarea_other" /> <text value="Specify Other"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser (autre)" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_pelvis_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_musculoskeletal" /> <text value="Musculoskeletal"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Musculosquelettique" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20473" /> <display value="Musculoskeletal"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Musculosquelettique" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_group" /> <prefix value="Musculoskeletal"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Musculosquelettique" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_musculoskeletal" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea" /> <text value="Specific area of interest"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Région d'intérêt précise" /> </extension> </extension> </text> <type value="choice" /> <required value="true" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20519" /> <display value="Shoulder"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Épaule" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20520" /> <display value="Humerus"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Humérus" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20521" /> <display value="Elbow"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Coude" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20522" /> <display value="Forearm"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Avant-bras" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20523" /> <display value="Wrist"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poignet" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20524" /> <display value="Hand"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Main" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20525" /> <display value="Finger"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Doigt" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20526" /> <display value="Bony Pelvis"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bassin osseux" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20527" /> <display value="Hip"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Hanche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20528" /> <display value="Femur / Thigh"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Fémur / cuisse" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20529" /> <display value="Knee"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Genou" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20530" /> <display value="Tibia and Fibula"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tibia et fibula" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20531" /> <display value="Ankle"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cheville" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20532" /> <display value="Foot"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pied" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20533" /> <display value="Toe"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Orteil" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_shoulder" /> <text value="Shoulder:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Épaule :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20519" /> <display value="Shoulder"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Épaule" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_humerus" /> <text value="Humerus:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Humérus :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20520" /> <display value="Humerus"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Humérus" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </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/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_elbow" /> <text value="Elbow:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Coude :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20521" /> <display value="Elbow"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Coude" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="text"> <valueString value="With" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_elbow_arthrogram" /> <text value="Arthrogram"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Arthrographie" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_elbow" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20535" /> <display value="Arthrogram"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Arthrographie" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </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/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_forearm" /> <text value="Forearm:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Avant-bras :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20522" /> <display value="Forearm"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Avant-bras" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </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/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_wrist" /> <text value="Wrist:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poignet :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20523" /> <display value="Wrist"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poignet" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="text"> <valueString value="With" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_wrist_arthrogram" /> <text value="Arthrogram"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Arthrographie" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_wrist" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20536" /> <display value="Arthrogram"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Arthrographie" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </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/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_hand" /> <text value="Hand:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Main :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20524" /> <display value="Hand"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Main" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_finger" /> <text value="Finger:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Doigt :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20525" /> <display value="Finger"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Doigt" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_hip" /> <text value="Hip:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Hanche :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20527" /> <display value="Hip"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Hanche" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="text"> <valueString value="With" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_hip_arthrogram" /> <text value="Arthrogram"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Arthrographie" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_hip" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20537" /> <display value="Arthrogram"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Arthrographie" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </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/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_femur" /> <text value="Femur:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Fémur :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20528" /> <display value="Femur / Thigh"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Fémur / cuisse" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_knee" /> <text value="Knee:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Genou :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20529" /> <display value="Knee"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Genou" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="text"> <valueString value="With" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_knee_arthrogram" /> <text value="Arthrogram"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Arthrographie" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_knee" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20538" /> <display value="Arthrogram"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Arthrographie" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </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/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_tibia" /> <text value="Tibia / Fibula:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tibia / fibula :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20530" /> <display value="Tibia and Fibula"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tibia et fibula" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </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/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_ankle" /> <text value="Ankle:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cheville :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20531" /> <display value="Ankle"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cheville" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="text"> <valueString value="With" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_ankle_arthrogram" /> <text value="Arthrogram"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Arthrographie" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_ankle" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20539" /> <display value="Arthrogram"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Arthrographie" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </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/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_foot" /> <text value="Foot:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pied :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20532" /> <display value="Foot"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pied" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_toe" /> <text value="Toe:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Orteil :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20533" /> <display value="Toe"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Orteil" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%resource.item.repeat(item).where(linkId = 'medicalImaging_examRequest_MRI_musculoskeletal_specificarea').answer.valueCoding.code.where($this = '20524' or $this = '20527' or $this = '20529').exists() and %resource.item.repeat(item).where(linkId = 'medicalImaging_examRequest_cds').answer.valueString.where($this = 'Show').exists()" /> </valueExpression> </extension> <linkId value="medicalImaging_MRI_CDS_Osteoarthritis_enabled" /> <text value="MRI osteoarthritis CDS display condition" /> <type value="boolean" /> <readOnly value="true" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="CT_CDS_MRI_Osteo" /> <text value="Osteoarthritis - Quality Standards MRI is not routinely indicated. Avoid advanced imaging (MRI) in arthritic joints. People who have persistent, atraumatic, movement-related joint pain or aching, and/or morning stiffness lasting less than 30 minutes, are diagnosed with osteoarthritis based on clinical assessment. Radiological imaging is not required to make a diagnosis in people aged 40 years or older if their symptoms are typical of osteoarthritis. Symptoms typical of osteoarthritis: Persistent atraumatic movement-related joint pain, aching, stiffness, and/or swelling. Morning stiffness lasting less than 30 minutes may or may not be present. Symptoms may affect one or a few joints. Atypical features: A recent history of injury, joint locking, prolonged morning joint-related stiffness, rapid onset of symptoms, the presence of a hot swollen joint, fever, chills, sweats, or feeling generally unwell. Atypical features usually indicate the need for further investigations to identify possible additional or alternative diagnoses, including loose body, meniscal injury, gout, or other inflammatory arthritides, such as rheumatoid arthritis, septic arthritis, and malignancy (if bone or soft tissue pain are present). Source: Ontario Health. Quality Standards – Osteoarthritis: Care for Adults with Osteoarthritis of the Knee, Hip, Hands, or Shoulder; 2024."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Osteoarthritis - Quality Standards MRI is not routinely indicated. Avoid advanced imaging (MRI) in arthritic joints. People who have persistent, atraumatic, movement-related joint pain or aching, and/or morning stiffness lasting less than 30 minutes, are diagnosed with osteoarthritis based on clinical assessment. Radiological imaging is not required to make a diagnosis in people aged 40 years or older if their symptoms are typical of osteoarthritis. Symptoms typical of osteoarthritis: Persistent atraumatic movement-related joint pain, aching, stiffness, and/or swelling. Morning stiffness lasting less than 30 minutes may or may not be present. Symptoms may affect one or a few joints. Atypical features: A recent history of injury, joint locking, prolonged morning joint-related stiffness, rapid onset of symptoms, the presence of a hot swollen joint, fever, chills, sweats, or feeling generally unwell. Atypical features usually indicate the need for further investigations to identify possible additional or alternative diagnoses, including loose body, meniscal injury, gout, or other inflammatory arthritides, such as rheumatoid arthritis, septic arthritis, and malignancy (if bone or soft tissue pain are present). Source: Ontario Health. Quality Standards – Osteoarthritis: Care for Adults with Osteoarthritis of the Knee, Hip, Hands, or Shoulder; 2024. " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Arthrose – Normes de qualité" /> </extension> </extension> </text> <type value="display" /> <enableWhen> <question value="medicalImaging_MRI_CDS_Osteoarthritis_enabled" /> <operator value="=" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="any" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension 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value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </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/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="medicalImaging_examRequest_MRI_breast_specificarea_breastimplant" /> <text value="Breast Implant:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Implant mammaire :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_breast_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20555" /> <display value="Implant"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Implant" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_cardiac" /> <text value="Cardiac"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cardiaque" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20477" /> <display value="Cardiac"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cardiaque" /> </extension> </extension> </display> </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> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_MRI_other" /> <text value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </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"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_MRI_other_specify" /> <text value="Specify"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_MRI_other" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="all" /> <required value="true" /> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="groupItems"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_MRI_clinicalindication_MRIrefnote" /> <text value="MRI Request: Clinical History / Indication"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'IRM : antécédents cliniques / indication" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20391" /> <display value="MRI Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'IRM" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <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=" " /> </extension> </valueString> </extension> </extension> <linkId value="medicalImaging_MRI_clinicalindication_text" /> <text value="Reason for exam (please also include presenting symptom(s), relevant underlying diagnosis and therapies, where applicable)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Motif de l'examen (veuillez aussi indiquer le ou les symptômes présents, le diagnostic sous-jacent pertinent et les traitements, le cas échéant)" /> </extension> </extension> </text> <type value="text" /> <required value="true" /> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="text"> <valueString value="X-Ray Exam/Region(s) of Interest:" /> </extension> <extension url="style"> <valueString value="font-weight:bold;text-decoration:underline;" /> </extension> <extension url="groupItems"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_group_XRAYrefnote" /> <text value="Select X-Ray Exam/Region(s) of Interest:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sélectionner l'examen/la ou les régions de radiographie d'intérêt :" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20392" /> <display value="X-Ray Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande de radiographie" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_chest" /> <text value="Chest (default Chest 2 views)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Thorax (par défaut : thorax, 2 incidences)" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20556" /> <display value="Chest (default Chest 2 views)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Thorax (par défaut : thorax, 2 incidences)" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_chest_group" /> <prefix value="Chest exams:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Examens du thorax :" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_chest" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_XRAY_chest_specificarea" /> <text value="Chest exams:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Examens du thorax :" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20566" /> <display value="One view (PA)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Une incidence (PA)" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20567" /> <display value="Two Views (PA, Lat)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Deux incidences (PA, latérale)" /> </extension> </extension> </display> </valueCoding> <initialSelected value="true" /> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20568" /> <display value="Three views (PA inspiration, PA expiration, Lat)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Trois incidences (PA en inspiration, PA en expiration, latérale)" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20569" /> <display value="Sternum"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sternum" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20570" /> <display value="Ribs"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Côtes" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20571" /> <display value="Thoracic inlet"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Orifice supérieur du thorax" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20572" /> <display value="Sternoclavicular Joints"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Articulations sternoclaviculaires" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_XRAY_chest_specificarea_other" /> <text value="Specify Other"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser (autre)" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_chest_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required 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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_chest_ribs" /> <text value="Ribs:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Côtes :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_chest_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20570" /> <display value="Ribs"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Côtes" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_abdomen" /> <text value="Abdomen"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Abdomen" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20557" /> <display value="Abdomen"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Abdomen" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_abdomen_group" /> <prefix value="Abdomen exams:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Examens de l'abdomen :" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_abdomen" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_XRAY_abdomen_specifcarea" /> <text value="Abdomen exams:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Examens de l'abdomen :" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20573" /> <display value="One view (Supine)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Une incidence (décubitus dorsal)" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20574" /> <display value="One view (Upright)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Une incidence (debout)" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20575" /> <display value="KUB (Kidney Ureters Bladder)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="KUB (reins, uretères et vessie)" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_XRAY_abdomen_specifcarea_other" /> <text value="Specify Other"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser (autre)" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_abdomen_specifcarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </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="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_spine" /> <text value="Spine"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Colonne vertébrale" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20558" /> <display value="Spine"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Colonne vertébrale" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_spine_group" /> <prefix value="Spine exams:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Examens de la colonne vertébrale :" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_spine" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_XRAY_spine_specificarea" /> <text value="Spine exams:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Examens de la colonne vertébrale :" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20576" /> <display value="Cervical"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cervical" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20577" /> <display value="Cervical spine flexion extension"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Colonne cervicale en flexion-extension" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20578" /> <display value="Thoracic"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Thoracique" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20579" /> <display value="Lumbar"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Lombaire" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20580" /> <display value="Lumbar spine flexion extension"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Colonne lombaire en flexion-extension" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20581" /> <display value="Sacrum"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sacrum" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20582" /> <display value="Coccyx"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Coccyx" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20583" /> <display value="Sacroiliac joints"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Articulations sacro-iliaques" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20584" /> <display value="Scoliosis spine"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Colonne – scoliose" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_XRAY_spine_specifcarea_other" /> <text value="Specify Other"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser (autre)" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_spine_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> </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="medicalImaging_examRequest_XRAY_spine_scoliosisviews" /> <text value="Scoliosis spine views:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Incidences de la colonne pour scoliose :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_spine_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20584" /> <display value="Scoliosis spine"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Colonne – scoliose" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <answerOption> <valueString value="PA views only"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Incidences PA seulement" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="PA and Lateral views"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Incidences PA et latérale" /> </extension> </extension> </valueString> </answerOption> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="Low_Back_Pain_Quality_Standard" /> <text value="Low Back Pain - Quality Standards People with acute low back pain do not receive diagnostic imaging tests unless they present with red flags that suggest serious pathological disease. Red flag signs or symptoms include: Neurological disorders: diffuse or substantial motor/sensory loss, progressive neurological deficits, cauda equina syndrome. Infection: fever, history of IV drug use, immunosuppression Fracture: trauma, osteoporosis risk/fragility fracture Tumour: history of cancer, unexplained weight loss, significant unexpected night pain, severe fatigue Inflammation: chronic low back pain for more than 3 months, age of onset less than 45 years, morning stiffness for more than 30 minutes, improvement with exercise, disproportionate night pain Source: Health Quality Ontario. Quality Standards – Low Back Pain: Care for Adults with Acute Low Back Pain; 2019."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Low Back Pain - Quality Standards People with acute low back pain do not receive diagnostic imaging tests unless they present with red flags that suggest serious pathological disease. Red flag signs or symptoms include: <li> Neurological disorders: diffuse or substantial motor/sensory loss, progressive neurological deficits, cauda equina syndrome. Infection: fever, history of IV drug use, immunosuppression </li> <li> Fracture: trauma, osteoporosis risk/fragility fracture </li> <li> Tumour: history of cancer, unexplained weight loss, significant unexpected night pain, severe fatigue </li> <li> Inflammation: chronic low back pain for more than 3 months, age of onset less than 45 years, morning stiffness for more than 30 minutes, improvement with exercise, disproportionate night pain </li> Source: Health Quality Ontario. Quality Standards – Low Back Pain: Care for Adults with Acute Low Back Pain; 2019. " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Lombalgie – Norme de qualité" /> </extension> </extension> </text> <type value="display" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_spine_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20579" /> <display value="Lumbar"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Lombaire" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest_cds" /> <operator value="=" /> <answerString value="Show" /> </enableWhen> <enableBehavior value="all" /> </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="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_head" /> <text value="Head and Neck"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tête et cou" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20559" /> <display value="Head and Neck"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tête et cou" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_head_group" /> <prefix value="Head and Neck exams:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Examens de la tête et du cou :" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_head" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_XRAY_head_specifcarea" /> <text value="Head and Neck exams:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Examens de la tête et du cou :" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20585" /> <display value="Skull"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Crâne" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20586" /> <display value="Orbits"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Orbites" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20587" /> <display value="Neck for soft tissue"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cou – tissus mous" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20588" /> <display value="Mastoids"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Mastoïdes" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20589" /> <display value="Nasal bones"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Os nasaux" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20590" /> <display value="Facal bones"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Os de la face" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20591" /> <display value="Mandible"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Mandibule" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20592" /> <display value="Temporomandibular joints"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Articulations temporomandibulaires" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20593" /> <display value="Sinus"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sinus" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_XRAY_head_specifcarea_other" /> <text value="Specify Other"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser (autre)" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_head_specifcarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required 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://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="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_head_specifcarea_orbit" /> <text value="Orbits exams:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Examens des orbites :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_head_specifcarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20586" /> <display value="Orbits"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Orbites" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20594" /> <display value="Trauma or injury"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Traumatisme ou blessure" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20595" /> <display value="Eye for foreign body"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Œil – recherche de corps étranger" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="Sinus_Exams_Display" /> <text value="Sinus x-rays are not covered by OHIP and are not recommended in adults with sinus disease."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Sinus x-rays are not covered by OHIP and are not recommended in adults with sinus disease." /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Les radiographies des sinus ne sont pas couvertes par l'OHIP et ne sont pas recommandées chez les adultes atteints d'une affection sinusienne." /> </extension> </extension> </text> <type value="display" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_head_specifcarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20593" /> <display value="Sinus"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sinus" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> </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="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_upperextremities" /> <text value="Upper Extremities"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Membres supérieurs" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20560" /> <display value="Upper Extremities"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Membres supérieurs" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_upperextremities_group" /> <prefix value="Upper Extremities exams:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Examens des membres supérieurs :" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_upperextremities" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea" /> <text value="Upper Extremities exams:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Examens des membres supérieurs :" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20596" /> <display value="Shoulder"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Épaule" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20597" /> <display value="Clavicle"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Clavicule" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20598" /> <display value="Acromioclavicular joints"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Articulations acromioclaviculaires" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20572" /> <display value="Sternoclavicular Joints"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Articulations sternoclaviculaires" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20599" /> <display value="Scapula"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Scapula" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20600" /> <display value="Humerus"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Humérus" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20601" /> <display value="Elbow"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Coude" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20602" /> <display value="Forearm"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Avant-bras" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20603" /> <display value="Wrist"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poignet" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20604" /> <display value="Scaphoid"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Scaphoïde" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20605" /> <display value="Hand"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Main" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20606" /> <display value="Finger"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Doigt" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea_other" /> <text value="Specify Other"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser (autre)" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required 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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea_shoulder" /> <text value="Shoulder:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Épaule :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20596" /> <display value="Shoulder"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Épaule" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </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="medicalImaging_examRequest_XRAY_upperextremities_specifcarea_clavicle" /> <text value="Clavicle:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Clavicule :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20597" /> <display value="Clavicle"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Clavicule" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea_acromioclavicular" /> <text value="Acromioclavicular joints:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Articulations acromioclaviculaires :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20598" /> <display value="Acromioclavicular joints"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Articulations acromioclaviculaires" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea_scapula" /> <text value="Scapula:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Scapula :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20599" /> <display value="Scapula"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Scapula" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea_humerus" /> <text value="Humerus:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Humérus :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20600" /> <display value="Humerus"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Humérus" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea_elbow" /> <text value="Elbow:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Coude :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20601" /> <display value="Elbow"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Coude" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea_forearm" /> <text value="Forearm:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Avant-bras :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20602" /> <display value="Forearm"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Avant-bras" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea_wrist" /> <text value="Wrist:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poignet :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20603" /> <display value="Wrist"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poignet" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea_scaphold" /> <text value="Scaphold:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Scaphoïde :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20604" /> <display value="Scaphoid"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Scaphoïde" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea_hand" /> <text value="Hand:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Main :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20605" /> <display value="Hand"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Main" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea_finger" /> <text value="Finger:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Doigt :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20606" /> <display value="Finger"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Doigt" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="Osteo_Quality_Standard" /> <text value="Osteoarthritis - Quality Standards X-ray is not routinely indicated People who have persistent, atraumatic, movement-related joint pain or aching, and/or morning stiffness lasting less than 30 minutes, are diagnosed with osteoarthritis based on clinical assessment. Radiological imaging is not required to make a diagnosis in people aged 40 years or older if their symptoms are typical of osteoarthritis. For X-Ray Hip or Shoulder: Plain radiographs (non-weight bearing for hip and AP view for shoulder) are required within the 6-month period prior to the patient’s first appointment with a surgeon. Symptoms typical of osteoarthritis: Persistent atraumatic movement-related joint pain, aching, stiffness, and/or swelling Morning stiffness lasting less than 30 minutes may or may not be present Symptoms may affect one or a few joints Atypical features: Recent history of injury Joint locking Prolonged morning joint-related stiffness Rapid onset of symptoms Presence of a hot swollen joint Fever, chills, sweats, or feeling generally unwell Atypical features usually indicate the need for further investigation to identify possible additional or alternative diagnoses, including loose body, meniscal injury, gout, or other inflammatory arthritides such as rheumatoid arthritis, septic arthritis, and malignancy (if bone or soft tissue pain are present). Source: Ontario Health. Quality Standards – Osteoarthritis: Care for Adults with Osteoarthritis of the Knee, Hip, Hands, or Shoulder; 2024."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Osteoarthritis - Quality Standards X-ray is not routinely indicated People who have persistent, atraumatic, movement-related joint pain or aching, and/or morning stiffness lasting less than 30 minutes, are diagnosed with osteoarthritis based on clinical assessment. Radiological imaging is not required to make a diagnosis in people aged 40 years or older if their symptoms are typical of osteoarthritis. For X-Ray Hip or Shoulder: Plain radiographs (non-weight bearing for hip and AP view for shoulder) are required within the 6-month period prior to the patient’s first appointment with a surgeon. Symptoms typical of osteoarthritis: <li> Persistent atraumatic movement-related joint pain, aching, stiffness, and/or swelling </li> <li> Morning stiffness lasting less than 30 minutes may or may not be present </li> <li> Symptoms may affect one or a few joints </li> Atypical features: <li>Recent history of injury</li> <li>Joint locking</li> <li>Prolonged morning joint-related stiffness</li> <li>Rapid onset of symptoms</li> <li>Presence of a hot swollen joint</li> <li>Fever, chills, sweats, or feeling generally unwell</li> Atypical features usually indicate the need for further investigation to identify possible additional or alternative diagnoses, including loose body, meniscal injury, gout, or other inflammatory arthritides such as rheumatoid arthritis, septic arthritis, and malignancy (if bone or soft tissue pain are present). Source: Ontario Health. Quality Standards – Osteoarthritis: Care for Adults with Osteoarthritis of the Knee, Hip, Hands, or Shoulder; 2024. " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Arthrose – Norme de qualité" /> </extension> </extension> </text> <type value="display" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20596" /> <display value="Shoulder"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Épaule" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest_cds" /> <operator value="=" /> <answerString value="Show" /> </enableWhen> <enableBehavior value="all" /> </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="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_lowerextremities" /> <text value="Lower Extremities"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Membres inférieurs" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20561" /> <display value="Lower Extremities"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Membres inférieurs" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_lowerextremities_group" /> <prefix value="Lower Extremities exams:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Examens des membres inférieurs :" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_lowerextremities" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_XRAY_lowerextremities_specificarea" /> <text value="Lower Extremities exams:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Examens des membres inférieurs :" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20607" /> <display value="Pelvis"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pelvis" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20608" /> <display value="Hip"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Hanche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20609" /> <display value="Femur"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Fémur" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20610" /> <display value="Knee"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Genou" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20611" /> <display value="Patella"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Rotule" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20612" /> <display value="Tibia and fibula"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tibia et fibula" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20613" /> <display value="Ankle"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cheville" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20614" /> <display value="Foot"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pied" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20615" /> <display value="Calcaneus"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Calcanéus" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20616" /> <display value="Toes"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Orteil" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20617" /> <display value="Leg length"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Longueur des jambes" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension 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<extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser (autre)" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_lowerextremities_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required 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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_lowerextremities_specificarea_hip" /> <text value="Hip:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Hanche :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_lowerextremities_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20608" /> <display value="Hip"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Hanche" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode 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value="medicalImaging_examRequest_XRAY_lowerextremities_specificarea_knee" /> <text value="Knee:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Genou :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_lowerextremities_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20610" /> <display value="Knee"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Genou" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_lowerextremities_specificarea_patella" /> <text value="Patella:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Rotule :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_lowerextremities_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20611" /> <display value="Patella"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Rotule" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_lowerextremities_specificarea_tibia" /> <text value="Tibia and fibula:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tibia et fibula :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_lowerextremities_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20612" /> <display value="Tibia and fibula"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tibia et fibula" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_lowerextremities_specificarea_ankle" /> <text value="Ankle:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cheville :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_lowerextremities_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20613" /> <display value="Ankle"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cheville" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_lowerextremities_specificarea_foot" /> <text value="Foot:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pied :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_lowerextremities_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20614" /> <display value="Foot"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pied" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_lowerextremities_specificarea_calcaneus" /> <text value="Calcaneus:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Calcanéus :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_lowerextremities_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20615" /> <display value="Calcaneus"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Calcanéus" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_lowerextremities_specificarea_toe" /> <text value="Toe:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Orteil :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_lowerextremities_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20616" /> <display value="Toes"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Orteil" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%resource.item.repeat(item).where(linkId = 'medicalImaging_examRequest_XRAY_lowerextremities_specificarea').answer.valueCoding.code.where($this = '20608' or $this = '20610').exists() and %resource.item.repeat(item).where(linkId = 'medicalImaging_examRequest_cds').answer.valueString.where($this = 'Show').exists()" /> </valueExpression> </extension> <linkId value="medicalImaging_XRAY_lower_CDS_Osteoarthritis_enabled" /> <text value="X-Ray lower-extremity osteoarthritis CDS display condition" /> <type value="boolean" /> <readOnly value="true" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="Osteo_Quality_Standard2" /> <text value="Osteoarthritis - Quality Standards X-ray is not routinely indicated People who have persistent, atraumatic, movement-related joint pain or aching, and/or morning stiffness lasting less than 30 minutes, are diagnosed with osteoarthritis based on clinical assessment. Radiological imaging is not required to make a diagnosis in people aged 40 years or older if their symptoms are typical of osteoarthritis. For X-Ray Knee: Weight-bearing images are required within the 6-month period prior to the patient’s first appointment with a surgeon. For X-Ray Hip or Shoulder: Plain radiographs (non-weight bearing for hip, and AP view for shoulder) are required within the 6-month period prior to the patient’s first appointment with a surgeon. Symptoms typical of osteoarthritis: Persistent atraumatic movement-related joint pain, aching, stiffness, and/or swelling. Morning stiffness lasting less than 30 minutes may or may not be present. Symptoms may affect one or a few joints. Atypical features: Recent history of injury, joint locking, prolonged morning joint-related stiffness, rapid onset of symptoms, presence of a hot swollen joint, fever, chills, sweats, or feeling generally unwell. Atypical features usually indicate the need for further investigation to identify possible additional or alternative diagnoses, including loose body, meniscal injury, gout, or other inflammatory arthritis such as rheumatoid arthritis, septic arthritis, and malignancy (if bone or soft tissue pain are present). Source: Ontario Health. Quality Standards – Osteoarthritis: Care for Adults with Osteoarthritis of the Knee, Hip, Hands, or Shoulder; 2024."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Osteoarthritis - Quality Standards X-ray is not routinely indicated People who have persistent, atraumatic, movement-related joint pain or aching, and/or morning stiffness lasting less than 30 minutes, are diagnosed with osteoarthritis based on clinical assessment. Radiological imaging is not required to make a diagnosis in people aged 40 years or older if their symptoms are typical of osteoarthritis. For X-Ray Knee: Weight-bearing images are required within the 6-month period prior to the patient’s first appointment with a surgeon. For X-Ray Hip or Shoulder: Plain radiographs (non-weight bearing for hip, and AP view for shoulder) are required within the 6-month period prior to the patient’s first appointment with a surgeon. Symptoms typical of osteoarthritis: Persistent atraumatic movement-related joint pain, aching, stiffness, and/or swelling. Morning stiffness lasting less than 30 minutes may or may not be present. Symptoms may affect one or a few joints. Atypical features: Recent history of injury, joint locking, prolonged morning joint-related stiffness, rapid onset of symptoms, presence of a hot swollen joint, fever, chills, sweats, or feeling generally unwell. Atypical features usually indicate the need for further investigation to identify possible additional or alternative diagnoses, including loose body, meniscal injury, gout, or other inflammatory arthritis such as rheumatoid arthritis, septic arthritis, and malignancy (if bone or soft tissue pain are present). Source: Ontario Health. Quality Standards – Osteoarthritis: Care for Adults with Osteoarthritis of the Knee, Hip, Hands, or Shoulder; 2024. " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Arthrose – Norme de qualité" /> </extension> </extension> </text> <type value="display" /> <enableWhen> <question value="medicalImaging_XRAY_lower_CDS_Osteoarthritis_enabled" /> <operator value="=" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="any" /> </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="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_mammogram" /> <text value="Mammogram (Non-OBSP)"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Mammographie (non-OBSP)" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20562" /> <display value="Mammogram (Non-OBSP)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Mammographie (non-OBSP)" /> </extension> </extension> </display> </valueCoding> </answerOption> <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="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_mammogram_specifcarea" /> <text value="Mammogram:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Mammographie :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_mammogram" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_boneage" /> <text value="Bone Age"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Âge osseux" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20563" /> <display value="Bone Age"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Âge osseux" /> </extension> </extension> </display> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_survey" /> <text value="Survey"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sondage" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20564" /> <display value="Survey"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sondage" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_survey_group" /> <prefix value="Survey"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sondage" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_survey" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_XRAY_survey_specificarea" /> <text value="Survey"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sondage" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20618" /> <display value="Metabolic"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Métabolique" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20619" /> <display value="Metastatic"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Métastatique" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20620" /> <display value="Rheumatoid"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Rhumatoïde" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20621" /> <display value="Babygram"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Babygramme" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20617" /> <display value="Leg length"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Longueur des jambes" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_XRAY_survey_specificarea_other" /> <text value="Specify Other"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser (autre)" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_survey_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </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="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_gastric" /> <text value="Gastric and Fluoroscopic imaging"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Imagerie gastrique et fluoroscopique" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20565" /> <display value="Gastric and Fluoroscopic imaging"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Imagerie gastrique et fluoroscopique" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_gastric_group" /> <prefix value="Gastric and Fluoroscopic imaging exams:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Examens d'imagerie gastrique et fluoroscopique :" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_gastric" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_XRAY_gastric_specifcarea" /> <text value="Gastric and Fluoroscopic imaging exams:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Examens d'imagerie gastrique et fluoroscopique :" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20622" /> <display value="Gastrointestinal tract"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tractus gastro-intestinal" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20623" /> <display value="Retrograde urethrogram"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Urétrographie rétrograde" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20624" /> <display value="Cystourethrogram"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cysto-urétrographie" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20625" /> <display value="Hysterosalpingogram"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Hystérosalpingographie" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20626" /> <display value="Sinogram"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sinographie" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20627" /> <display value="Musculoskeletal injections"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Injections musculosquelettiques" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_XRAY_gastric_specifcarea_other" /> <text value="Specify Other"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser (autre)" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_gastric_specifcarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required 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://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="border-style:solid;" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_XRAY_gastric_specifcarea_gastro" /> <text value="Gastrointestinal tract exams:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Examens du tractus gastro-intestinal :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_gastric_specifcarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20622" /> <display value="Gastrointestinal tract"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tractus gastro-intestinal" /> </extension> </extension> </display> </answerCoding> </enableWhen> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20629" /> <display value="Barium swallow"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gorgée barytée" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20628" /> <display value="Modified barium swallow (Video fluoroscope swallowing exam)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gorgée barytée modifiée (examen vidéofluoroscopique de la déglutition)" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20630" /> <display value="Upper GI series (Esophagus, stomach and duodenum)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Examen du tractus gastro-intestinal supérieur (œsophage, estomac et duodénum)" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20631" /> <display value="Small bowel follow through"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Transit du grêle" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20632" /> <display value="Barium enema"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Lavement baryté" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_XRAY_gastric_specifcarea_gastro_other" /> <text value="Specify Other"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser (autre)" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_gastric_specifcarea_gastro" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required 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://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="border-style:solid;" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_XRAY_gastric_specifcarea_cysto" /> <text value="Cystourethrogram:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cysto-urétrographie :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_gastric_specifcarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20624" /> <display value="Cystourethrogram"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cysto-urétrographie" /> </extension> </extension> </display> </answerCoding> </enableWhen> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20633" /> <display value="Stress"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="À l'effort" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20634" /> <display value="Voiding"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Mictionnel" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_gastric_specifcarea_sinogram" /> <text value="Sinogram: specify"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sinographie : préciser" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_gastric_specifcarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20626" /> <display value="Sinogram"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sinographie" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_gastric_specifcarea_musculoskeletal" /> <text value="Musculoskeletal injection: specify"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Injection musculosquelettique : préciser" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_gastric_specifcarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20627" /> <display value="Musculoskeletal injections"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Injections musculosquelettiques" /> </extension> </extension> </display> </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://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_other" /> <text value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </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"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_XRAY_other_specify" /> <text value="Other:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_XRAY_other" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="all" /> <required value="true" /> </item> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="groupItems"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_XRAY_clinicalindication_XRAYrefnote" /> <text value="X-Ray Request: Clinical History / Indication"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande de radiographie : antécédents cliniques / indication" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20392" /> <display value="X-Ray Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande de radiographie" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <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=" " /> </extension> </valueString> </extension> </extension> <linkId value="medicalImaging_XRAY_clinicalindication_text" /> <text value="Reason for exam (please also include presenting symptom(s), relevant underlying diagnosis and therapies, where applicable)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Motif de l'examen (veuillez aussi indiquer le ou les symptômes présents, le diagnostic sous-jacent pertinent et les traitements, le cas échéant)" /> </extension> </extension> </text> <type value="text" /> <required value="true" /> </item> <item> <linkId value="medicalImaging_XRAY_clinicalindication_views" /> <text value="Additional relevant information (e.g. request specific views)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Renseignements pertinents supplémentaires (p. ex. demander des incidences précises)" /> </extension> </extension> </text> <type value="string" /> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="text"> <valueString value="Ultrasound Exam/Region(s) of Interest:" /> </extension> <extension url="style"> <valueString value="font-weight:bold;text-decoration:underline;" /> </extension> <extension url="groupItems"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_group_USrefnote" /> <text value="Select Ultrasound Exam/Region(s) of Interest:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sélectionner l'examen/la ou les régions d'échographie d'intérêt :" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20393" /> <display value="Ultrasound Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'échographie" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_abdomen" /> <text value="Abdomen"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Abdomen" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20635" /> <display value="Abdomen"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Abdomen" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_abdomen_group" /> <prefix value="Abdomen:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Abdomen :" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_US_abdomen" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_US_abdomen_specificarea" /> <text value="Abdomen:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Abdomen :" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20643" /> <display value="Complete abdomen"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Abdomen complet" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20644" /> <display value="Appendix"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Appendice" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20645" /> <display value="Gallbladder"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Vésicule biliaire" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20646" /> <display value="Kidney Ureters Bladder"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Reins, uretères et vessie" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20647" /> <display value="Liver"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Foie" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20648" /> <display value="Liver elastography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Élastographie hépatique" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20649" /> <display value="Pancreas"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pancréas" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20650" /> <display value="Portal hypertension"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Hypertension portale" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20651" /> <display value="Renal"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Rénal" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20652" /> <display value="Right upper quadrant"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Quadrant supérieur droit" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20653" /> <display value="Spleen"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Rate" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20654" /> <display value="Abdomen contrast"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Abdomen avec contraste" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20655" /> <display value="Abdominal wall"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Paroi abdominale" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_US_abdomen_specificarea_other" /> <text value="Specify:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_US_abdomen_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_pelvis" /> <text value="Pelvis"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pelvis" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20636" /> <display value="Pelvis"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pelvis" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_pelvis_group" /> <prefix value="Pelvis:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pelvis :" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_US_pelvis" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_US_pelvis_specificarea" /> <text value="Pelvis:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pelvis :" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20656" /> <display value="Complete pelvis"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pelvis complet" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20657" /> <display value="Pelvis transabdominal"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pelvis (transabdominale)" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20658" /> <display value="Female pelvis (transvaginal)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pelvis féminin (transvaginale)" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20659" /> <display value="Follicular monitoring"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Monitorage folliculaire" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20660" /> <display value="Limited non-pregnancy (for IUD insertion placement check)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Examen limité (hors grossesse) (pour vérifier la mise en place d'un stérilet)" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20661" /> <display value="Saline Infusion Sonohysterography"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sonohystérographie avec perfusion de solution saline" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20662" /> <display value="Male pelvis (Transrectal)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pelvis masculin (transrectale)" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20663" /> <display value="Prostate"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Prostate" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20664" /> <display value="Penile"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pénien" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20665" /> <display value="Testicles/Scrotum"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Testicules / scrotum" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20666" /> <display value="Bladder"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Vessie" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20667" /> <display value="Groin"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Aine" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_US_pelvis_specificarea_other" /> <text value="Specify:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_US_pelvis_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </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/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="medicalImaging_examRequest_US_pelvis_specificarea_groin" /> <text value="Groin:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Aine :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_pelvis_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20667" /> <display value="Groin"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Aine" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_obstetrical" /> <text value="Obstetrical"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Obstétrical" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20637" /> <display value="Obstetrical"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Obstétrical" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_obstetrical_group" /> <prefix value="Obstetrical:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Obstétrical :" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_US_obstetrical" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_obstetrical_pregnancytype" /> <text value="Pregnancy type:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Type de grossesse :" /> </extension> </extension> </text> <type value="choice" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20668" /> <display value="Singleton"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Grossesse unique" /> </extension> </extension> </display> </valueCoding> <initialSelected value="true" /> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20669" /> <display value="Twins"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Jumeaux" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20670" /> <display value="Triplets"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Triplés" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20671" /> <display value="Unknown"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Inconnu" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <linkId value="medicalImaging_examRequest_US_obstetrical_pregnancytype_other" /> <text value="Specify:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_US_obstetrical_pregnancytype" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> </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://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_US_obstetrical_specificarea" /> <text value="Obstetrical options"> <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="20672" /> <display value="Dating (<16 weeks)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Datation (< 16 semaines)" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20673" /> <display value="Prenatal screening (NT/eFTS) 11-14 weeks"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Dépistage prénatal (clarté nucale/eFTS) 11-14 semaines" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20674" /> <display value="Anatomy (20 week scan)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Anatomie (échographie de 20 semaines)" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20675" /> <display value="2nd or 3rd trimester scan"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Échographie du 2e ou 3e trimestre" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20676" /> <display value="Biophysical profile"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Profil biophysique" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20677" /> <display value="Growth"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Croissance" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20678" /> <display value="Cervical length"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Longueur du col utérin" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20679" /> <display value="Multi-gestational study"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Étude de grossesse multiple" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20680" /> <display value="High risk pregnancy"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Grossesse à risque élevé" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20681" /> <display value="Uterine artery doppler studies"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Études Doppler de l'artère utérine" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20682" /> <display value="Umbilical artery doppler studies"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Études Doppler de l'artère ombilicale" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20683" /> <display value="Fetal doppler"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Doppler fœtal" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20745" /> <display value="With transvaginal"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Avec transvaginale" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_US_obstetrical_specificarea_other" /> <text value="Specify:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_US_obstetrical_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required 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> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="answerStyle"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_US_obstetrical_specificarea_anatomy" /> <text value="Anatomy (20 week scan) additional option:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Anatomie (échographie de 20 semaines), option supplémentaire :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_obstetrical_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20674" /> <display value="Anatomy (20 week scan)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Anatomie (échographie de 20 semaines)" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20684" /> <display value="Report sex"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Indiquer le sexe du fœtus" /> </extension> </extension> </display> </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://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="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_obstetrical_specificarea_highrisk" /> <text value="High-Risk Pregnancy Trimester:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Trimestre de la grossesse à risque élevé :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_obstetrical_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20680" /> <display value="High risk pregnancy"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Grossesse à risque élevé" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20685" /> <display value="1st Trimester"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="1er trimestre" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20686" /> <display value="2nd and 3rd Trimester"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="2e et 3e trimestre" /> </extension> </extension> </display> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_neonatal" /> <text value="Neonatal and Paediatric"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Néonatal et pédiatrique" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20638" /> <display value="Neonatal and Paediatric"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Néonatal et pédiatrique" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_neonatal_group" /> <prefix value="Neonatal and paediatric:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Néonatal et pédiatrique :" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_US_neonatal" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_US_neonatal_specificarea" /> <text value="Neonatal and paediatric:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Néonatal et pédiatrique :" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20689" /> <display value="Brain"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cerveau" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20688" /> <display value="Spine"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Colonne vertébrale" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20691" /> <display value="Pylorus and Hypertrophic Pyloric Stenosis"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pylore et sténose hypertrophique du pylore" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20692" /> <display value="Bowel"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Intestin" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20644" /> <display value="Appendix"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Appendice" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20690" /> <display value="Hips"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Hanches" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_US_neonatal_specificarea_other" /> <text value="Specify:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_US_neonatal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal" /> <text value="Musculoskeletal"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Musculosquelettique" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20639" /> <display value="Musculoskeletal"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Musculosquelettique" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_group" /> <prefix value="Musculoskeletal"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Musculosquelettique" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <prefix value="Musculoskeletal:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Musculosquelettique :" /> </extension> </extension> </prefix> <type value="choice" /> <required value="true" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20712" /> <display value="Shoulders"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Épaule" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20713" /> <display value="Rotator cuff"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Coiffe des rotateurs" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20710" /> <display value="Biceps"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Biceps" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20711" /> <display value="Triceps"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Triceps" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20709" /> <display value="Elbow"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Coude" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20707" /> <display value="Carpal tunnel"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Canal carpien" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20706" /> <display value="Wrist"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poignet" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20705" /> <display value="Hand"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Main" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20715" /> <display value="Finger(s)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Doigt(s)" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20704" /> <display value="Gluteal region"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Région fessière" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20703" /> <display value="Hip"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Hanche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20702" /> <display value="Thigh/Hamstrings"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cuisse / ischio-jambiers" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20701" /> <display value="Quadriceps tendon"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tendon quadricipital" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20699" /> <display value="Patellar tendon"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tendon rotulien" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20698" /> <display value="Knee"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Genou" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20700" /> <display value="Popliteal fossa"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Creux poplité" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20697" /> <display value="Calf/Lower leg/Gastrocnemius"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Mollet / jambe / gastrocnémien" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20696" /> <display value="Achilles"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tendon d'Achille" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20695" /> <display value="Ankle"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cheville" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20693" /> <display value="Foot"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pied" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20694" /> <display value="Plantar fascia"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Fascia plantaire" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20714" /> <display value="Toe(s)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Orteil(s)" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20716" /> <display value="Palpable masses"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Masses palpables" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20717" /> <display value="Foreign body"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Corps étranger" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20708" /> <display value="Forearm"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Avant-bras" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_shoulder" /> <text value="Shoulder:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Épaule :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20712" /> <display value="Shoulders"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Épaule" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_rotatorcuff" /> <text value="Rotator cuff:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Coiffe des rotateurs :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20713" /> <display value="Rotator cuff"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Coiffe des rotateurs" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_biceps" /> <text value="Biceps:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Biceps :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20710" /> <display value="Biceps"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Biceps" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_triceps" /> <text value="Triceps:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Triceps :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20711" /> <display value="Triceps"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Triceps" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_elbow" /> <text value="Elbow:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Coude :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20709" /> <display value="Elbow"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Coude" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_forearm" /> <text value="Forearm:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Avant-bras :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20708" /> <display value="Forearm"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Avant-bras" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_carpaltunnel" /> <text value="Carpal tunnel:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Canal carpien :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20707" /> <display value="Carpal tunnel"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Canal carpien" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_wrist" /> <text value="Wrist:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poignet :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20706" /> <display value="Wrist"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poignet" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_hand" /> <text value="Hand:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Main :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20705" /> <display value="Hand"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Main" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_finger" /> <text value="Finger(s):" /> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20715" /> <display value="Finger(s)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Doigt(s)" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </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="medicalImaging_examRequest_US_musculoskeletal_specificarea_finger_left" /> <text value="Left digit(s):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Doigt(s)/orteil(s) gauche(s) :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea_finger" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea_finger" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="any" /> <required value="true" /> <repeats value="true" /> <answerOption> <valueString value="1"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="1" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="2"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="2" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="3"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="3" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="4"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="4" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="5"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="5" /> </extension> </extension> </valueString> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </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="medicalImaging_examRequest_US_musculoskeletal_specificarea_finger_right" /> <text value="Right digit(s):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Doigt(s) droit(s) :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea_finger" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea_finger" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="any" /> <required value="true" /> <repeats value="true" /> <answerOption> <valueString value="1"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="1" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="2"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="2" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="3"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="3" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="4"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="4" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="5"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="5" /> </extension> </extension> </valueString> </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://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_gluteal" /> <text value="Gluteal region:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Région fessière :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20704" /> <display value="Gluteal region"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Région fessière" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_hip" /> <text value="Hip:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Hanche :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20703" /> <display value="Hip"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Hanche" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_thigh" /> <text value="Thigh/Hamstrings:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cuisse / ischio-jambiers :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20702" /> <display value="Thigh/Hamstrings"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cuisse / ischio-jambiers" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_quadriceps" /> <text value="Quadriceps tendon:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tendon quadricipital :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20701" /> <display value="Quadriceps tendon"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tendon quadricipital" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_patellar" /> <text value="Patellar tendon:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tendon rotulien :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20699" /> <display value="Patellar tendon"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tendon rotulien" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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" /> <display value="Drop down" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_knee" /> <text value="Knee:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Genou :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20698" /> <display value="Knee"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Genou" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_popliteal" /> <text value="Popliteal fossa:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Creux poplité :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20700" /> <display value="Popliteal fossa"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Creux poplité" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_calf" /> <text value="Calf/Lower leg/Gastrocnemius:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Mollet / jambe / gastrocnémien :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20697" /> <display value="Calf/Lower leg/Gastrocnemius"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Mollet / jambe / gastrocnémien" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_achilles" /> <text value="Achilles:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tendon d'Achille :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20696" /> <display value="Achilles"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tendon d'Achille" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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" /> <display value="Drop down" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_ankle" /> <text value="Ankle:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cheville :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20695" /> <display value="Ankle"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cheville" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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" /> <display value="Drop down" /> </coding> </valueCodeableConcept> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_ankle_specify" /> <text value="Ankle specify:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cheville, préciser :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea_ankle" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <repeats value="true" /> <answerOption> <valueString value="Medial"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Médial" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="Lateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Latéral" /> </extension> </extension> </valueString> </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" /> <display value="Drop down" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_foot" /> <text value="Foot:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pied :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20693" /> <display value="Foot"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pied" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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" /> <display value="Drop down" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_plantar" /> <text value="Plantar fascia:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Fascia plantaire :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20694" /> <display value="Plantar fascia"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Fascia plantaire" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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" /> <display value="Drop down" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_toe" /> <text value="Toe:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Orteil :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20714" /> <display value="Toe(s)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Orteil(s)" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_toe_left" /> <text value="Left digit(s):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Doigt(s)/orteil(s) gauche(s) :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea_toe" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea_toe" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="any" /> <required value="true" /> <repeats value="true" /> <answerOption> <valueString value="1"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="1" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="2"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="2" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="3"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="3" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="4"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="4" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="5"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="5" /> </extension> </extension> </valueString> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </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="medicalImaging_examRequest_US_musculoskeletal_specificarea_toe_right" /> <text value="Right digits(s):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Doigt(s) droit(s) :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea_toe" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea_toe" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="any" /> <required value="true" /> <repeats value="true" /> <answerOption> <valueString value="1"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="1" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="2"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="2" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="3"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="3" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="4"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="4" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="5"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="5" /> </extension> </extension> </valueString> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_palpablemass" /> <text value="Palpable masses specify:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Masses palpables, préciser :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20716" /> <display value="Palpable masses"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Masses palpables" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_foreignbody" /> <text value="Foreign body specify:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Corps étranger, préciser :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20717" /> <display value="Foreign body"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Corps étranger" /> </extension> </extension> </display> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_vascular" /> <text value="Vascular"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Vasculaire" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20640" /> <display value="Vascular"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Vasculaire" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_vascular_group" /> <prefix value="Vascular:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Vasculaire :" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_US_vascular" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="all" /> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </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="medicalImaging_examRequest_US_vascular_specificarea" /> <text value="Vascular:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Vasculaire :" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20718" /> <display value="Upper extremity arterial"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Artériel des membres supérieurs" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20719" /> <display value="Upper extremity venous"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Veineux des membres supérieurs" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20720" /> <display value="Lower extremity arterial"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Artériel des membres inférieurs" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20721" /> <display value="Lower extremity venous thrombosis"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Thrombose veineuse des membres inférieurs" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20722" /> <display value="Lower extremity venous reflux"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Reflux veineux des membres inférieurs" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20723" /> <display value="Abdominal aortic aneurysm screen"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Dépistage de l'anévrisme de l'aorte abdominale" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20724" /> <display value="Ankle brachial index" /> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20725" /> <display value="Arterial venous fistula"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Fistule artérioveineuse" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20726" /> <display value="Carotid"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Carotide" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20727" /> <display value="Inferior vena cava"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Veine cave inférieure" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20728" /> <display value="Portal vein"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Veine porte" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20729" /> <display value="Renal arteries"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Artères rénales" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20730" /> <display value="Superior mesenteric artery (SMA)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Artère mésentérique supérieure (AMS)" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20731" /> <display value="Temporal arteries"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Artères temporales" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21375" /> <display value="Thoracic outlet syndrome"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Syndrome du défilé thoracobrachial" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20732" /> <display value="Venous mapping"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cartographie veineuse" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_US_vascular_specificarea_other" /> <text value="Specify:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_US_vascular_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required 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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_vascular_specificarea_uea" /> <text value="Upper extremity arterial ultrasound:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Échographie artérielle des membres supérieurs :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_vascular_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20718" /> <display value="Upper extremity arterial"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Artériel des membres supérieurs" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_vascular_specificarea_uev" /> <text value="Upper extremity venous ultrasound:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Échographie veineuse des membres supérieurs :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_vascular_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20719" /> <display value="Upper extremity venous"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Veineux des membres supérieurs" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_vascular_specificarea_lea" /> <text value="Lower extremity arterial ultrasound:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Échographie artérielle des membres inférieurs :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_vascular_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20720" /> <display value="Lower extremity arterial"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Artériel des membres inférieurs" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_vascular_specificarea_lev" /> <text value="Lower extremity venous thrombosis ultrasound:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Échographie de la thrombose veineuse des membres inférieurs :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_vascular_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20721" /> <display value="Lower extremity venous thrombosis"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Thrombose veineuse des membres inférieurs" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_vascular_specificarea_levr" /> <text value="Lower extremity venous reflux ultrasound:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Échographie du reflux veineux des membres inférieurs :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_vascular_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20722" /> <display value="Lower extremity venous reflux"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Reflux veineux des membres inférieurs" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_vascular_specificarea_ankle" /> <text value="Specify extremity:" /> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_US_vascular_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20724" /> <display value="Ankle brachial index"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Indice de pression systolique cheville-bras" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required 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://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="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_vascular_specificside_avf" /> <text value="AVF specify side:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="FAV, préciser le côté :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_vascular_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20725" /> <display value="Arterial venous fistula"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Fistule artérioveineuse" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" /> <code value="push-button" /> <display value="Push Button" /> </coding> </valueCodeableConcept> </extension> <linkId value="medicalImaging_examRequest_US_vascular_specificarea_avf" /> <text value="AVF specify area:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="FAV, préciser la région :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_vascular_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20725" /> <display value="Arterial venous fistula"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Fistule artérioveineuse" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21378" /> <display value="Arm"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bras" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21379" /> <display value="Leg"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Jambe" /> </extension> </extension> </display> </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://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" /> <code value="push-button" /> <display value="Push Button" /> </coding> </valueCodeableConcept> </extension> <linkId value="medicalImaging_examRequest_US_vascular_specificarea_sma" /> <text value="SMA specify:" /> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_vascular_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20730" /> <display value="Superior mesenteric artery (SMA)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Artère mésentérique supérieure (AMS)" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21381" /> <display value="Fasting"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="À jeun" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21382" /> <display value="Post-prandial"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Postprandial" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </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/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <linkId value="medicalImaging_examRequest_US_vascular_specificarea_temporal" /> <text value="Temporal arteries:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Artères temporales :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_vascular_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20731" /> <display value="Temporal arteries"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Artères temporales" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" /> <code value="push-button" /> <display value="Push Button" /> </coding> </valueCodeableConcept> </extension> <linkId value="medicalImaging_examRequest_US_vascular_specificarea_thoracicoutlet" /> <text value="Thoracic outlet syndrome:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Syndrome du défilé thoracobrachial :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_vascular_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21375" /> <display value="Thoracic outlet syndrome"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Syndrome du défilé thoracobrachial" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required value="true" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21376" /> <display value="Arterial"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Artériel" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21377" /> <display value="Venous"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Veineux" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_vascular_specificarea_venous" /> <text value="Venous mapping: Specify extremity"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cartographie veineuse : préciser le membre" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_US_vascular_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20732" /> <display value="Venous mapping"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cartographie veineuse" /> </extension> </extension> </display> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_head" /> <text value="Head and Neck"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tête et cou" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20641" /> <display value="Head and Neck"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tête et cou" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_head_group" /> <prefix value="Head and Neck"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tête et cou" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_US_head" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_US_head_specificarea" /> <text value="Head and Neck:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tête et cou :" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20733" /> <display value="Neck/Salivary gland"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cou / glande salivaire" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20734" /> <display value="Lymph nodes"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Ganglions lymphatiques" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20735" /> <display value="Thyroid"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Thyroïde" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_US_head_specificarea_other" /> <text value="Specify:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_US_head_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_head_specificarea_neck" /> <text value="Neck/Salivary gland: Specify"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cou / glande salivaire : préciser" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_US_head_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20733" /> <display value="Neck/Salivary gland"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cou / glande salivaire" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_head_specificarea_lymph" /> <text value="Lymph nodes:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Ganglions lymphatiques :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_US_head_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20734" /> <display value="Lymph nodes"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Ganglions lymphatiques" /> </extension> </extension> </display> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_breast" /> <text value="Breast and Axilla"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sein et aisselle" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20642" /> <display value="Breast and Axilla"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sein et aisselle" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_breast_group" /> <prefix value="Breast and Axilla"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sein et aisselle" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_US_breast" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_US_breast_specificarea" /> <text value="Breast and Axilla:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sein et aisselle :" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20736" /> <display value="Breast"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sein" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20737" /> <display value="Axilla"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Aisselle" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_US_breast_specificarea_other" /> <text value="Specify:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_US_breast_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </answerCoding> </enableWhen> <required 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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_breast_specificarea_breast" /> <text value="Breast:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sein :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_breast_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20736" /> <display value="Breast"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sein" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_breast_specificarea_axilla" /> <text value="Axilla:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Aisselle :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_breast_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20737" /> <display value="Axilla"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Aisselle" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </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="medicalImaging_examRequest_US_misc" /> <text value="Miscellaneous"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Divers" /> </extension> </extension> </text> <type value="string" /> <repeats value="true" /> <answerOption> <valueString value="Miscellaneous"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Divers" /> </extension> </extension> </valueString> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_misc_group" /> <prefix value="Miscellaneous"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Divers" /> </extension> </extension> </prefix> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_US_misc" /> <operator value="exists" /> <answerBoolean value="true" /> </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://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="text"> <valueString value="Specific area of interest" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_US_misc_specificarea" /> <text value="Miscellaneous:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Divers :" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20738" /> <display value="Chest"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Thorax" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20739" /> <display value="Chest wall (mass)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Paroi thoracique (masse)" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20740" /> <display value="Soft tissue"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tissus mous" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Other specific area of interest" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_US_misc_specificarea_other" /> <text value="Specify:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_US_misc_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required 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://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="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_US_misc_specificarea_chest" /> <text value="Chest:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Thorax :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_misc_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20738" /> <display value="Chest"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Thorax" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </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="medicalImaging_examRequest_US_misc_specificarea_softtissue" /> <text value="Soft tissue: Specify"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tissus mous : préciser" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest_US_misc_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20740" /> <display value="Soft tissue"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tissus mous" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21321" /> <display value="Left"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Gauche" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21322" /> <display value="Right"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Droite" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21323" /> <display value="Bilateral"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bilatéral" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="groupItems"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_US_clinicalindication_USrefnote" /> <text value="Ultrasound Request: Clinical History / Indication"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'échographie : antécédents cliniques / indication" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20393" /> <display value="Ultrasound Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'échographie" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <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=" " /> </extension> </valueString> </extension> </extension> <linkId value="medicalImaging_US_clinicalindication_text" /> <text value="Reason for exam (please also include presenting symptom(s), relevant underlying diagnosis and therapies, where applicable)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Motif de l'examen (veuillez aussi indiquer le ou les symptômes présents, le diagnostic sous-jacent pertinent et les traitements, le cas échéant)" /> </extension> </extension> </text> <type value="text" /> <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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_examRequest_BMD_group_BMDrefnote" /> <text value="Select BMD Exam of Interest:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sélectionner l'examen d'ostéodensitométrie d'intérêt :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20394" /> <display value="Bone Mineral Density Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'ostéodensitométrie" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20741" /> <display value="Baseline"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="De référence" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20742" /> <display value="Low Risk"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Risque faible" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20743" /> <display value="High Risk"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Risque élevé" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="bmd_ordering_guidelines" /> <text value="BMD Ordering Guidelines Baseline test: Once per lifetime Low Risk Patients: (FRAX or equivalent fracture risk <10%) Subsequent test: every 60 months Medium Risk Patients: (FRAX or equivalent fracture risk 10-15%) Subsequent test: every 60 months High Risk Patients or therapy monitoring or risk factor for secondary osteoporosis: (FRAX or equivalent fracture risk>15%) Subsequent test: every 36 months Therapy monitoring is limited to: 1 test ≥36 months after initiating pharmacotherapy; and/or 1 test ≥36 months after stopping bisphosphonate therapy Hypercortisolism/Cushing's syndrome or receiving high-dose glucocorticoid therapy of <20 mg Prednisone equivalent per day Additional test: every 12 months Source: Ontario Ministry of Health, Schedule of Benefits for Physician Services (Diagnostic Radiology – BMD Measurement), updated March 9, 2026, effective April 1, 2026."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="BMD Ordering Guidelines Baseline test: Once per lifetime Low Risk Patients: (FRAX or equivalent fracture risk <10%) Subsequent test: every 60 months Medium Risk Patients: (FRAX or equivalent fracture risk 10-15%) Subsequent test: every 60 months High Risk Patients or therapy monitoring or risk factor for secondary osteoporosis: (FRAX or equivalent fracture risk>15%) Subsequent test: every 36 months Therapy monitoring is limited to: 1 test ≥36 months after initiating pharmacotherapy; and/or 1 test ≥36 months after stopping bisphosphonate therapy Hypercortisolism/Cushing's syndrome or receiving high-dose glucocorticoid therapy of <20 mg Prednisone equivalent per day Additional test: every 12 months Source: Ontario Ministry of Health, Schedule of Benefits for Physician Services (Diagnostic Radiology – BMD Measurement), updated March 9, 2026, effective April 1, 2026. " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Lignes directrices pour la demande d'ostéodensitométrie" /> </extension> </extension> </text> <type value="display" /> <enableWhen> <question value="medicalImaging_examRequest_cds" /> <operator value="=" /> <answerString value="Show" /> </enableWhen> </item> <item> <linkId value="medicalImaging_examRequest_BMD_Specify" /> <text value="Specify:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser :" /> </extension> </extension> </text> <type value="text" /> <enableWhen> <question value="medicalImaging_examRequest_BMD_group_BMDrefnote" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> </item> <item> <linkId value="medicalImaging_examRequest_BMD_previous_display" /> <text value="Previous Relevant BMD"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Ostéodensitométrie antérieure pertinente" /> </extension> </extension> </text> <type value="display" /> <enableWhen> <question value="medicalImaging_examRequest_BMD_group_BMDrefnote" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20742" /> <display value="Low Risk"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Risque faible" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest_BMD_group_BMDrefnote" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20743" /> <display value="High Risk"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Risque élevé" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="any" /> </item> <item> <linkId value="medicalImaging_examRequest_BMD_previous_date" /> <text value="Date of most recent BMD (Year and Month if known):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Date de la plus récente ostéodensitométrie (année et mois, si connus) :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_BMD_group_BMDrefnote" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20742" /> <display value="Low Risk"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Risque faible" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest_BMD_group_BMDrefnote" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20743" /> <display value="High Risk"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Risque élevé" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="any" /> </item> <item> <linkId value="medicalImaging_examRequest_BMD_previous_location" /> <text value="Location of most recent BMD:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Lieu de la plus récente ostéodensitométrie :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest_BMD_group_BMDrefnote" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20742" /> <display value="Low Risk"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Risque faible" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest_BMD_group_BMDrefnote" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20743" /> <display value="High Risk"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Risque élevé" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="any" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="groupItems"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_BMD_clinicalindication_BMDrefnote" /> <text value="BMD Request: Clinical History / Indication"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'ostéodensitométrie : antécédents cliniques / indication" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20394" /> <display value="Bone Mineral Density Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'ostéodensitométrie" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <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=" " /> </extension> </valueString> </extension> </extension> <linkId value="medicalImaging_BMD_clinicalindication_text" /> <text value="Reason for exam (please also include presenting symptom(s), relevant underlying diagnosis and therapies, where applicable)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Motif de l'examen (veuillez aussi indiquer le ou les symptômes présents, le diagnostic sous-jacent pertinent et les traitements, le cas échéant)" /> </extension> </extension> </text> <type value="text" /> </item> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> </extension> <linkId value="medicalImaging_examRequest_BMD_Display" /> <text value="Patient risk factor screening questionnaire will be provided by the imaging facility before or on the day of the exam" /> <type value="display" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20394" /> <display value="Bone Mineral Density Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'ostéodensitométrie" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="any" /> </item> <item> <linkId value="medicalImaging_examRequest_BMD_Previous_group" /> <text value="Previous Relevant BMD"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Ostéodensitométrie antérieure pertinente" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20394" /> <display value="Bone Mineral Density Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'ostéodensitométrie" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="any" /> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_BMD_Previous_Date" /> <text value="Date of most recent BMD (Year and Month if known):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Date de la plus récente ostéodensitométrie (année et mois, si connus) :" /> </extension> </extension> </text> <type value="string" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_examRequest_BMD_Previous_Location" /> <text value="Location of most recent BMD:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Lieu de la plus récente ostéodensitométrie :" /> </extension> </extension> </text> <type value="string" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="application/pdf" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/maxSize"> <valueDecimal value="0" /> </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="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="image/tiff" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="application/vnd.wordperfect" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="text/plain" /> </extension> <linkId value="medicalImaging_examRequest_BMD_Previous_Attachment" /> <text value="Add Attachments" /> <type value="attachment" /> </item> </item> <item> <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="groupItems"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_MRIsafety_group_MRIrefnote" /> <text value="MRI Safety Screening"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Dépistage de sécurité pour l'IRM" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20391" /> <display value="MRI Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'IRM" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <required value="true" /> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> </extension> <linkId value="MRI_safety_screening_display" /> <text value="To prevent delays in scheduling, please provide all relevant information. *"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pour éviter les retards de planification, veuillez fournir tous les renseignements pertinents. *" /> </extension> </extension> </text> <type value="display" /> </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="text"> <valueString> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> </valueString> </extension> </extension> <linkId value="medicalImaging_MRIsafety_metalfragments" /> <text value="Has metal fragments in eye(s)/body"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Présence de fragments métalliques dans les yeux ou le corps" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21296" /> <display value="Has metal fragments in eye(s)/body"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Présence de fragments métalliques dans les yeux ou le corps" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_MRIsafety_attachxray" /> <text value="Attach x-ray reports post injury, if available"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Joindre les comptes rendus de radiographie post-traumatiques, s'ils sont disponibles" /> </extension> </extension> </text> <type value="display" /> <enableWhen> <question value="medicalImaging_MRIsafety_metalfragments" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="all" /> </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="text"> <valueString value="Has active electronic implants"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> </valueString> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_MRIsafety_electronicimplant" /> <text value="Has active electronic implants (e.g. Cardiac Implantable Electronic Device, Neurostimulator, Cochlear Implant, etc.) or retained parts (e.g. leads, etc.):"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Porte des implants électroniques actifs (p. ex. dispositif cardiaque électronique implantable, neurostimulateur, implant cochléaire, etc.) ou des éléments résiduels (p. ex. sondes, etc.) :" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21297" /> <display value="Has active electronic implants (e.g. Cardiac Implantable Electronic Device, Neurostimulator, Cochlear Implant, Medication Pump, etc.) or retained parts (e.g. leads, etc.):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Porte des implants électroniques actifs (p. ex. dispositif cardiaque électronique implantable, neurostimulateur, implant cochléaire, pompe à médicaments, etc.) ou des éléments résiduels (p. ex. sondes, etc.) :" /> </extension> </extension> </display> </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://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="text"> <valueString value="Specify" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_MRIsafety_electronicimplant_specify" /> <text value="What implants does the patient have:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Quels implants le patient porte-t-il :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_MRIsafety_electronicimplant" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="all" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21299" /> <display value="CIED"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="CIED" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21300" /> <display value="Neurostimulator"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Neurostimulateur" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21301" /> <display value="Cochlear Implant"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Implant cochléaire" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21302" /> <display value="Medication Pump"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pompe à médicaments" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <linkId value="medicalImaging_MRIsafety_electronicimplant_otherspecify" /> <text value="Specify"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_MRIsafety_electronicimplant_specify" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </answerCoding> </enableWhen> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Implant details" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_MRIsafety_electronicimplant_implantdetails" /> <text value="Implant details including make, model, institution and date (if known). Attach relevant report if available."> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Détails de l'implant, y compris la marque, le modèle, l'établissement et la date (si connus). Joindre le compte rendu pertinent, s'il est disponible." /> </extension> </extension> </text> <type value="text" /> <enableWhen> <question value="medicalImaging_MRIsafety_electronicimplant_specify" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> </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="text"> <valueString value="Has other metal containing devices"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" " /> </extension> </valueString> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_MRIsafety_metaldevices" /> <text value="Has other metal containing devices (e.g. Aneurysm clip, IUD, Tissue expander, Stent, Coil,etc.), metal foreign bodies (Shrapnel, Bullets Etc), or Large orthopedic device greater than 10cm in length:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Porte d'autres dispositifs contenant du métal (p. ex. clip d'anévrisme, stérilet, expanseur tissulaire, endoprothèse, spire d'embolisation, etc.), des corps étrangers métalliques (éclats, balles, etc.) ou un gros dispositif orthopédique de plus de 10 cm de longueur :" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21298" /> <display value="Has other metal containing devices (e.g. Aneurysm Clip, IUD, Tissue Expander, Shunt, Stent, Coil, Traction Device, Glucose Monitor, etc.), metal foreign bodies (Shrapnel, Bullets, Subdermal Piercings, Etc), or orthopedic device:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Porte d'autres dispositifs contenant du métal (p. ex. clip d'anévrisme, stérilet, expanseur tissulaire, dérivation, endoprothèse, spire d'embolisation, dispositif de traction, capteur de glycémie, etc.), des corps étrangers métalliques (éclats, balles, piercings sous-cutanés, etc.) ou un dispositif orthopédique :" /> </extension> </extension> </display> </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://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="text"> <valueString value="Specify" /> </extension> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_MRIsafety_metaldevices_specify" /> <text value="What implants does the patient have:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Quels implants le patient porte-t-il :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_MRIsafety_metaldevices" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="all" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21303" /> <display value="Aneurysm Clip"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Clip d'anévrisme" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21304" /> <display value="Coil"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Spire d'embolisation" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21305" /> <display value="Glucose Monitor"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Capteur de glycémie" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21306" /> <display value="Heart Valve"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Valve cardiaque" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21307" /> <display value="Copper or Stainless Steel IUD"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Stérilet en cuivre ou en acier inoxydable" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21308" /> <display value="Orthopedic Devices"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Dispositifs orthopédiques" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21309" /> <display value="Pessary"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pessaire" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21310" /> <display value="Prosthesis"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Prothèse" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21311" /> <display value="Shunt"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Dérivation" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21312" /> <display value="Stent"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Endoprothèse" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21313" /> <display value="Subdermal Piercings"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Piercings sous-cutanés" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21314" /> <display value="Tissue Expander"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Expanseur tissulaire" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21315" /> <display value="Traction Device"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Dispositif de traction" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21399" /> <display value="None of the above"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Aucune de ces réponses" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <linkId value="medicalImaging_MRIsafety_metaldevices_otherspecify" /> <text value="Specify"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_MRIsafety_metaldevices_specify" /> <operator value="=" /> <answerCoding> <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" /> <code value="OTH" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </answerCoding> </enableWhen> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="text"> <valueString value="Implant details" /> </extension> <extension url="style"> <valueString value="font-weight:bold;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="MRI_safety_implantDetails" /> <text value="Implant details including make, model, institution and date (if known). Attach relevant report if available."> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Détails de l'implant, y compris la marque, le modèle, l'établissement et la date (si connus). Joindre le compte rendu pertinent, s'il est disponible." /> </extension> </extension> </text> <type value="text" /> <enableWhen> <question value="medicalImaging_MRIsafety_metaldevices" /> <operator value="exists" /> <answerBoolean value="true" /> </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://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="MRI_safety_none" /> <text value="None of the above"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Aucune de ces réponses" /> </extension> </extension> </text> <type value="string" /> <repeats value="false" /> <answerOption> <valueString value="None of the above"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Aucune de ces réponses" /> </extension> </extension> </valueString> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_MRIsafety_previoussurgeries_MRIrefnote" /> <text value="Previous surgeries:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Chirurgies antérieures :" /> </extension> </extension> </text> <type value="text" /> </item> </item> <item> <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="groupItems"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_patientsafety_group" /> <text value="Patient Safety Screening Select where applicable"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" Patient Safety Screening Select where applicable "> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value=" Dépistage relatif à la sécurité du patient Sélectionner s'il y a lieu " /> </extension> </extension> </valueString> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Dépistage relatif à la sécurité du patient Sélectionner s'il y a lieu" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="any" /> <item> <linkId value="medicalImaging_patientsafety_cardiac_section" /> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest_CT_cardiac_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20464" /> <display value="Cardiac CT"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="TDM cardiaque" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest_CT_cardiac_specificarea" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20465" /> <display value="Coronary Angiography (CCTA)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Angiographie coronarienne par TDM (CCTA)" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="any" /> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </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="medicalImaging_patientsafety_cardiac_cds" /> <text value="Heart Rate and Beta-Blocker Information for Cardiac CT Exams"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Renseignements sur la fréquence cardiaque et les bêtabloquants pour les examens de TDM cardiaque" /> </extension> </extension> </text> <type value="string" /> <answerOption> <valueString value="Hide"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Masquer" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="Show"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Afficher" /> </extension> </extension> </valueString> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> </extension> <linkId value="medicalImaging_patientsafety_cardiac_cds_display" /> <text value="To support optimal Cardiac CT imaging, a heart rate of less than 65 beats per minute (bpm) is required. Beta-blockers should be prescribed to achieve adequate heart rate control. Premedication before the exam is expected and is the most effective approach . While beta-blockers may be given on the day of the exam, this approach is less effective and will prolong the patient's overall exam duration. For patients already on beta-blockers Adjust as per clinical judgment. If the patient’s heart rate is >65 bpm, consider increasing the beta-blocker dose the day before and on the day of the CT scan. If the patient’s intrinsic heart rate is <65 bpm, no beta-blocker is required. Beta-blocker premedication For beta-blocker naive patients, Metoprolol may be used to target a heart rate of less than 65 bpm. Dosing may vary based on baseline heart rate, blood pressure, and body size. For example: 50 mg the day before at 16:00 (4:00 PM) 50 mg the night before the scan 50 mg one hour before the scan Dosing may need to be modified if the patient is receiving concomitant AV nodal blocking agents. Please advise patients to avoid caffeine intake within 24 hours of the CT exam."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" To support optimal Cardiac CT imaging, a heart rate of less than 65 beats per minute (bpm) is required. Beta-blockers should be prescribed to achieve adequate heart rate control. Premedication before the exam is expected and is the most effective approach . While beta-blockers may be given on the day of the exam, this approach is less effective and will prolong the patient's overall exam duration. For patients already on beta-blockers Adjust as per clinical judgment. If the patient’s heart rate is >65 bpm, consider increasing the beta-blocker dose the day before and on the day of the CT scan. If the patient’s intrinsic heart rate is <65 bpm, no beta-blocker is required. Beta-blocker premedication For beta-blocker naive patients, Metoprolol may be used to target a heart rate of less than 65 bpm. Dosing may vary based on baseline heart rate, blood pressure, and body size. For example: <li> 50 mg the day before at 16:00 (4:00 PM) </li> <li> 50 mg the night before the scan </li> <li> 50 mg one hour before the scan </li> Dosing may need to be modified if the patient is receiving concomitant AV nodal blocking agents. Please advise patients to avoid caffeine intake within 24 hours of the CT exam. " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Pour favoriser une imagerie optimale" /> </extension> </extension> </text> <type value="display" /> <enableWhen> <question value="medicalImaging_patientsafety_cardiac_cds" /> <operator value="=" /> <answerString value="Show" /> </enableWhen> </item> <item> <linkId value="medicalImaging_patientsafety_cardiac_restingHR" /> <text value="What is the patient's current resting heart rate (bpm)?"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Quelle est la fréquence cardiaque au repos actuelle du patient (bpm)?" /> </extension> </extension> </text> <type value="integer" /> <repeats value="false" /> </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="medicalImaging_patientsafety_cardiac_known_contraindications_Nitro" /> <text value="Known contraindications to Nitroglycerin: (e.g., allergy, on PDE inhibitor such as Viagra® or Cialis®)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Contre-indications connues à la nitroglycérine : (p. ex. allergie, prise d'un inhibiteur de la PDE tel que Viagra® ou Cialis®)" /> </extension> </extension> </text> <type value="string" /> <required value="true" /> <answerOption> <valueString value="No"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Non" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="Yes"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Oui" /> </extension> </extension> </valueString> </answerOption> </item> <item> <linkId value="medicalImaging_patientsafety_cardiac_known_contraindications_Nitro_yes" /> <text value="If the patient is taking phosphodiesterase type 5 (PDE‑5) inhibitors, hold the medication for 48 hours prior to the CT scan."> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Si le patient prend des inhibiteurs de la phosphodiestérase de type 5 (PDE‑5), cesser ce médicament pendant les 48 heures précédant la TDM." /> </extension> </extension> </text> <type value="display" /> <enableWhen> <question value="medicalImaging_patientsafety_cardiac_known_contraindications_Nitro" /> <operator value="=" /> <answerString value="Yes" /> </enableWhen> </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="medicalImaging_patientsafety_cardiac_on_betaBlockers" /> <text value="Is the patient currently on beta-blockers?"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Le patient prend-il actuellement des bêtabloquants?" /> </extension> </extension> </text> <type value="string" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueString value="No"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Non" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="Yes"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Oui" /> </extension> </extension> </valueString> </answerOption> </item> <item> <linkId value="medicalImaging_patientsafety_cardiac_betaBlockers_cds" /> <text value="Beta-blockers are usually required for a Cardiac CT to slow the heart rate to <65 beats per minute (bpm). Please review Heart Rate and Beta Blocker Information for Cardiac CT Exams above."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" Beta-blockers are usually required for a Cardiac CT to slow the heart rate to <65 beats per minute (bpm). Please review Heart Rate and Beta Blocker Information for Cardiac CT Exams above. "> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value=" Les bêtabloquants sont habituellement requis pour une TDM cardiaque afin de ralentir la fréquence cardiaque à moins de 65 battements par minute (bpm). Veuillez consulter les renseignements sur la fréquence cardiaque et les bêtabloquants pour les examens de TDM cardiaque ci-dessus. " /> </extension> </extension> </valueString> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Les bêtabloquants sont habituellement requis pour une TDM cardiaque afin de ralentir la fréquence cardiaque à moins de 65 battements par minute (bpm). Veuillez consulter les renseignements sur la fréquence cardiaque et les bêtabloquants pour les examens de TDM cardiaque ci-dessus." /> </extension> </extension> </text> <type value="display" /> <enableWhen> <question value="medicalImaging_patientsafety_cardiac_on_betaBlockers" /> <operator value="=" /> <answerString value="No" /> </enableWhen> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="listSeparator"> <valueString value="," /> </extension> <extension url="lastSeparator"> <valueString value="and" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </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="medicalImaging_patientsafety_cardiac_betaBlocker_concerns" /> <text value="Concerns for beta-blockers use:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préoccupations concernant l'utilisation de bêtabloquants :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_patientsafety_cardiac_on_betaBlockers" /> <operator value="=" /> <answerString value="No" /> </enableWhen> <repeats value="true" /> <answerOption> <valueString value="Severe/critical aortic stenosis"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sténose aortique grave/critique" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="Severe symptomatic aortic insufficiency"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Insuffisance aortique grave symptomatique" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="Decompensated congestive heart failure"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Insuffisance cardiaque congestive décompensée" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="Allergy to Beta-blockers"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Allergie aux bêtabloquants" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="Prior hospitalization for lung disease"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Hospitalisation antérieure pour une maladie pulmonaire" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="Active bronchospasm"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bronchospasme actif" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="2nd or 3rd degree heart block, or 1st degree with PR>0.42s"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Bloc cardiaque du 2e ou 3e degré, ou du 1er degré avec PR > 0,42 s" /> </extension> </extension> </valueString> </answerOption> </item> <item> <linkId value="medicalImaging_patientsafety_cardiac_betaBlocker_Ivabradine" /> <text value="If beta-blockers are contraindicated, Ivabradine (e.g., Lancora) should be considered. A recommended protocol is as follows: Ivabradine 7.5 mg PO BID for 1 week until the day of the CT study"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" If beta-blockers are contraindicated, Ivabradine (e.g., Lancora) should be considered.  A recommended protocol is as follows:  Ivabradine 7.5 mg PO BID for 1 week until the day of the CT study " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Si les bêtabloquants sont contre-indiqués" /> </extension> </extension> </text> <type value="display" /> <enableWhen> <question value="medicalImaging_patientsafety_cardiac_betaBlocker_concerns" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> </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="medicalImaging_patientsafety_cardiac_betaBlockerRx" /> <text value="Will the patient be prescribed a beta-blocker?"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Prescrira-t-on un bêtabloquant au patient?" /> </extension> </extension> </text> <type value="string" /> <required value="true" /> <repeats value="false" /> <answerOption> <valueString value="No"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Non" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="Yes"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Oui" /> </extension> </extension> </valueString> </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://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" /> <code value="push-button" /> <display value="Push Button" /> </coding> </valueCodeableConcept> </extension> <linkId value="medicalImaging_patientsafety_renal" /> <text value="Renal Assessment Questions:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Questions d'évaluation rénale :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20390" /> <display value="CT Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande de TDM" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20391" /> <display value="MRI Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'IRM" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="any" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21283" /> <display value="No known kidney issues"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Aucun problème rénal connu" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21316" /> <display value="Patient has impaired renal function or a history of renal transplant"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Le patient présente une insuffisance rénale ou des antécédents de greffe rénale" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> <extension url="groupItems"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_patientsafety_mri_note" /> <text value="MRI Note"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Note IRM" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20391" /> <display value="MRI Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'IRM" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <item> <linkId value="medicalImaging_patientsafety_MRI_screeningForRenalFunction" /> <text value="Please note: Screening for renal function is only applicable for MRI facilities using Group I Gadolinium-Based Contrast Agents"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="Please note: Screening for renal function is only applicable for MRI facilities using Group I Gadolinium-Based Contrast Agents" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Note IRM" /> </extension> </extension> </text> <type value="display" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_patientsafety_recentegfr" /> <text value="Recent (within 6 months) estimated Glomerular Filtration Rate (eGFR):"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Débit de filtration glomérulaire estimé (DFGe) récent (dans les 6 derniers mois) :" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_patientsafety_renal" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21316" /> <display value="Patient has impaired renal function or a history of renal transplant"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Le patient présente une insuffisance rénale ou des antécédents de greffe rénale" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <item> <linkId value="medicalImaging_patientsafety_eGFR_display" /> <text value="Recent (within 6 months) estimated Glomerular Filtration Rate (eGFR):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Débit de filtration glomérulaire estimé (DFGe) récent (dans les 6 derniers mois) :" /> </extension> </extension> </text> <type value="display" /> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> </extension> <linkId value="medicalImaging_patientsafety_eGFR_display2" /> <text value="Note: if eGFR is not available at the time of referral, please ensure it is available prior to exam date."> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;color:#AA0000;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Remarque : si le DFGe n'est pas disponible au moment de la demande, veuillez vous assurer qu'il le soit avant la date de l'examen." /> </extension> </extension> </text> <type value="display" /> </item> <item> <linkId value="medicalImaging_patientsafety_eGFR_result" /> <code> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21285" /> </code> <text value="eGFR result:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Résultat du DFGe :" /> </extension> </extension> </text> <type value="integer" /> </item> <item> <linkId value="medicalImaging_patientsafety_eGFR_date" /> <text value="eGFR date:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Date du DFGe :" /> </extension> </extension> </text> <type value="date" /> </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="medicalImaging_patientsafety_hasDiabetes" /> <text value="Has diabetes:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Est diabétique :" /> </extension> </extension> </text> <type value="choice" /> <enableWhen> <question value="medicalImaging_patientsafety_eGFR_result" /> <operator value="<=" /> <answerInteger value="30" /> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20390" /> <display value="CT Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande de TDM" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21286" /> <display value="Has diabetes"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Est diabétique" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_patientsafety_metforminDisplay" /> <text value="If the patient is on metformin, please hold metformin at the time of, or prior to, iodinated contrast administration, and Metformin should not be restarted for at least 48 hours and only then if kidney function remains stable"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Si le patient prend de la metformine, veuillez cesser la metformine au moment de l'administration du produit de contraste iodé, ou avant celle-ci. La metformine ne doit pas être reprise avant au moins 48 heures, et seulement si la fonction rénale demeure stable" /> </extension> </extension> </text> <type value="display" /> <enableWhen> <question value="medicalImaging_patientsafety_hasDiabetes" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="all" /> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_patientsafety_dialysis" /> <text value="On dialysis:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sous dialyse :" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_patientsafety_renal" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21316" /> <display value="Patient has impaired renal function or a history of renal transplant"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Le patient présente une insuffisance rénale ou des antécédents de greffe rénale" /> </extension> </extension> </display> </answerCoding> </enableWhen> <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="medicalImaging_patientsafety_onDialysis" /> <text value="On dialysis:"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sous dialyse :" /> </extension> </extension> </text> <type value="choice" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21287" /> <display value="On dialysis"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sous dialyse :" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_patientsafety_contrastguidance" /> <text value="Guidance on Contrast"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20390" /> <display value="CT Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande de TDM" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_patientsafety_renal" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21316" /> <display value="Patient has impaired renal function or a history of renal transplant"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Le patient présente une insuffisance rénale ou des antécédents de greffe rénale" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="all" /> <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="medicalImaging_patientsafety_contrastguidance_question" /> <text value="Guidance on Contrast Associated Acute Kidney Injury"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Directives sur l'insuffisance rénale aiguë associée au produit de contraste" /> </extension> </extension> </text> <type value="string" /> <repeats value="false" /> <answerOption> <valueString value="Hide"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Masquer" /> </extension> </extension> </valueString> <initialSelected value="true" /> </answerOption> <answerOption> <valueString value="Show"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Afficher" /> </extension> </extension> </valueString> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_patientsafety_contrastguidance_display" /> <text value="For non-emergent presentation of stable outpatients, inpatients, and emergency patients when eGFR is available: If eGFR >30 mL/min/1.73 m2 and no signs and symptoms of acute kidney injury (AKI), then proceed with an indicated contrast imaging study. Imaging with ICM can be performed in patients on peritoneal or hemodialysis regardless of residual urine output and no change in dialysis schedule is required. Macdonald DB, Hurrell C, Costa AF, et al. Canadian Association of Radiologists Guidance on Contrast Associated Acute Kidney Injury. Can Assoc Radiol J. 2022;73(3):499-514. doi:10.1177/08465371221083970"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value=" For non-emergent presentation of stable outpatients, inpatients, and emergency patients when eGFR is available: <li> If eGFR >30 mL/min/1.73 m2 and no signs and symptoms of acute kidney injury (AKI), then proceed with an indicated contrast imaging study. </li> <li> Imaging with ICM can be performed in patients on peritoneal or hemodialysis regardless of residual urine output and no change in dialysis schedule is required. </li> Macdonald DB, Hurrell C, Costa AF, et al. Canadian Association of Radiologists Guidance on Contrast Associated Acute Kidney Injury. Can Assoc Radiol J. 2022;73(3):499-514. doi:10.1177/08465371221083970 " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Directives" /> </extension> </extension> </text> <type value="display" /> <enableWhen> <question value="medicalImaging_patientsafety_contrastguidance_question" /> <operator value="=" /> <answerString value="Show" /> </enableWhen> </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="medicalImaging_patientsafety_knownhypersensitivity" /> <code> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21288" /> </code> <text value="Known hypersensitivity to contrast agents:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Hypersensibilité connue aux produits de contraste :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20390" /> <display value="CT Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande de TDM" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20391" /> <display value="MRI Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'IRM" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="any" /> <required value="true" /> <answerOption> <valueString value="Yes"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Oui" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="No"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Non" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="Unknown"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Inconnu" /> </extension> </extension> </valueString> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> <extension url="groupItems"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_patientsafety_knownhypersensitivity_reaction_group" /> <type value="group" /> <enableWhen> <question value="medicalImaging_patientsafety_knownhypersensitivity" /> <operator value="=" /> <answerString value="Yes" /> </enableWhen> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_patientsafety_knownhypersensitivity_reaction_contrastAgent" /> <text value="Name of contrast agent causing hypersensitivity (if known):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Nom du produit de contraste à l'origine de l'hypersensibilité (si connu) :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_patientsafety_knownhypersensitivity" /> <operator value="=" /> <answerString value="Yes" /> </enableWhen> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_patientsafety_knownhypersensitivity_reaction_type" /> <text value="Type of reaction:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Type de réaction :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_patientsafety_knownhypersensitivity" /> <operator value="=" /> <answerString value="Yes" /> </enableWhen> <required value="true" /> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_patientsafety_contrastHypersensitivity" /> <text value="Contrast Hypersensitivity Pre-Medication Guidance"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Directives de prémédication en cas d'hypersensibilité au produit de contraste" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_patientsafety_knownhypersensitivity" /> <operator value="=" /> <answerString value="Yes" /> </enableWhen> <repeats value="false" /> <answerOption> <valueString value="Hide"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Masquer" /> </extension> </extension> </valueString> <initialSelected value="true" /> </answerOption> <answerOption> <valueString value="Show"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Afficher" /> </extension> </extension> </valueString> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_patientsafety_contrastHypersensitivity_guidance" /> <text value="For mild to moderate hypersensitivity reactions, the referring provider can provide the following for the patient to bring to their appointment: Oral second-generation antihistamine at least 1 hour before exam (optional) Steroid premedication is not recommended Second/third generation antihistamines include Bilastine, Cetirizine, Desloratadine, Fexofenadine, Levocetirizine, Loratadine, and Rupatadine. Sources: Byrne A, Macdonald DB, Kirkpatrick IDC, Pham M, Green CR, Copaescu AM et al. CAR/CSACI Practice Guidance for Contrast Media Hypersensitivity. Can Assoc Radiol J. 2025 Jan 11. Available from: https://doi.org/10.1177/08465371241311253 Wang C, Ramsey A, Lang D, Copaescu AM, Krishnan P, Kuruvilla M, et al. Management and Prevention of Hypersensitivity Reactions to Radiocontrast Media: A Consensus Statement from the American College of Radiology and the American Academy of Allergy, Asthma & Immunology. Radiology. 2025 May 1;315(2). Available from: https://doi.org/10.1148/radiol.240100"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml"> <valueString value="For mild to moderate hypersensitivity reactions, the referring provider can provide the following for the patient to bring to their appointment: <li>Oral second-generation antihistamine at least 1 hour before exam (optional) </li> <li>Steroid premedication is not recommended</li> Second/third generation antihistamines include Bilastine, Cetirizine, Desloratadine, Fexofenadine, Levocetirizine, Loratadine, and Rupatadine. <img 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Sources: <li>Byrne A, Macdonald DB, Kirkpatrick IDC, Pham M, Green CR, Copaescu AM et al. CAR/CSACI Practice Guidance for Contrast Media Hypersensitivity. Can Assoc Radiol J. 2025 Jan 11. Available from: https://doi.org/10.1177/08465371241311253 </li> <li>Wang C, Ramsey A, Lang D, Copaescu AM, Krishnan P, Kuruvilla M, et al. Management and Prevention of Hypersensitivity Reactions to Radiocontrast Media: A Consensus Statement from the American College of Radiology and the American Academy of Allergy, Asthma & Immunology. Radiology. 2025 May 1;315(2). Available from: https://doi.org/10.1148/radiol.240100 </li> " /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="directives" /> </extension> </extension> </text> <type value="display" /> <enableWhen> <question value="medicalImaging_patientsafety_contrastHypersensitivity" /> <operator value="=" /> <answerString value="Show" /> </enableWhen> </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 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<extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Claustrophobie" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_patientsafety_requiresedation_claustrophobia" /> <text value="For patients with claustrophobia requiring oral sedation, the referring clinician is responsible for prescribing the medications. 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<extension url="content"> <valueString value="Demande de TDM" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20391" /> <display value="MRI Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'IRM" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="any" /> <repeats value="false" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21295" /> <display value="Require general anesthesia"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Nécessite une anesthésie générale" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation"> <valueCode value="horizontal" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </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="medicalImaging_patientsafety_piccporta" /> <text value="Existing vascular access:" /> <type value="choice" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20390" /> <display value="CT Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande de TDM" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20391" /> <display value="MRI Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'IRM" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="any" /> <repeats value="true" /> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21383" /> <display value="Existing PICC line"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Cathéter central à insertion périphérique (PICC) en place" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21384" /> <display value="Existing Port-a-Cath"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Port-a-Cath en place" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> <item> <linkId value="medicalImaging_patientsafety_requiresedation_rationale" /> <text value="Rationale:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Justification :" /> </extension> </extension> </text> <type value="text" /> <enableWhen> <question value="medicalImaging_patientsafety_anesthesia" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="all" /> <required value="true" /> </item> <item> <linkId value="medicalImaging_weight_height" /> <text value="Patient Weight and Height"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poids et taille du patient" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_weightHeightRequirement" /> <operator value="!=" /> <answerString value="HIDE" /> </enableWhen> <enableBehavior value="any" /> <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="medicalImaging_weight_height_units" /> <text value="Units:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Unités :" /> </extension> </extension> </text> <type value="string" /> <enableBehavior value="any" /> <repeats value="false" /> <answerOption> <valueString value="Imperial (ft.in/lbs)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Système impérial (pi.po/lb)" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="Metric (cm/kgs)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Système métrique (cm/kg)" /> </extension> </extension> </valueString> <initialSelected value="true" /> </answerOption> </item> <item> <linkId value="medicalImaging_weight_height_group" /> <text value="Imperial height and weight required"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Taille et poids requis en unités impériales" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_weight_height_units" /> <operator value="=" /> <answerString value="Imperial (ft.in/lbs)" /> </enableWhen> <enableWhen> <question value="medicalImaging_weightHeightRequirement" /> <operator value="=" /> <answerString value="MRI_HEIGHT_WEIGHT_REQUIRED" /> </enableWhen> <enableBehavior value="all" /> <item> <linkId value="medicalImaging_weight_height_lb" /> <code> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20918" /> <display value="Weight (lbs)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poids (lb)" /> </extension> </extension> </display> </code> <text value="Weight (lbs):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poids (lb) :" /> </extension> </extension> </text> <type value="integer" /> <enableBehavior value="any" /> <required value="true" /> </item> <item> <linkId value="medicalImaging_weight_height_ft" /> <code> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20916" /> <display value="Height (ft)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Taille (pi)" /> </extension> </extension> </display> </code> <text value="Height (ft):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Taille (pi) :" /> </extension> </extension> </text> <type value="decimal" /> <enableBehavior value="any" /> <required value="true" /> </item> <item> <linkId value="medicalImaging_weight_height_in" /> <code> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20917" /> <display value="Height (in)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Taille (po)" /> </extension> </extension> </display> </code> <text value="Height (in):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Taille (po) :" /> </extension> </extension> </text> <type value="decimal" /> <enableBehavior value="any" /> </item> </item> <item> <linkId value="medicalImaging_weight_height_req" /> <text value="Imperial weight required"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poids requis en unités impériales" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_weight_height_units" /> <operator value="=" /> <answerString value="Imperial (ft.in/lbs)" /> </enableWhen> <enableWhen> <question value="medicalImaging_weightHeightRequirement" /> <operator value="=" /> <answerString value="CT_WEIGHT_REQUIRED" /> </enableWhen> <enableBehavior value="all" /> <item> <linkId value="medicalImaging_weight_height_required_lb" /> <code> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20918" /> <display value="Weight (lbs)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poids (lb)" /> </extension> </extension> </display> </code> <text value="Weight (lbs):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poids (lb) :" /> </extension> </extension> </text> <type value="decimal" /> <enableBehavior value="any" /> <required value="true" /> </item> <item> <linkId value="medicalImaging_weight_height_required_ft" /> <code> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20916" /> <display value="Height (ft)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Taille (pi)" /> </extension> </extension> </display> </code> <text value="Height (ft):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Taille (pi) :" /> </extension> </extension> </text> <type value="decimal" /> <enableBehavior value="any" /> </item> <item> <linkId value="medicalImaging_weight_height_required_in" /> <code> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20917" /> <display value="Height (in)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Taille (po)" /> </extension> </extension> </display> </code> <text value="Height (in):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Taille (po) :" /> </extension> </extension> </text> <type value="decimal" /> <enableBehavior value="any" /> </item> </item> <item> <linkId value="medicalImaging_weight_height_notrequired" /> <text value="Imperial not required"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Unités impériales non requises" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_weight_height_units" /> <operator value="=" /> <answerString value="Imperial (ft.in/lbs)" /> </enableWhen> <enableWhen> <question value="medicalImaging_weightHeightRequirement" /> <operator value="=" /> <answerString value="BMD_HEIGHT_WEIGHT_OPTIONAL" /> </enableWhen> <enableBehavior value="all" /> <item> <linkId value="medicalImaging_weight_height_notrequired_lb" /> <code> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20918" /> <display value="Weight (lbs)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poids (lb)" /> </extension> </extension> </display> </code> <text value="Weight (lbs):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poids (lb) :" /> </extension> </extension> </text> <type value="decimal" /> <enableBehavior value="any" /> </item> <item> <linkId value="medicalImaging_weight_height_notrequired_ft" /> <code> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20916" /> <display value="Height (ft)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Taille (pi)" /> </extension> </extension> </display> </code> <text value="Height (ft):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Taille (pi) :" /> </extension> </extension> </text> <type value="decimal" /> <enableBehavior value="any" /> </item> <item> <linkId value="medicalImaging_weight_height_notrequired_in" /> <code> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20917" /> <display value="Height (in)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Taille (po)" /> </extension> </extension> </display> </code> <text value="Height (in):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Taille (po) :" /> </extension> </extension> </text> <type value="decimal" /> <enableBehavior value="any" /> </item> </item> <item> <linkId value="medicalImaging_weight_height_required_metric" /> <text value="Metric height and weight required"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Taille et poids requis en unités métriques" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_weight_height_units" /> <operator value="=" /> <answerString value="Metric (cm/kgs)" /> </enableWhen> <enableWhen> <question value="medicalImaging_weightHeightRequirement" /> <operator value="=" /> <answerString value="MRI_HEIGHT_WEIGHT_REQUIRED" /> </enableWhen> <enableBehavior value="all" /> <item> <linkId value="medicalImaging_weight_height_required_metric_kg" /> <code> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20823" /> <display value="Weight (kg)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poids (kg)" /> </extension> </extension> </display> </code> <text value="Weight (kgs):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poids (kg) :" /> </extension> </extension> </text> <type value="decimal" /> <required value="true" /> </item> <item> <linkId value="medicalImaging_weight_height_required_metric_cm" /> <code> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20822" /> <display value="Height (cm)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Taille (cm)" /> </extension> </extension> </display> </code> <text value="Height (cm):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Taille (cm) :" /> </extension> </extension> </text> <type value="decimal" /> <enableBehavior value="all" /> <required value="true" /> </item> </item> <item> <linkId value="medicalImaging_weight_required_metric" /> <text value="Metric weight required"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poids requis en unités métriques" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_weight_height_units" /> <operator value="=" /> <answerString value="Metric (cm/kgs)" /> </enableWhen> <enableWhen> <question value="medicalImaging_weightHeightRequirement" /> <operator value="=" /> <answerString value="CT_WEIGHT_REQUIRED" /> </enableWhen> <enableBehavior value="all" /> <item> <linkId value="medicalImaging_weight_required_metric_kg" /> <code> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20823" /> <display value="Weight (kg)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poids (kg)" /> </extension> </extension> </display> </code> <text value="Weight (kgs):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poids (kg) :" /> </extension> </extension> </text> <type value="decimal" /> <required value="true" /> </item> <item> <linkId value="medicalImaging_weight_required_metric_cm" /> <code> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20822" /> <display value="Height (cm)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Taille (cm)" /> </extension> </extension> </display> </code> <text value="Height (cm):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Taille (cm) :" /> </extension> </extension> </text> <type value="decimal" /> <enableBehavior value="all" /> </item> </item> <item> <linkId value="medicalImaging_weight_notrequired_metric" /> <text value="Metric not required"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Unités métriques non requises" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_weight_height_units" /> <operator value="=" /> <answerString value="Metric (cm/kgs)" /> </enableWhen> <enableWhen> <question value="medicalImaging_weightHeightRequirement" /> <operator value="=" /> <answerString value="BMD_HEIGHT_WEIGHT_OPTIONAL" /> </enableWhen> <enableBehavior value="all" /> <item> <linkId value="medicalImaging_weight_notrequired_metric_kg" /> <code> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20823" /> <display value="Weight (kg)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poids (kg)" /> </extension> </extension> </display> </code> <text value="Weight (kgs):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Poids (kg) :" /> </extension> </extension> </text> <type value="decimal" /> </item> <item> <linkId value="medicalImaging_weight_notrequired_metric_cm" /> <code> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20822" /> <display value="Height (cm)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Taille (cm)" /> </extension> </extension> </display> </code> <text value="Height (cm):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Taille (cm) :" /> </extension> </extension> </text> <type value="decimal" /> <enableBehavior value="all" /> </item> </item> <item> <linkId value="medicalImaging_weight_height_date" /> <text value="Date of Weight/Height:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Date de la mesure du poids/de la taille :" /> </extension> </extension> </text> <type value="date" /> <enableWhen> <question value="medicalImaging_weight_height_units" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> </item> </item> </item> <item> <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="groupItems"> <valueBoolean value="false" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <linkId value="medicalImaging_scheduling_" /> <text value="Scheduling"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Planification" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <enableBehavior value="any" /> <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="medicalImaging_scheduling" /> <text value="Request specific appointment date or time interval based on:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demander une date de rendez-vous précise ou un intervalle de temps en fonction de :" /> </extension> </extension> </text> <type value="string" /> <repeats value="true" /> <answerOption> <valueString value="Clinical Reasons"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Raisons cliniques" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="Other Considerations"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autres considérations" /> </extension> </extension> </valueString> </answerOption> </item> <item> <linkId value="medicalImaging_scheduling_clinicalreasons_other" /> <text value="Specify Timeframe:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Préciser le délai :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_scheduling" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <required value="true" /> </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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_scheduling_clinicalreasons" /> <text value="Clinical Reasons:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Raisons cliniques :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_scheduling" /> <operator value="=" /> <answerString value="Clinical Reasons" /> </enableWhen> <repeats value="false" /> <answerOption> <valueString value="Timed follow-up (eg,. 6 months interval study)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Suivi programmé (p. ex. examen à 6 mois d'intervalle)" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="Procedural (eg., pre/post op)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Intervention (p. ex. pré/postopératoire)" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="Patient navigation (eg., Before a specialist appointment)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Accompagnement du patient (p. ex. avant un rendez-vous avec un spécialiste)" /> </extension> </extension> </valueString> </answerOption> <answerOption> <valueString value="Other clinical reasons"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autres raisons cliniques" /> </extension> </extension> </valueString> </answerOption> </item> <item> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="sameLine"> <valueBoolean value="true" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="medicalImaging_scheduling_clinicalreasons_rationale" /> <text value="Specify Rationale:" /> <type value="string" /> <enableWhen> <question value="medicalImaging_scheduling_clinicalreasons" /> <operator value="=" /> <answerString value="Other clinical reasons" /> </enableWhen> <required value="true" /> </item> <item> <linkId value="medicalImaging_scheduling_nonclinical" /> <text value="Non-Clinical Considerations:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Considérations non cliniques :" /> </extension> </extension> </text> <type value="string" /> <enableWhen> <question value="medicalImaging_scheduling" /> <operator value="=" /> <answerString value="Other Considerations" /> </enableWhen> </item> </item> <item> <linkId value="pref_consultant_group" /> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20390" /> <display value="CT Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande de TDM" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20391" /> <display value="MRI Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'IRM" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20392" /> <display value="X-Ray Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande de radiographie" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="any" /> <item> <linkId value="preferredconsultlocation_header" /> <text value="Preferred Consultant or Location"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Consultant ou lieu préféré" /> </extension> </extension> </text> <type value="group" /> <item> <linkId value="preferredconsultlocation_display" /> <text value="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/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Tous les patients seront orientés vers le délai d'attente le plus court, à moins qu'un consultant ou un lieu préféré ne soit indiqué." /> </extension> </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" /> <display value="Check-box" /> </coding> </valueCodeableConcept> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="preferredconsultlocation_selector" /> <text value="Preferred consultant or location"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Consultant ou lieu préféré" /> </extension> </extension> </text> <type value="string" /> <repeats value="false" /> <answerOption> <valueString value="Preferred consultant or location"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Consultant ou lieu préféré" /> </extension> </extension> </valueString> </answerOption> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="border-style:solid;" /> </extension> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info"> <extension url="enableWhenExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="false" /> </valueExpression> </extension> <extension url="groupItems"> <valueBoolean value="false" /> </extension> </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 url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Veuillez préciser un consultant ou un lieu préféré :" /> </extension> </extension> </valueString> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Veuillez préciser un consultant préféré ou un lieu préféré :" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="preferredconsultlocation_selector" /> <operator value="exists" /> <answerBoolean value="true" /> </enableWhen> <item> <linkId value="preferredconsultlocation_consultant" /> <text value="Consultant:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Consultant :" /> </extension> </extension> </text> <type value="string" /> </item> <item> <linkId value="preferredconsultlocation_location" /> <text value="Location:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Lieu :" /> </extension> </extension> </text> <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> <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="preferredconsultlocation_willingtotravel" /> <text value="Patient willing to travel for shorter wait time"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Le patient est prêt à se déplacer pour obtenir un délai d'attente plus court" /> </extension> </extension> </text> <type value="string" /> <repeats value="false" /> <answerOption> <valueString value="Patient willing to travel for shorter wait time"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Le patient est prêt à se déplacer pour obtenir un délai d'attente plus court" /> </extension> </extension> </valueString> </answerOption> </item> <item> <linkId value="preferredconsultlocation_otherconsiderations" /> <text value="Other considerations:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autres considérations :" /> </extension> </extension> </text> <type value="string" /> </item> </item> </item> <item> <linkId value="supportingDocumentation_header" /> <text value="Supporting Documentation"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Documents à l'appui" /> </extension> </extension> </text> <type value="group" /> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20390" /> <display value="CT Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande de TDM" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20391" /> <display value="MRI Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'IRM" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20392" /> <display value="X-Ray Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande de radiographie" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableWhen> <question value="medicalImaging_examRequest" /> <operator value="=" /> <answerCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="20394" /> <display value="Bone Mineral Density Requisition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Demande d'ostéodensitométrie" /> </extension> </extension> </display> </answerCoding> </enableWhen> <enableBehavior value="any" /> <item> <linkId value="supportingDocumentation_relevant_imaging" /> <text value="Previous Relevant Imaging (if applicable)"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Imagerie antérieure pertinente (le cas échéant)" /> </extension> </extension> </text> <type value="string" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/mimeType"> <valueCode value="application/pdf" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/maxSize"> <valueDecimal value="5000000" /> </extension> <linkId value="supportingDocumentation_attachment" /> <text value="Add attachments"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Ajouter des pièces jointes" /> </extension> </extension> </text> <type value="attachment" /> </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://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info"> <extension url="style"> <valueString value="display:none;" /> </extension> <extension url="sameLine"> <valueBoolean value="false" /> </extension> <extension url="quoteAnswer"> <valueBoolean value="false" /> </extension> </extension> <linkId value="657300800304" /> <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-style"> <valueString value="display:none;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Des renseignements personnels sur la santé qui sont pertinents sur le plan médical n'ont pas été divulgués à la demande du patient." /> </extension> </extension> </text> <type value="string" /> <repeats value="false" /> <answerOption> <valueString 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/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Des renseignements personnels sur la santé qui sont pertinents sur le plan médical n'ont pas été divulgués à la demande du patient." /> </extension> </extension> </valueString> </answerOption> </item> <item> <linkId value="feedbacksurvey_MI" /> <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/MISRF"> Click here to provide feedback on this form </a> "> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value=" <a href="https://www.surveymonkey.com/r/MISRF"> Cliquez ici pour donner votre avis sur ce formulaire </a> " /> </extension> </extension> </valueString> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Sondage de rétroaction : imagerie médicale" /> </extension> </extension> </text> <type value="display" /> </item> <item> <linkId value="602618746069" /> <text value="Referrer's Information"> <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style"> <valueString value="font-weight:bold;" /> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Renseignements sur le demandeur" /> </extension> </extension> </text> <type value="group" /> <item> <linkId value="referrer_sitename" /> <text value="Site Name:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Nom de l'établissement :" /> </extension> </extension> </text> <type value="string" /> </item> <item> <linkId value="referrer_address_line1" /> <text value="Address (Line 1):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Adresse (ligne 1) :" /> </extension> </extension> </text> <type value="string" /> <required value="true" /> </item> <item> <linkId value="referrer_address_line2" /> <text value="Address (Line 2):"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Adresse (ligne 2) :" /> </extension> </extension> </text> <type value="string" /> </item> <item> <linkId value="referrer_address_city" /> <text value="City:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Ville :" /> </extension> </extension> </text> <type value="string" /> <required value="true" /> </item> <item> <linkId value="referrer_address_province" /> <text value="Province:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Province :" /> </extension> </extension> </text> <type value="string" /> <required value="true" /> <maxLength value="2" /> </item> <item> <linkId value="referrer_address_postalcode" /> <text value="Postal Code:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Code postal :" /> </extension> </extension> </text> <type value="string" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="phone4" /> </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}$'))" /> </valueExpression> </extension> <extension url="human"> <valueString value="Please enter a valid north-american phone number. e.g. XXX-XXX-XXXX." /> </extension> </extension> <linkId value="referrer_phone" /> <text value="Phone #:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="N° de téléphone :" /> </extension> </extension> </text> <type value="string" /> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint"> <extension url="key"> <valueId value="phone5" /> </extension> <extension url="severity"> <valueCode value="error" /> </extension> <extension url="expression"> <valueExpression> <language value="text/fhirpath" /> <expression value="%resource.repeat(item).where(linkId='referrer_fax').answer.all(value.matches('^(\+\d{1,2}\s?)?$?\d{3}$?[\s.-]?\d{3}[\s.-]?\d{4}$'))" /> </valueExpression> </extension> <extension url="human"> <valueString value="Please enter a valid north-american phone number. e.g. XXX-XXX-XXXX." /> </extension> </extension> <linkId value="referrer_fax" /> <text value="Fax #:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="N° de télécopieur :" /> </extension> </extension> </text> <type value="string" /> </item> <item> <linkId value="referrer_billing" /> <text value="Billing Number:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Numéro de facturation :" /> </extension> </extension> </text> <type value="integer" /> </item> <item> <linkId value="referrer_professionalid" /> <text value="Professional ID:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="N° d'identification professionnel :" /> </extension> </extension> </text> <type value="integer" /> </item> <item> <linkId value="referrer_signature" /> <text value="Signed:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Signé :" /> </extension> </extension> </text> <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:"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Rôle :" /> </extension> </extension> </text> <type value="choice" /> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="309398001" /> <display value="Allied Health Professional"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Professionnel paramédical" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21276" /> <display value="Family Physician"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Médecin de famille" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="449161006" /> <display value="Physician Assistant"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Adjoint au médecin" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="398130009" /> <display value="Medical Student"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Étudiant en médecine" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="106292003" /> <display value="Nurse"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Infirmier" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://snomed.info/sct" /> <code value="224571005" /> <display value="Nurse Practitioner"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Infirmier praticien" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21281" /> <display value="Resident"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Résident" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21282" /> <display value="Specialist"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Spécialiste" /> </extension> </extension> </display> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" /> <code value="21402" /> <display value="Other"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="Autre" /> </extension> </extension> </display> </valueCoding> </answerOption> </item> </item> <item> <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden"> <valueBoolean value="true" /> </extension> <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression"> <valueExpression> <language value="text/fhirpath" /> <expression value="( iif(%resource.item.repeat(item).where(linkId='medicalImaging_examRequest') .answer.where(valueCoding.code = '20390').exists(), 'CT', {}) | iif(%resource.item.repeat(item).where(linkId='medicalImaging_examRequest') .answer.where(valueCoding.code = '20391').exists(), 'MRI', {}) | iif(%resource.item.repeat(item).where(linkId='medicalImaging_examRequest') .answer.where(valueCoding.code = '20392').exists(), 'X_RAY', {}) | iif(%resource.item.repeat(item).where(linkId='medicalImaging_examRequest') .answer.where(valueCoding.code = '20393').exists(), 'ULTRASOUND', {}) | iif(%resource.item.repeat(item).where(linkId='medicalImaging_examRequest') .answer.where(valueCoding.code = '20394').exists(), 'BONE_MINERAL_DENSITY', {}) ).join(' | ')" /> </valueExpression> </extension> <linkId value="referralService" /> <text value="referralService"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="fr" /> </extension> <extension url="content"> <valueString value="referralService" /> </extension> </extension> </text> <type value="string" /> </item> </Questionnaire>


  
    
      
      
    
  
  
    
  
  
    
      
    
  
  
  
  
  <status value="active" />
  <experimental value="true" />
  <subjectType value="Patient" />
  <date value="2026-08-04T09:22:28.489-04:00" />
  <publisher value="Ontario Health" />
  <description value="A medical imaging form that includes both English and French language text for form content" />
  <effectivePeriod>
    <start value="2026-07-31" />
  </effectivePeriod>
  <code>
    <system value="http://snomed.info/sct" />
    <code value="708175003" />
    <display value="Diagnostic imaging service" />
  </code>
  <item>
    <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info">
      <extension url="enableWhenExpression">
        <valueExpression>
          <language value="text/fhirpath" />
          <expression value="false" />
        </valueExpression>
      </extension>
    </extension>
    <linkId value="medicalImaging_header_display" />
    <text value="Ontario Breast Screening Program (OBSP)

 and 

  Ontario Lung Screening Program (OLSP)

 are provincial screening programs with separate referral forms and eligibility criteria. Please refer to the program websites for details.
 

  Note: Not all imaging sites offer OBSP or OLSP exams">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
        <valueString value="<a href="https://www.cancercareontario.ca/en/cancer-care-ontario/programs/screening-programs/ontario-breast-obsp">
  Ontario Breast Screening Program (OBSP)
</a>
 and 
<a href="https://www.cancercareontario.ca/en/cancer-care-ontario/programs/screening-programs/ontario-lung-screening-program">
  Ontario Lung Screening Program (OLSP)
</a>
 are provincial screening programs with separate referral forms and eligibility criteria. Please refer to the program websites for details.
<br/>
<i>
  Note: Not all imaging sites offer OBSP or OLSP exams
</i>" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Remarques :" />
        </extension>
      </extension>
    </text>
    <type value="display" />
  </item>
  <item>
    <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="groupItems">
        <valueBoolean value="false" />
      </extension>
    </extension>
    <linkId value="patient_header" />
    <text value="Patient Information">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="font-weight:bold;" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Renseignements sur le patient" />
        </extension>
      </extension>
    </text>
    <type value="group" />
    <item>
      <linkId value="patient_surname" />
      <text value="Surname:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Nom de famille :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <required value="true" />
    </item>
    <item>
      <linkId value="patient_firstname" />
      <text value="First Name:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Prénom :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <required value="true" />
    </item>
    <item>
      <linkId value="patient_date_of_birth" />
      <text value="DOB:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Date de naissance :" />
          </extension>
        </extension>
      </text>
      <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>
      <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
        <valueCode value="horizontal" />
      </extension>
      <linkId value="patient_gender" />
      <text value="Gender:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Genre :" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <required value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://hl7.org/fhir/administrative-gender" />
          <code value="male" />
          <display value="Male">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Masculin" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://hl7.org/fhir/administrative-gender" />
          <code value="female" />
          <display value="Female">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Féminin" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://hl7.org/fhir/administrative-gender" />
          <code value="other" />
          <display value="Other">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Autre" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <linkId value="patient_hc_pc" />
      <text value="HN PC:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Code de province (assurance-maladie) :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <maxLength value="2" />
    </item>
    <item>
      <linkId value="patient_hc_number" />
      <text value="HN:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="N° d'assurance-maladie :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <maxLength value="10" />
    </item>
    <item>
      <linkId value="patient_hc_vc" />
      <text value="HN VC:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Code de version (assurance-maladie) :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
    </item>
    <item>
      <linkId value="patient_address_line1" />
      <text value="Address (Line 1):">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Adresse (ligne 1) :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <required value="true" />
    </item>
    <item>
      <linkId value="patient_address_line2" />
      <text value="Address (Line 2):">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Adresse (ligne 2) :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
    </item>
    <item>
      <linkId value="patient_address_city" />
      <text value="City:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Ville :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <required value="true" />
    </item>
    <item>
      <linkId value="patient_address_province" />
      <text value="Province:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Province :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <required value="true" />
      <maxLength value="2" />
    </item>
    <item>
      <linkId value="patient_address_postalcode" />
      <text value="Postal Code:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Code postal :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <required value="true" />
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint">
        <extension url="key">
          <valueId value="phone1" />
        </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="Please enter a valid north-american phone number.  e.g. XXX-XXX-XXXX." />
        </extension>
      </extension>
      <linkId value="patient_phone_mobile" />
      <text value="Mobile #:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="N° de cellulaire :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint">
        <extension url="key">
          <valueId value="phone2" />
        </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="Please enter a valid north-american phone number.  e.g. XXX-XXX-XXXX." />
        </extension>
      </extension>
      <linkId value="patient_phone_home" />
      <text value="Home #:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="N° à domicile :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint">
        <extension url="key">
          <valueId value="phone3" />
        </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}$'))" />
          </valueExpression>
        </extension>
        <extension url="human">
          <valueString value="Please enter a valid north-american phone number.  e.g. XXX-XXX-XXXX." />
        </extension>
      </extension>
      <linkId value="patient_phone_business" />
      <text value="Business #:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Téléphone professionnel :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint">
        <extension url="key">
          <valueId value="email1" />
        </extension>
        <extension url="severity">
          <valueCode value="error" />
        </extension>
        <extension url="expression">
          <valueExpression>
            <language value="text/fhirpath" />
            <expression value="%resource.repeat(item).where(linkId='patient_email').answer.all(value.matches('(?:[a-z0-9!#$%&'*+/=?^_`{|}~-]+(?:\.[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="Please enter a valid email address." />
        </extension>
      </extension>
      <linkId value="patient_email" />
      <text value="Email:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Courriel :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
    </item>
  </item>
  <item>
    <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="groupItems">
        <valueBoolean value="false" />
      </extension>
    </extension>
    <linkId value="additionalinfo_header" />
    <text value="[Optional] Additional Patient Information">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="font-weight:bold;" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="[Facultatif] Renseignements supplémentaires sur le patient" />
        </extension>
      </extension>
    </text>
    <type value="group" />
    <item>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="sameLine">
          <valueBoolean value="true" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <linkId value="additionalinfo_preferredname" />
      <text value="Preferred Name">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Nom préféré" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <enableBehavior value="all" />
    </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>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="sameLine">
          <valueBoolean value="true" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <linkId value="additionalinfo_sexassignedatbirth" />
      <text value="Sex assigned at birth:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Sexe assigné à la naissance :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <repeats value="false" />
      <answerOption>
        <valueString value="Female">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Féminin" />
            </extension>
          </extension>
        </valueString>
      </answerOption>
      <answerOption>
        <valueString value="Male">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Masculin" />
            </extension>
          </extension>
        </valueString>
      </answerOption>
      <answerOption>
        <valueString value="Intersex">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Intersexe" />
            </extension>
          </extension>
        </valueString>
      </answerOption>
      <answerOption>
        <valueString value="Unknown">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Inconnu" />
            </extension>
          </extension>
        </valueString>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
        <valueCode value="horizontal" />
      </extension>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="sameLine">
          <valueBoolean value="true" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </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_pronouns" />
      <text value="Pronouns:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Pronoms :" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <repeats value="false" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21317" />
          <display value="She/Her">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Elle/Elle" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21318" />
          <display value="He/Him">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Il/Lui" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21319" />
          <display value="They/Them">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Iel/Iel" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
          <code value="OTH" />
          <display value="Other">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Autre" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="sameLine">
          <valueBoolean value="true" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <linkId value="additionalinfo_pronouns_other" />
      <text value="Other pronouns:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Autres pronoms :" />
          </extension>
        </extension>
      </text>
      <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">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Autre" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <required 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://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">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Langue préférée" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <repeats value="false" />
      <answerOption>
        <valueCoding>
          <system value="urn:ietf:bcp:47" />
          <code value="en" />
          <display value="English">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Anglais" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="urn:ietf:bcp:47" />
          <code value="fr" />
          <display value="French">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Français" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
          <code value="OTH" />
          <display value="Other">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Autre" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="additionalinfo_preferredlanguage_section" />
      <type value="group" />
      <enableWhen>
        <question value="additionalinfo_preferredlanguage" />
        <operator value="=" />
        <answerCoding>
          <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
          <code value="OTH" />
          <display value="Other">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Autre" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="additionalinfo_preferredlanguage_specify" />
        <text value="Specify language and considerations:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préciser la langue et les considérations :" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <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://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="style">
            <valueString value="display:none;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="additionalinfo_preferredlanguage_interpreterrequired" />
        <text value="Interpreter Required">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Interprète requis" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <repeats value="false" />
        <answerOption>
          <valueString value="Interpreter Required">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Interprète requis" />
              </extension>
            </extension>
          </valueString>
        </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://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:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Meilleur moyen de communication :" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <repeats value="false" />
      <answerOption>
        <valueCoding>
          <system value="http://hl7.org/fhir/contact-point-use" />
          <code value="mobile" />
          <display value="Mobile">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Cellulaire" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://hl7.org/fhir/contact-point-use" />
          <code value="home" />
          <display value="Home">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Domicile" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://hl7.org/fhir/contact-point-use" />
          <code value="work" />
          <display value="Work">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Travail" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://hl7.org/fhir/contact-point-system" />
          <code value="email" />
          <display value="Email">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Courriel" />
              </extension>
            </extension>
          </display>
        </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://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <linkId value="additionalinfo_bestmethodofcontact_voicemails" />
      <text value="Voicemails acceptable">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Messages vocaux acceptés" />
          </extension>
        </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">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Cellulaire" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableWhen>
        <question value="additionalinfo_bestmethodofcontact" />
        <operator value="=" />
        <answerCoding>
          <system value="http://hl7.org/fhir/contact-point-use" />
          <code value="home" />
          <display value="Home">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Domicile" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableWhen>
        <question value="additionalinfo_bestmethodofcontact" />
        <operator value="=" />
        <answerCoding>
          <system value="http://hl7.org/fhir/contact-point-use" />
          <code value="work" />
          <display value="Work">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Travail" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableBehavior value="any" />
      <repeats value="true" />
      <answerOption>
        <valueString value="Voicemails acceptable">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Messages vocaux acceptés" />
            </extension>
          </extension>
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      </answerOption>
    </item>
    <item>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="text">
          <valueString value="Patient prefers SMS/text if available" />
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        <extension url="sameLine">
          <valueBoolean value="false" />
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        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </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="additionalinfo_bestmethodofcontact_prefersms" />
      <text value="Prefer SMS/Text if available">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Préférence pour les SMS/textos, si possible" />
          </extension>
        </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">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Cellulaire" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableBehavior value="any" />
      <repeats value="true" />
      <answerOption>
        <valueString value="Prefer SMS/Text if available">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préférence pour les SMS/textos, si possible" />
            </extension>
          </extension>
        </valueString>
      </answerOption>
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    <item>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
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        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </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="additionalinfo_parentguardianSDM" />
      <text value="Identify parent/guardian, care contact, or Substitute Decision Maker (SDM)">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Indiquer le parent/tuteur, la personne-ressource pour les soins ou le décideur substitut (SDM)" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <repeats value="false" />
      <answerOption>
        <valueString value="Identify parent/guardian, care contact, or Substitute Decision Maker">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Indiquer le parent/tuteur, la personne-ressource pour les soins ou le décideur substitut" />
            </extension>
          </extension>
        </valueString>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
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      <linkId value="additionalinfo_parentguardianSDM_section" />
      <type value="group" />
      <enableWhen>
        <question value="additionalinfo_parentguardianSDM" />
        <operator value="exists" />
        <answerBoolean value="true" />
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      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="additionalinfo_parentguardianSDM_firstcontact_name" />
        <text value="First Contact name:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Nom de la première personne-ressource :" />
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          </extension>
        </text>
        <type value="string" />
        <required value="true" />
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      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="sameLine">
            <valueBoolean value="true" />
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          <extension url="quoteAnswer">
            <valueBoolean value="false" />
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        </extension>
        <linkId value="additionalinfo_parentguardianSDM_firstcontact_phone" />
        <text value="Phone (if different than pt):">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Téléphone (s'il diffère de celui du patient) :" />
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          </extension>
        </text>
        <type value="string" />
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      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="sameLine">
            <valueBoolean value="true" />
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          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="additionalinfo_parentguardianSDM_firstcontact_email" />
        <text value="Email (if different than pt):">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Courriel (s'il diffère de celui du patient) :" />
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          </extension>
        </text>
        <type value="string" />
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      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="sameLine">
            <valueBoolean value="true" />
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          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="additionalinfo_parentguardianSDM_firstcontact_relation" />
        <text value="Relationship (incl. SDM):">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Lien (y compris décideur substitut) :" />
            </extension>
          </extension>
        </text>
        <type value="string" />
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </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_parentguardianSDM_firstcontact_apptbookcontact" />
        <text value="Is this person an appointment booking contact?">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Cette personne est-elle une personne-ressource pour la prise de rendez-vous?" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <required value="true" />
        <answerOption>
          <valueString value="Yes">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Oui" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
        <answerOption>
          <valueString value="No">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Non" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="additionalinfo_parentguardianSDM_secondcontact_name" />
        <text value="Second Contact name:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Nom de la deuxième personne-ressource :" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <required value="false" />
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="additionalinfo_parentguardianSDM_secondcontact_phone" />
        <text value="Phone (if different than pt):">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Téléphone (s'il diffère de celui du patient) :" />
            </extension>
          </extension>
        </text>
        <type value="string" />
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="additionalinfo_parentguardianSDM_secondcontact_email" />
        <text value="Email (if different than pt):">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Courriel (s'il diffère de celui du patient) :" />
            </extension>
          </extension>
        </text>
        <type value="string" />
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="additionalinfo_parentguardianSDM_secondcontact_relation" />
        <text value="Relationship (incl. SDM):">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Lien (y compris décideur substitut) :" />
            </extension>
          </extension>
        </text>
        <type value="string" />
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </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_parentguardianSDM_secondcontact_apptbookcontact" />
        <text value="Is this person an appointment booking contact?">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Cette personne est-elle une personne-ressource pour la prise de rendez-vous?" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <required value="false" />
        <repeats value="false" />
        <answerOption>
          <valueString value="Yes">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Oui" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
        <answerOption>
          <valueString value="No">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Non" />
              </extension>
            </extension>
          </valueString>
        </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://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <linkId value="additionalinfo_unsafecontactsprivacy_select" />
      <text value="Do not contact (e.g. safety, privacy)">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display: none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Ne pas communiquer (p. ex. sécurité, confidentialité)" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <repeats value="true" />
      <answerOption>
        <valueString value="Do not contact (e.g. safety, privacy)">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Ne pas communiquer (p. ex. sécurité, confidentialité)" />
            </extension>
          </extension>
        </valueString>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="additionalinfo_unsafecontactsprivacy_section" />
      <type value="group" />
      <enableWhen>
        <question value="additionalinfo_unsafecontactsprivacy_select" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </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://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="style">
            <valueString value="display:none;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="additionalinfo_unsafecontacts_speakwithpatientdirectly" />
        <text value="Only contact patient directly">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display: none;" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Communiquer uniquement avec le patient directement" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <repeats value="true" />
        <answerOption>
          <valueString value="Only contact patient directly">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Communiquer uniquement avec le patient directement" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="additionalinfo_unsafecontacts_donotspeakwith" />
        <text value="Do not speak with:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Ne pas parler avec :" />
            </extension>
          </extension>
        </text>
        <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>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <linkId value="additionalinfo_accessibilityconcernsordisability_select" />
      <text value="Accessibility concerns or disability">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Préoccupations liées à l'accessibilité ou incapacité" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <repeats value="false" />
      <answerOption>
        <valueString value="Accessibility concerns or disability">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préoccupations liées à l'accessibilité ou incapacité" />
            </extension>
          </extension>
        </valueString>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="additionalinfo_accessibilityconcernsordisability_section" />
      <type value="group" />
      <enableWhen>
        <question value="additionalinfo_accessibilityconcernsordisability_select" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </enableWhen>
      <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_accessibilityconcernsordisability" />
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21269" />
            <display value="Cognitively impaired">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Déficience cognitive" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21270" />
            <display value="Falls risk">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Risque de chute" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21271" />
            <display value="Hearing impaired">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Malentendant" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21272" />
            <display value="Patient requires lift">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Le patient nécessite un lève-personne" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21273" />
            <display value="Vision impaired">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Malvoyant" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21274" />
            <display value="Wheelchair">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Fauteuil roulant" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <linkId value="additionalinfo_accessibilityconcernsordisability_specify" />
        <text value="Specify">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préciser" />
            </extension>
          </extension>
        </text>
        <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="additionalinfo_specialconsiderations_select" />
      <text value="Special considerations">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
          <valueString value="<p style="display:none;"/>" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
      </text>
      <type value="string" />
      <repeats value="false" />
      <answerOption>
        <valueString value="Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, requires escort, current location)">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Considérations particulières (p. ex. obstacles, conseils pour la prestation des soins, assurance d'un tiers, accompagnateur requis, lieu actuel)" />
            </extension>
          </extension>
        </valueString>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="additionalinfo_specialconsiderations_group" />
      <type value="group" />
      <enableWhen>
        <question value="additionalinfo_specialconsiderations_select" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </enableWhen>
      <item>
        <linkId value="additionalinfo_specialconsiderations" />
        <text value="Details of special considerations:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Détails des considérations particulières :" />
            </extension>
          </extension>
        </text>
        <type value="text" />
        <enableWhen>
          <question value="additionalinfo_specialconsiderations_select" />
          <operator value="exists" />
          <answerBoolean value="true" />
        </enableWhen>
        <required value="true" />
      </item>
    </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://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
      <extension url="style">
        <valueString value="display:none;" />
      </extension>
      <extension url="sameLine">
        <valueBoolean value="false" />
      </extension>
      <extension url="quoteAnswer">
        <valueBoolean value="false" />
      </extension>
    </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="<p style="display:none;"/>" />
      </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">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Envoyer des copies des comptes rendus à d'autres fournisseurs de soins" />
          </extension>
        </extension>
      </valueString>
    </answerOption>
  </item>
  <item>
    <linkId value="additionalinfo_sendcopiestoadditionalproviders_group" />
    <type value="group" />
    <enableWhen>
      <question value="additionalinfo_sendcopiestoadditionalproviders" />
      <operator value="exists" />
      <answerBoolean value="true" />
    </enableWhen>
    <enableBehavior value="all" />
    <item>
      <linkId value="additionalinfo_sendcopiestoadditionalproviders_names" />
      <text value="Name(s):">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Nom(s) :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <required value="true" />
    </item>
    <item>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="sameLine">
          <valueBoolean value="true" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <linkId value="additionalinfo_sendcopiestoadditionalproviders_contactinfo" />
      <text value="Contact information:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Coordonnées :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <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="<p style="display:none;"/>" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
      </text>
      <type value="string" />
      <enableBehavior value="all" />
      <repeats value="false" />
      <answerOption>
        <valueString value="This is the Primary Care Provider">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Il s'agit du fournisseur de soins primaires" />
            </extension>
          </extension>
        </valueString>
      </answerOption>
    </item>
  </item>
  <item>
    <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
      <extension url="sameLine">
        <valueBoolean value="true" />
      </extension>
      <extension url="quoteAnswer">
        <valueBoolean value="false" />
      </extension>
    </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="medicalImaging_payerType" />
    <text value="Payer Type">
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Type de payeur" />
        </extension>
      </extension>
    </text>
    <type value="string" />
    <repeats value="false" />
    <answerOption>
      <valueString value="OHIP">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="OHIP" />
          </extension>
        </extension>
      </valueString>
    </answerOption>
    <answerOption>
      <valueString value="WSIB Case">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Dossier WSIB" />
          </extension>
        </extension>
      </valueString>
    </answerOption>
    <answerOption>
      <valueString value="DND">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="DND" />
          </extension>
        </extension>
      </valueString>
    </answerOption>
    <answerOption>
      <valueString value="IFH">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="IFH" />
          </extension>
        </extension>
      </valueString>
    </answerOption>
    <answerOption>
      <valueString value="RAMQ">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="RAMQ" />
          </extension>
        </extension>
      </valueString>
    </answerOption>
    <answerOption>
      <valueString value="Other">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Autre" />
          </extension>
        </extension>
      </valueString>
    </answerOption>
  </item>
  <item>
    <linkId value="medicalImaging_payerType_other" />
    <text value="Other">
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Autre" />
        </extension>
      </extension>
    </text>
    <type value="string" />
    <enableWhen>
      <question value="medicalImaging_payerType" />
      <operator value="=" />
      <answerString value="Other" />
    </enableWhen>
  </item>
  <item>
    <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info">
      <extension url="enableWhenExpression">
        <valueExpression>
          <language value="text/fhirpath" />
          <expression value="repeat(item).answer.exists()" />
        </valueExpression>
      </extension>
      <extension url="text">
        <valueString value="Exam(s) Requested" />
      </extension>
      <extension url="style">
        <valueString value="font-weight:bold;text-decoration:underline;" />
      </extension>
      <extension url="groupItems">
        <valueBoolean value="false" />
      </extension>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
      <valueString value="border-style:solid;" />
    </extension>
    <linkId value="847648250958" />
    <text value="Select Exam Request">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="font-weight:bold;" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Sélectionner la demande d'examen" />
        </extension>
      </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="listSeparator">
          <valueString value="," />
        </extension>
        <extension url="lastSeparator">
          <valueString value="and" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <linkId value="medicalImaging_examRequest" />
      <text>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="font-weight:bold;" />
        </extension>
      </text>
      <type value="choice" />
      <required value="true" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20390" />
          <display value="CT Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Demande de TDM" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20391" />
          <display value="MRI Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Demande d'IRM" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20392" />
          <display value="X-Ray Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Demande de radiographie" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20393" />
          <display value="Ultrasound Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Demande d'échographie" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20394" />
          <display value="Bone Mineral Density Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Demande d'ostéodensitométrie" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden">
        <valueBoolean value="true" />
      </extension>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="enableWhenExpression">
          <valueExpression>
            <language value="text/fhirpath" />
            <expression value="false" />
          </valueExpression>
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression">
        <valueExpression>
          <language value="text/fhirpath" />
          <expression value="iif(%resource.item.repeat(item).where(linkId='medicalImaging_examRequest').answer.where(valueCoding.code = '20391').exists(), 'MRI_HEIGHT_WEIGHT_REQUIRED', iif(%resource.item.repeat(item).where(linkId='medicalImaging_examRequest').answer.where(valueCoding.code = '20390').exists(), 'CT_WEIGHT_REQUIRED', iif(%resource.item.repeat(item).where(linkId='medicalImaging_examRequest').answer.where(valueCoding.code = '20394').exists(), 'BMD_HEIGHT_WEIGHT_OPTIONAL', 'HIDE')))" />
        </valueExpression>
      </extension>
      <linkId value="medicalImaging_weightHeightRequirement" />
      <text value="Weight/height requirement">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Exigence de poids/taille" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <readOnly value="true" />
    </item>
  </item>
  <item>
    <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="groupItems">
        <valueBoolean value="false" />
      </extension>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
      <valueString value="border-style:solid;" />
    </extension>
    <linkId value="medicalImaging_referral_triageconsiderations" />
    <text value="Triage Considerations">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="font-weight:bold;" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Considérations de triage" />
        </extension>
      </extension>
    </text>
    <type value="group" />
    <enableWhen>
      <question value="medicalImaging_examRequest" />
      <operator value="exists" />
      <answerBoolean value="true" />
    </enableWhen>
    <enableBehavior value="all" />
    <item>
      <linkId value="medicalImaging_referral_triageconsiderations_display" />
      <text value="If the patient requires emergent attention, do not submit this form. Please contact your nearest imaging facility directly.">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Si le patient nécessite des soins urgents, ne pas soumettre ce formulaire. Veuillez communiquer directement avec l'établissement d'imagerie le plus proche." />
          </extension>
        </extension>
      </text>
      <type value="display" />
    </item>
    <item>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="answerStyle">
          <valueString value="font-weight:bold;color:#EE6B00;" />
        </extension>
        <extension url="style">
          <valueString value="font-weight:bold;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
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        <extension url="quoteAnswer">
          <valueBoolean value="false" />
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      <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="medicalImaging_examRequest_triage" />
      <text value="Requested Triage Priority">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Priorité de triage demandée" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <repeats value="false" />
      <answerOption>
        <valueString value="Routine">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="De routine" />
            </extension>
          </extension>
        </valueString>
        <initialSelected value="true" />
      </answerOption>
      <answerOption>
        <valueString value="Urgent">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Urgent" />
            </extension>
          </extension>
        </valueString>
      </answerOption>
    </item>
    <item>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="font-weight:bold;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
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        <extension url="quoteAnswer">
          <valueBoolean value="false" />
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      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_CT_triage_urgentReason" />
      <text value="Reason for urgent triage:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Motif du triage urgent :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <enableWhen>
        <question value="medicalImaging_examRequest_triage" />
        <operator value="=" />
        <answerString value="Urgent" />
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      <required value="true" />
      <repeats value="false" />
    </item>
  </item>
  <item>
    <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info">
      <extension url="enableWhenExpression">
        <valueExpression>
          <language value="text/fhirpath" />
          <expression value="false" />
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      <extension url="groupItems">
        <valueBoolean value="false" />
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    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
      <valueString value="border-style:solid;" />
    </extension>
    <linkId value="medicalImaging_referral_cds" />
    <text value="Clinical Decision Support">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="font-weight:bold;" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Aide à la décision clinique" />
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      </extension>
    </text>
    <type value="group" />
    <enableWhen>
      <question value="medicalImaging_examRequest" />
      <operator value="=" />
      <answerCoding>
        <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
        <code value="20390" />
        <display value="CT Requisition">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
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            <extension url="content">
              <valueString value="Demande de TDM" />
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        </display>
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    <enableWhen>
      <question value="medicalImaging_examRequest" />
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      <answerCoding>
        <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
        <code value="20391" />
        <display value="MRI Requisition">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
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            <extension url="content">
              <valueString value="Demande d'IRM" />
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        </display>
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    </enableWhen>
    <enableWhen>
      <question value="medicalImaging_examRequest" />
      <operator value="=" />
      <answerCoding>
        <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
        <code value="20392" />
        <display value="X-Ray Requisition">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Demande de radiographie" />
            </extension>
          </extension>
        </display>
      </answerCoding>
    </enableWhen>
    <enableWhen>
      <question value="medicalImaging_examRequest" />
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      <answerCoding>
        <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
        <code value="20394" />
        <display value="Bone Mineral Density Requisition">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Demande d'ostéodensitométrie" />
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        </display>
      </answerCoding>
    </enableWhen>
    <enableBehavior value="any" />
    <item>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="enableWhenExpression">
          <valueExpression>
            <language value="text/fhirpath" />
            <expression value="false" />
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        <extension url="sameLine">
          <valueBoolean value="false" />
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        <extension url="quoteAnswer">
          <valueBoolean value="false" />
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      <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" />
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      </extension>
      <linkId value="medicalImaging_examRequest_cds" />
      <text value="Display Clinical Decision Support (CDS)">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Afficher l'aide à la décision clinique (ADC)" />
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        </extension>
      </text>
      <type value="string" />
      <enableWhen>
        <question value="medicalImaging_examRequest" />
        <operator value="=" />
        <answerCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20390" />
          <display value="CT Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Demande de TDM" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableWhen>
        <question value="medicalImaging_examRequest" />
        <operator value="=" />
        <answerCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20391" />
          <display value="MRI Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Demande d'IRM" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableWhen>
        <question value="medicalImaging_examRequest" />
        <operator value="=" />
        <answerCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20392" />
          <display value="X-Ray Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Demande de radiographie" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableWhen>
        <question value="medicalImaging_examRequest" />
        <operator value="=" />
        <answerCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20394" />
          <display value="Bone Mineral Density Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Demande d'ostéodensitométrie" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableBehavior value="any" />
      <repeats value="false" />
      <answerOption>
        <valueString value="Hide">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Masquer" />
            </extension>
          </extension>
        </valueString>
        <initialSelected value="true" />
      </answerOption>
      <answerOption>
        <valueString value="Show">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Afficher" />
            </extension>
          </extension>
        </valueString>
      </answerOption>
      <item>
        <linkId value="medicalImaging_examRequest_CT_cds_show" />
        <text value="CDS will show for selections below where available.
  Click 'Hide' to remove.">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<p>
  CDS will <span style="text-decoration: underline">show</span> for selections below where available.
  Click 'Hide' to remove.
</p>">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="<p>
  L'ADC <span style="text-decoration: underline">s'affichera</span> pour les sélections ci-dessous lorsque c'est possible. Cliquez sur « Masquer » pour la retirer.
</p>" />
                </extension>
              </extension>
            </valueString>
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Afficher" />
            </extension>
          </extension>
        </text>
        <type value="display" />
        <enableWhen>
          <question value="medicalImaging_examRequest_cds" />
          <operator value="=" />
          <answerString value="Show" />
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        <enableBehavior value="all" />
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      <item>
        <linkId value="medicalImaging_examRequest_CT_cds_hide" />
        <text value="CDS is hidden for selections below.
  Click 'Show' to display where available.">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<p>
  CDS is <span style="text-decoration: underline">hidden</span> for selections below.
  Click 'Show' to display where available.
</p>">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="<p>
  L'ADC est <span style="text-decoration: underline">masquée</span> pour les sélections ci-dessous. Cliquez sur « Afficher » pour l'afficher lorsque c'est possible.
</p>" />
                </extension>
              </extension>
            </valueString>
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Masquer" />
            </extension>
          </extension>
        </text>
        <type value="display" />
        <enableWhen>
          <question value="medicalImaging_examRequest_cds" />
          <operator value="=" />
          <answerString value="Hide" />
        </enableWhen>
        <enableBehavior value="all" />
      </item>
    </item>
  </item>
  <item>
    <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info">
      <extension url="text">
        <valueString value="CT Exam/Region(s) of Interest:" />
      </extension>
      <extension url="listSeparator">
        <valueString value="," />
      </extension>
      <extension url="style">
        <valueString value="font-weight:bold;text-decoration:underline;" />
      </extension>
      <extension url="groupItems">
        <valueBoolean value="false" />
      </extension>
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    <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
      <valueString value="border-style:solid;" />
    </extension>
    <linkId value="medicalImaging_examRequest_CT_group" />
    <text value="Select CT Exam/Region(s) of Interest:">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="font-weight:bold;" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Sélectionner l'examen/la ou les régions de TDM d'intérêt :" />
        </extension>
      </extension>
    </text>
    <type value="group" />
    <enableWhen>
      <question value="medicalImaging_examRequest" />
      <operator value="=" />
      <answerCoding>
        <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
        <code value="20390" />
        <display value="CT Requisition">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Demande de TDM" />
            </extension>
          </extension>
        </display>
      </answerCoding>
    </enableWhen>
    <enableBehavior value="all" />
    <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>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_CT_head" />
      <text value="Head">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Tête" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20395" />
          <display value="Head">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Tête" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_CT_head_group" />
      <prefix value="Head">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Tête" />
          </extension>
        </extension>
      </prefix>
      <type value="group" />
      <enableWhen>
        <question value="medicalImaging_examRequest_CT_head" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </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://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="text">
            <valueString value="Specific area of interest" />
          </extension>
          <extension url="listSeparator">
            <valueString value="," />
          </extension>
          <extension url="lastSeparator">
            <valueString value="and" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_CT_head_specificarea" />
        <text value="Specific area of interest (optional)">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Région d'intérêt précise (facultatif)" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20406" />
            <display value="Brain">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Cerveau" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20408" />
            <display value="Facial bones">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Os de la face" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20447" />
            <display value="Head angiography">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Angiographie de la tête" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20456" />
            <display value="Head venography">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Phlébographie de la tête" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20409" />
            <display value="Internal auditory canals">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Conduits auditifs internes" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20410" />
            <display value="Orbits">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Orbites" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20411" />
            <display value="Sinuses">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Sinus" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20412" />
            <display value="Temporal bones">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Os temporaux" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Other specific area of interest" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_CT_head_specificarea_other" />
        <text value="Specify:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préciser :" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_CT_head_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </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>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
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        <extension url="quoteAnswer">
          <valueBoolean value="false" />
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      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
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      <linkId value="medicalImaging_examRequest_CT_neck" />
      <text value="Neck">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Cou" />
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        </extension>
      </text>
      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20396" />
          <display value="Neck">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Cou" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
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      <linkId value="medicalImaging_examRequest_CT_neck_group" />
      <prefix value="Neck">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Cou" />
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      <type value="group" />
      <enableWhen>
        <question value="medicalImaging_examRequest_CT_neck" />
        <operator value="exists" />
        <answerBoolean value="true" />
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      <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://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
              <code value="push-button" />
              <display value="Push Button" />
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        </extension>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Specific area of interest" />
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          <extension url="listSeparator">
            <valueString value="," />
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          <extension url="lastSeparator">
            <valueString value="and" />
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          <extension url="style">
            <valueString value="font-weight:bold;" />
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          <extension url="sameLine">
            <valueBoolean value="true" />
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          <extension url="quoteAnswer">
            <valueBoolean value="false" />
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        </extension>
        <linkId value="medicalImaging_examRequest_CT_neck_specificarea" />
        <text value="Specific area of interest (optional)">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Région d'intérêt précise (facultatif)" />
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        <type value="choice" />
        <enableBehavior value="any" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20448" />
            <display value="Neck angiography">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Angiographie du cou" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20414" />
            <display value="Soft Tissue Neck">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Tissus mous du cou" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Other specific area of interest" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_CT_neck_specificarea_other" />
        <text value="Specify:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préciser :" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_CT_neck_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </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>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
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        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
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      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_CT_spine" />
      <text value="Spine">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Colonne vertébrale" />
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        </extension>
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      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20397" />
          <display value="Spine">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Colonne vertébrale" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_CT_spine_group" />
      <prefix value="Spine">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Colonne vertébrale" />
          </extension>
        </extension>
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      <type value="group" />
      <enableWhen>
        <question value="medicalImaging_examRequest_CT_spine" />
        <operator value="exists" />
        <answerBoolean value="true" />
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      <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">
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    People with acute low back pain do not receive diagnostic imaging
    tests unless they present with red flags that suggest serious
    pathological disease.
  


Red flag signs or symptoms include:


  
    Neurological disorders: diffuse or substantial motor/sensory loss,
    progressive neurological deficits, cauda equina syndrome
  

  
    Infection: fever, history of IV drug use, immunosuppression
  

  
    Fracture: trauma, osteoporosis risk/fragility fracture
  

  
    Tumour: history of cancer, unexplained weight loss, significant
    unexpected night pain, severe fatigue
  

  
    Inflammation: chronic low back pain for more than 3 months,
    age of onset less than 45 years, morning stiffness for more than
    30 minutes, improvement with exercise, disproportionate night pain.
  



  
    Source: Health Quality Ontario. Quality Standards – Low Back Pain:
    Care for Adults with Acute Low Back Pain; 2019.">
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<p>
  <b>
    People with acute low back pain do not receive diagnostic imaging
    tests unless they present with red flags that suggest serious
    pathological disease.
  </b>
</p>

<p><b>Red flag</b> signs or symptoms include:</p>

<span style="text-decoration: underline;">
  <li>
    Neurological disorders: diffuse or substantial motor/sensory loss,
    progressive neurological deficits, cauda equina syndrome
  </li>

  <li>
    Infection: fever, history of IV drug use, immunosuppression
  </li>

  <li>
    Fracture: trauma, osteoporosis risk/fragility fracture
  </li>

  <li>
    Tumour: history of cancer, unexplained weight loss, significant
    unexpected night pain, severe fatigue
  </li>

  <li>
    Inflammation: chronic low back pain for more than 3 months,
    age of onset less than 45 years, morning stiffness for more than
    30 minutes, improvement with exercise, disproportionate night pain.
  </li>
</span>

<p>
  <i>
    Source: Health Quality Ontario. Quality Standards – Low Back Pain:
    Care for Adults with Acute Low Back Pain; 2019.
  </i>
</p>" />
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                  <valueString value="Pelvis seulement" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20430" />
            <display value="Colonography">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Coloscopie virtuelle" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20431" />
            <display value="Enterography">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Entérographie" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20432" />
            <display value="Renal Colic">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Colique néphrétique" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20433" />
            <display value="Urography">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Urographie" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Other specific area of interest" />
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          <extension url="style">
            <valueString value="font-weight:bold;" />
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          <extension url="sameLine">
            <valueBoolean value="false" />
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          <extension url="quoteAnswer">
            <valueBoolean value="false" />
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        </extension>
        <linkId value="medicalImaging_examRequest_CT_abdomenpelvis_specificarea_other" />
        <text value="Specify:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préciser :" />
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        <type value="string" />
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          <question value="medicalImaging_examRequest_CT_abdomenpelvis_specificarea" />
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          <answerCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
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            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <enableBehavior value="all" />
        <required value="true" />
      </item>
    </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" />
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        </valueCodeableConcept>
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      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
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        <extension url="sameLine">
          <valueBoolean value="false" />
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        <extension url="quoteAnswer">
          <valueBoolean value="false" />
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      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
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      <linkId value="medicalImaging_examRequest_CT_musculoskeletal" />
      <text value="Musculoskeletal">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Musculosquelettique" />
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        </extension>
      </text>
      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20400" />
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            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Musculosquelettique" />
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            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
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      <linkId value="medicalImaging_examRequest_musculoskeletal_group" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Musculosquelettique" />
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      <type value="group" />
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        <question value="medicalImaging_examRequest_CT_musculoskeletal" />
        <operator value="exists" />
        <answerBoolean value="true" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
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          <valueCodeableConcept>
            <coding>
              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
              <code value="push-button" />
              <display value="Push Button" />
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        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Specific area of interest" />
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          <extension url="listSeparator">
            <valueString value="," />
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          <extension url="lastSeparator">
            <valueString value="and" />
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          <extension url="style">
            <valueString value="font-weight:bold;" />
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          <extension url="sameLine">
            <valueBoolean value="false" />
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          <extension url="quoteAnswer">
            <valueBoolean value="true" />
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        <linkId value="medicalImaging_examRequest_CT_musculoskeletal_specificarea" />
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          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
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            <extension url="content">
              <valueString value="Région d'intérêt précise" />
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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="20434" />
            <display value="Shoulder">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Épaule" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20435" />
            <display value="Humerus">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Humérus" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20436" />
            <display value="Elbow">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Coude" />
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              </extension>
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        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20437" />
            <display value="Forearm">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Avant-bras" />
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              </extension>
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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            <display value="Wrist">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Poignet" />
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              </extension>
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        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20439" />
            <display value="Hand">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Main" />
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              </extension>
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20440" />
            <display value="Bony Pelvis">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Bassin osseux" />
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        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20441" />
            <display value="Hip">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Hanche" />
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              </extension>
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        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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            <display value="Femur">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Fémur" />
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20443" />
            <display value="Knee">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Genou" />
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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            <display value="Tibia and Fibula">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Tibia et fibula" />
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        <answerOption>
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20445" />
            <display value="Ankle">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Cheville" />
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        <answerOption>
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20446" />
            <display value="Foot">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Pied" />
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          </valueCoding>
        </answerOption>
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        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
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          <valueCodeableConcept>
            <coding>
              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
              <code value="push-button" />
              <display value="Push Button" />
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          <extension url="style">
            <valueString value="font-weight:bold;" />
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          <extension url="sameLine">
            <valueBoolean value="false" />
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            <valueBoolean value="false" />
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          <valueString value="border-style:solid;" />
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            <extension url="lang">
              <valueCode value="fr" />
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            <extension url="content">
              <valueString value="Épaule :" />
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            <code value="20434" />
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              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Épaule" />
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        <required value="true" />
        <repeats value="false" />
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21321" />
            <display value="Left">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Gauche" />
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21322" />
            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Droite" />
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21323" />
            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Bilatéral" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
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            <coding>
              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
              <code value="push-button" />
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          <extension url="style">
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          <extension url="sameLine">
            <valueBoolean value="false" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
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          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
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            <extension url="content">
              <valueString value="Humérus :" />
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Humérus" />
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Gauche" />
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Droite" />
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              </extension>
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Bilatéral" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
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          <valueCodeableConcept>
            <coding>
              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
              <code value="push-button" />
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        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="style">
            <valueString value="font-weight:bold;" />
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          <extension url="sameLine">
            <valueBoolean value="false" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
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        <linkId value="medicalImaging_examRequest_CT_musculoskeletal_elbow" />
        <text value="Elbow:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
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            <extension url="content">
              <valueString value="Coude :" />
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          </extension>
        </text>
        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_CT_musculoskeletal_specificarea" />
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          <valueCodeableConcept>
            <coding>
              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
              <code value="push-button" />
              <display value="Push Button" />
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          </valueCodeableConcept>
        </extension>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="style">
            <valueString value="font-weight:bold;" />
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          <extension url="sameLine">
            <valueBoolean value="false" />
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          <extension url="quoteAnswer">
            <valueBoolean value="false" />
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        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </extension>
        <linkId value="medicalImaging_examRequest_CT_musculoskeletal_tibia" />
        <text value="Tibia and Fibula:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Tibia et fibula :" />
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        <type value="choice" />
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            <code value="20444" />
            <display value="Tibia and Fibula">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Tibia et fibula" />
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        <enableBehavior value="all" />
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        <repeats value="false" />
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            <code value="21321" />
            <display value="Left">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Gauche" />
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                <extension url="lang">
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                <extension url="content">
                  <valueString value="Droite" />
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        <answerOption>
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            <code value="21323" />
            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Bilatéral" />
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      <item>
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          <valueCodeableConcept>
            <coding>
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              <code value="push-button" />
              <display value="Push Button" />
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        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
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            <valueString value="font-weight:bold;" />
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          <extension url="sameLine">
            <valueBoolean value="false" />
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            <valueBoolean value="false" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </extension>
        <linkId value="medicalImaging_examRequest_CT_musculoskeletal_ankle" />
        <text value="Ankle:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Cheville :" />
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        <type value="choice" />
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            <code value="20445" />
            <display value="Ankle">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Cheville" />
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        <required value="true" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Gauche" />
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        <answerOption>
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21322" />
            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Droite" />
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        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21323" />
            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Bilatéral" />
                </extension>
              </extension>
            </display>
          </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://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="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </extension>
        <linkId value="medicalImaging_examRequest_CT_musculoskeletal_foot" />
        <text value="Foot:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Pied :" />
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        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_CT_musculoskeletal_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20446" />
            <display value="Foot">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Pied" />
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        <enableBehavior value="all" />
        <required value="true" />
        <repeats value="false" />
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21321" />
            <display value="Left">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Gauche" />
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21322" />
            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Droite" />
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          </valueCoding>
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21323" />
            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Bilatéral" />
                </extension>
              </extension>
            </display>
          </valueCoding>
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    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden">
        <valueBoolean value="true" />
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      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="enableWhenExpression">
          <valueExpression>
            <language value="text/fhirpath" />
            <expression value="false" />
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        <extension url="sameLine">
          <valueBoolean value="false" />
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        <extension url="quoteAnswer">
          <valueBoolean value="false" />
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      </extension>
      <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression">
        <valueExpression>
          <language value="text/fhirpath" />
          <expression value="%resource.item.repeat(item).where(linkId = 'medicalImaging_examRequest_CT_musculoskeletal_specificarea').answer.valueCoding.code.where($this = '20441' or $this = '20443' or $this = '20438' or $this = '20434').exists() and %resource.item.repeat(item).where(linkId = 'medicalImaging_examRequest_cds').answer.valueString.where($this = 'Show').exists()" />
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      </extension>
      <linkId value="medicalImaging_CT_CDS_Osteoarthritis_enabled" />
      <text value="CT osteoarthritis CDS display condition" />
      <type value="boolean" />
      <readOnly value="true" />
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    <item>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info">
        <extension url="enableWhenExpression">
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            <language value="text/fhirpath" />
            <expression value="false" />
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      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
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      <linkId value="CT_CDS_Osteoarthritis" />
      <text value="Osteoarthritis - Quality Standards
People who have persistent, atraumatic, movement related joint pain or aching, and/or morning stiffness lasting less than 30 minutes, are diagnosed with osteoarthritis based on clinical assessment. Radiological imaging is not required to make a diagnosis in people aged 40 years or older if their symptoms are typical of osteoarthritis

Symptoms typical of osteoarthritis: Persistent atraumatic movement-related joint pain, aching, stiffness, and/or swelling. Morning stiffness lasting less than 30 minutes may or may not be present. Symptoms may affect one or a few joints.
Atypical features: A recent history of injury, joint locking, prolonged morning joint-related stiffness, rapid onset of symptoms, the presence of a hot swollen joint, fever, chills, sweats, or feeling generally unwell. Atypical features usually indicate the need for further investigations to identify possible additional or alternative diagnoses, including loose body, meniscal injury, gout, or other inflammatory arthritides, such as rheumatoid arthritis, septic arthritis, and malignancy (if bone or soft tissue pain are present). 

Source: Ontario Health. Quality Standards – Osteoarthritis: Care for Adults with Osteoarthritis of the Knee, Hip, Hands, or Shoulder; 2024.">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
          <valueString value="<p><b>Osteoarthritis - Quality Standards</b></p>
<p><b>People who have persistent, atraumatic, movement related joint pain or aching, and/or morning stiffness lasting less than 30 minutes, are diagnosed with osteoarthritis based on clinical assessment. Radiological imaging is not required to make a diagnosis in people aged 40 years or older if their symptoms are typical of osteoarthritis</b></p>

<p>Symptoms <b>typical</b> of osteoarthritis: Persistent atraumatic movement-related joint pain, aching, stiffness, and/or swelling. Morning stiffness lasting less than 30 minutes may or may not be present. Symptoms may affect one or a few joints.</p>
<p><b>Atypical</b> features: A recent history of injury, joint locking, prolonged morning joint-related stiffness, rapid onset of symptoms, the presence of a hot swollen joint, fever, chills, sweats, or feeling generally unwell. Atypical features usually indicate the need for further investigations to identify possible additional or alternative diagnoses, including loose body, meniscal injury, gout, or other inflammatory arthritides, such as rheumatoid arthritis, septic arthritis, and malignancy (if bone or soft tissue pain are present). </p>

<i><sub>Source: Ontario Health. Quality Standards – Osteoarthritis: Care for Adults with Osteoarthritis of the Knee, Hip, Hands, or Shoulder; 2024.</sub></i>" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Arthrose – Normes de qualité" />
          </extension>
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        <operator value="=" />
        <answerBoolean value="true" />
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    <item>
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        <valueCode value="horizontal" />
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        <valueCodeableConcept>
          <coding>
            <system value="http://hl7.org/fhir/questionnaire-item-control" />
            <code value="check-box" />
            <display value="Check-box" />
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        <extension url="style">
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          <valueBoolean value="false" />
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          <valueBoolean value="false" />
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      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_CT_angiographyarterial" />
      <text value="CT Angiography">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Angiographie par TDM" />
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        </extension>
      </text>
      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20401" />
          <display value="Angiography">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Angiographie" />
              </extension>
            </extension>
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        </valueCoding>
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    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_angiographyarterial_group" />
      <prefix value="Angiography Arterial">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Angiographie artérielle" />
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      <type value="group" />
      <enableWhen>
        <question value="medicalImaging_examRequest_CT_angiographyarterial" />
        <operator value="exists" />
        <answerBoolean value="true" />
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      <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://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
              <code value="push-button" />
              <display value="Push Button" />
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          </valueCodeableConcept>
        </extension>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Specific area of interest" />
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          <extension url="listSeparator">
            <valueString value="," />
          </extension>
          <extension url="lastSeparator">
            <valueString value="and" />
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          <extension url="style">
            <valueString value="font-weight:bold;" />
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          <extension url="sameLine">
            <valueBoolean value="true" />
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          <extension url="quoteAnswer">
            <valueBoolean value="false" />
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        <linkId value="medicalImaging_examRequest_CT_angiographyarterial_specificarea" />
        <text value="Specific area of interest">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Région d'intérêt précise" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <required value="true" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20447" />
            <display value="Head Angiography">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Angiographie de la tête" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20448" />
            <display value="Neck Angiography">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Angiographie du cou" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20449" />
            <display value="Chest Angiography">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Angiographie du thorax" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20450" />
            <display value="Chest Abdomen Pelvis Angiography">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Angiographie du thorax, de l'abdomen et du pelvis" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20451" />
            <display value="Abdomen Angiography">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Angiographie de l'abdomen" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20452" />
            <display value="Abdomen Pelvis Angiography">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Angiographie de l'abdomen et du pelvis" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20453" />
            <display value="Pelvis Angiography">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Angiographie du pelvis" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20454" />
            <display value="Upper Extremity Angiography">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Angiographie des membres supérieurs" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20455" />
            <display value="Lower Extremity Angiography">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
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            <display value="Bilateral">
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      <text value="Cardiac">
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      <text value="CCTA Patient Selection Guidance
Patients appropriate for CCTA:
Symptomatic patients with no known coronary artery disease (CAD) and no prior testingSymptomatic patients with no known CAD and with prior CAD testing showing results that are incongruent with clinical impression.Suspected anomalous coronary anatomy
Patients not appropriate for CCTA
History of CADAtrial fibrillation (depending on scanner)Contraindication to nitratesContraindication to heart rate modifying medicationsContraindications to radiationContraindication to contrastInability to comply with breath-hold and breath-hold instructionsSource: Ontario Health. Ontario Clinical Guidance on Patient Selection and Prioritization for Coronary Computed Tomography Angiography (CCTA); 2024.">
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<p><b>Patients appropriate for CCTA:</b>
<span style="text-decoration: underline;"><li>Symptomatic patients with no known coronary artery disease (CAD) and no prior testing</li><li>Symptomatic patients with no known CAD and with prior CAD testing showing results that are incongruent with clinical impression.</li><li>Suspected anomalous coronary anatomy</li></span></p>
<p><b>Patients not appropriate for CCTA</b>
<span style="text-decoration: underline;"><li>History of CAD</li><li>Atrial fibrillation (depending on scanner)</li><li>Contraindication to nitrates</li><li>Contraindication to heart rate modifying medications</li><li>Contraindications to radiation</li><li>Contraindication to contrast</li><li>Inability to comply with breath-hold and breath-hold instructions</li></span></p><p><i><sub>Source: Ontario Health. Ontario Clinical Guidance on Patient Selection and Prioritization for Coronary Computed Tomography Angiography (CCTA); 2024.</sub></i></p>" />
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          <display value="Coronary Angiography (CCTA)">
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            <extension url="content">
              <valueString value="Préciser la région d'intérêt :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <required value="true" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21366" />
            <display value="Adrenals">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Surrénales" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21367" />
            <display value="Bone">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Os" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21368" />
            <display value="Kidneys">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Reins" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21369" />
            <display value="Liver">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Foie" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21370" />
            <display value="Lung">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Poumon" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21371" />
            <display value="Lymph nodes">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Ganglions lymphatiques" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21372" />
            <display value="Mediastinal mass">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Masse médiastinale" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21373" />
            <display value="Pancreas">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Pancréas" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21374" />
            <display value="Pelvis">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Pelvis" />
                </extension>
              </extension>
            </display>
          </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>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_CT_other" />
      <text value="Other">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Autre" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <answerOption>
        <valueCoding>
          <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
          <code value="OTH" />
          <display value="Other">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Autre" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="font-weight:bold;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_CT_other_specify" />
      <text value="Specify:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Préciser :" />
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        </extension>
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      <type value="string" />
      <enableWhen>
        <question value="medicalImaging_examRequest_CT_other" />
        <operator value="exists" />
        <answerBoolean value="true" />
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      <enableBehavior value="all" />
      <required value="true" />
    </item>
  </item>
  <item>
    <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info">
      <extension url="style">
        <valueString value="font-weight:bold;" />
      </extension>
      <extension url="groupItems">
        <valueBoolean value="false" />
      </extension>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
      <valueString value="border-style:solid;" />
    </extension>
    <linkId value="medicalImaging_CT_clinicalindication_CTrefnote" />
    <text value="CT Request: Clinical History / Indication">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="font-weight:bold;" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Demande de TDM : antécédents cliniques / indication" />
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      </extension>
    </text>
    <type value="group" />
    <enableWhen>
      <question value="medicalImaging_examRequest" />
      <operator value="=" />
      <answerCoding>
        <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
        <code value="20390" />
        <display value="CT Requisition">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Demande de TDM" />
            </extension>
          </extension>
        </display>
      </answerCoding>
    </enableWhen>
    <enableBehavior value="all" />
    <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="<br/>" />
            </extension>
          </valueString>
        </extension>
      </extension>
      <linkId value="medicalImaging_CT_clinicalindication_text" />
      <text value="Reason for exam (please also include presenting symptom(s), relevant underlying diagnosis and therapies, where applicable)">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Motif de l'examen (veuillez aussi indiquer le ou les symptômes présents, le diagnostic sous-jacent pertinent et les traitements, le cas échéant)" />
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        </extension>
      </text>
      <type value="text" />
      <required value="true" />
    </item>
  </item>
  <item>
    <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info">
      <extension url="text">
        <valueString value="MRI Exam/Region(s) of Interest:" />
      </extension>
      <extension url="style">
        <valueString value="font-weight:bold;text-decoration:underline;" />
      </extension>
      <extension url="groupItems">
        <valueBoolean value="false" />
      </extension>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
      <valueString value="border-style:solid;" />
    </extension>
    <linkId value="medicalImaging_examRequest_MRI_group_MRIrefnote" />
    <text value="Select MRI Exam/Region(s) of Interest:">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="font-weight:bold;" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Sélectionner l'examen/la ou les régions d'IRM d'intérêt :" />
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      </extension>
    </text>
    <type value="group" />
    <enableWhen>
      <question value="medicalImaging_examRequest" />
      <operator value="=" />
      <answerCoding>
        <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
        <code value="20391" />
        <display value="MRI Requisition">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Demande d'IRM" />
            </extension>
          </extension>
        </display>
      </answerCoding>
    </enableWhen>
    <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>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_MRI_head" />
      <text value="Head">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Tête" />
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        </extension>
      </text>
      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20467" />
          <display value="Head">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Tête" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_MRI_head_group" />
      <prefix value="Head">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Tête" />
          </extension>
        </extension>
      </prefix>
      <type value="group" />
      <enableWhen>
        <question value="medicalImaging_examRequest_MRI_head" />
        <operator value="exists" />
        <answerBoolean value="true" />
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      <enableBehavior value="all" />
      <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://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="text">
            <valueString value="Specific area of interest" />
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          <extension url="listSeparator">
            <valueString value="," />
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          <extension url="lastSeparator">
            <valueString value="and" />
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          <extension url="style">
            <valueString value="font-weight:bold;" />
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          <extension url="sameLine">
            <valueBoolean value="true" />
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          <extension url="quoteAnswer">
            <valueBoolean value="false" />
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        <linkId value="medicalImaging_examRequest_MRI_head_specificarea" />
        <text value="Specific area of interest (optional)">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Région d'intérêt précise (facultatif)" />
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          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20478" />
            <display value="Brain">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Cerveau" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20540" />
            <display value="Head angiography">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Angiographie de la tête" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20480" />
            <display value="Internal auditory canals">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Conduits auditifs internes" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20481" />
            <display value="Orbits">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Orbites" />
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          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20482" />
            <display value="Pituitary / Sella">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Hypophyse / selle turcique" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20483" />
            <display value="Sinuses">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Sinus" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20484" />
            <display value="Temporomandibular joints">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Articulations temporomandibulaires" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20485" />
            <display value="Trigeminal nerve">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Nerf trijumeau" />
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              </extension>
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        <answerOption>
          <valueCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Other specific area of interest" />
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          <extension url="style">
            <valueString value="font-weight:bold;" />
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          <extension url="sameLine">
            <valueBoolean value="false" />
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          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_MRI_head_specificarea_other" />
        <text value="Specify Other">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préciser (autre)" />
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        </text>
        <type value="string" />
        <enableWhen>
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          <answerCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <enableBehavior value="all" />
        <required value="true" />
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    <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" />
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      </extension>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
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      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
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      <text value="Low Back Pain - Quality Standards


  
    People with acute low back pain do not receive diagnostic imaging
    tests unless they present with red flags that suggest serious
    pathological disease.
  


Red flag signs or symptoms include:


  
    Neurological disorders: diffuse or substantial motor/sensory loss,
    progressive neurological deficits, cauda equina syndrome
  
  
    Infection: fever, history of IV drug use, immunosuppression
  
  
    Fracture: trauma, osteoporosis risk/fragility fracture
  
  
    Tumour: history of cancer, unexplained weight loss, significant
    unexpected night pain, severe fatigue
  
  
    Inflammation: chronic low back pain for more than 3 months,
    age of onset less than 45 years, morning stiffness for more than
    30 minutes, improvement with exercise, disproportionate night pain
  



  
    Source: Health Quality Ontario. Quality Standards – Low Back Pain:
    Care for Adults with Acute Low Back Pain; 2019.">
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<p>
  <b>
    People with acute low back pain do not receive diagnostic imaging
    tests unless they present with red flags that suggest serious
    pathological disease.
  </b>
</p>

<p><b>Red flag signs or symptoms include:</b></p>

<span style="text-decoration: underline;">
  <li>
    Neurological disorders: diffuse or substantial motor/sensory loss,
    progressive neurological deficits, cauda equina syndrome
  </li>
  <li>
    Infection: fever, history of IV drug use, immunosuppression
  </li>
  <li>
    Fracture: trauma, osteoporosis risk/fragility fracture
  </li>
  <li>
    Tumour: history of cancer, unexplained weight loss, significant
    unexpected night pain, severe fatigue
  </li>
  <li>
    Inflammation: chronic low back pain for more than 3 months,
    age of onset less than 45 years, morning stiffness for more than
    30 minutes, improvement with exercise, disproportionate night pain
  </li>
</span>

<p>
  <i>
    Source: Health Quality Ontario. Quality Standards – Low Back Pain:
    Care for Adults with Acute Low Back Pain; 2019.
  </i>
</p>" />
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        <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="text">
            <valueString value="Specific area of interest" />
          </extension>
          <extension url="listSeparator">
            <valueString value="," />
          </extension>
          <extension url="lastSeparator">
            <valueString value="and" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_MRI_thorax_specificarea" />
        <text value="Specific area of interest (optional)">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Région d'intérêt précise (facultatif)" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20495" />
            <display value="Chest">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Thorax" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20496" />
            <display value="Chest wall">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Paroi thoracique" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20497" />
            <display value="Pulmonary arteries">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Artères pulmonaires" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20498" />
            <display value="Sternoclavicular joints">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Articulations sternoclaviculaires" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20499" />
            <display value="Sternum">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Sternum" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20542" />
            <display value="Chest Angiography">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Angiographie du thorax" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20501" />
            <display value="Thoracic Outlet">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Défilé thoracobrachial" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Other specific area of interest" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_MRI_thorax_specificarea_other" />
        <text value="Specify Other">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préciser (autre)" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_MRI_thorax_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </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>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_MRI_abdomen" />
      <text value="Abdomen">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Abdomen" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20471" />
          <display value="Abdomen">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Abdomen" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_MRI_abdomen_group" />
      <prefix value="Abdomen">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Abdomen" />
          </extension>
        </extension>
      </prefix>
      <type value="group" />
      <enableWhen>
        <question value="medicalImaging_examRequest_MRI_abdomen" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </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://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="text">
            <valueString value="Specific area of interest" />
          </extension>
          <extension url="listSeparator">
            <valueString value="," />
          </extension>
          <extension url="lastSeparator">
            <valueString value="and" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_MRI_abdomen_specificarea" />
        <text value="Specific area of interest (optional)">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Région d'intérêt précise (facultatif)" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21398" />
            <display value="Abdomen Pelvis Angiography">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Angiographie de l'abdomen et du pelvis" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20503" />
            <display value="Abdominal wall">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Paroi abdominale" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20504" />
            <display value="Adrenal glands">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Glandes surrénales" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20505" />
            <display value="Biliary and pancreatic ducts">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Voies biliaires et pancréatiques" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20506" />
            <display value="Enterography">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Entérographie" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20507" />
            <display value="Kidneys">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Reins" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20508" />
            <display value="Liver">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Foie" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20509" />
            <display value="Pancreas">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Pancréas" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20510" />
            <display value="Renal artery">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Artère rénale" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20511" />
            <display value="Urography">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Urographie" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Other specific area of interest" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
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          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_MRI_abdomen_specificarea_other" />
        <text value="Specify Other">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préciser (autre)" />
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          </extension>
        </text>
        <type value="string" />
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          <question value="medicalImaging_examRequest_MRI_abdomen_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
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              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <enableBehavior value="all" />
        <required value="true" />
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    </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>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
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        <extension url="sameLine">
          <valueBoolean value="false" />
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        <extension url="quoteAnswer">
          <valueBoolean value="false" />
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      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
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      <linkId value="medicalImaging_examRequest_MRI_pelvis" />
      <text value="Pelvis">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Pelvis" />
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        </extension>
      </text>
      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20472" />
          <display value="Pelvis">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Pelvis" />
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            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_MRI_pelvis_group" />
      <prefix value="Pelvis">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Pelvis" />
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        </extension>
      </prefix>
      <type value="group" />
      <enableWhen>
        <question value="medicalImaging_examRequest_MRI_pelvis" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </enableWhen>
      <enableBehavior value="all" />
      <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://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="text">
            <valueString value="Specific area of interest" />
          </extension>
          <extension url="listSeparator">
            <valueString value="," />
          </extension>
          <extension url="lastSeparator">
            <valueString value="and" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
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          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_MRI_pelvis_specificarea" />
        <text value="Specific area of interest (optional)">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Région d'intérêt précise (facultatif)" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20512" />
            <display value="Bladder">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Vessie" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20513" />
            <display value="Gynecology (Uterus/ Ovaries/ Adnexal)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Gynécologie (utérus / ovaires / annexes)" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20514" />
            <display value="Iliac arteries">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Artères iliaques" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20515" />
            <display value="Piriformis">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Piriforme" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20516" />
            <display value="Prostate">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Prostate" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20517" />
            <display value="Rectum/ Anal">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Rectum / anus" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20518" />
            <display value="Urogenital (Testicular/ Penile)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Urogénital (testiculaire / pénien)" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Other specific area of interest" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_MRI_pelvis_specificarea_other" />
        <text value="Specify Other">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préciser (autre)" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_MRI_pelvis_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </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>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_MRI_musculoskeletal" />
      <text value="Musculoskeletal">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Musculosquelettique" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20473" />
          <display value="Musculoskeletal">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Musculosquelettique" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_group" />
      <prefix value="Musculoskeletal">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Musculosquelettique" />
          </extension>
        </extension>
      </prefix>
      <type value="group" />
      <enableWhen>
        <question value="medicalImaging_examRequest_MRI_musculoskeletal" />
        <operator value="exists" />
        <answerBoolean value="true" />
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      <enableBehavior value="all" />
      <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://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="text">
            <valueString value="Specific area of interest" />
          </extension>
          <extension url="listSeparator">
            <valueString value="," />
          </extension>
          <extension url="lastSeparator">
            <valueString value="and" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea" />
        <text value="Specific area of interest">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Région d'intérêt précise" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <required value="true" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20519" />
            <display value="Shoulder">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Épaule" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20520" />
            <display value="Humerus">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Humérus" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20521" />
            <display value="Elbow">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Coude" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20522" />
            <display value="Forearm">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Avant-bras" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20523" />
            <display value="Wrist">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Poignet" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20524" />
            <display value="Hand">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Main" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20525" />
            <display value="Finger">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Doigt" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20526" />
            <display value="Bony Pelvis">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Bassin osseux" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20527" />
            <display value="Hip">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Hanche" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20528" />
            <display value="Femur / Thigh">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Fémur / cuisse" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20529" />
            <display value="Knee">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Genou" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20530" />
            <display value="Tibia and Fibula">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Tibia et fibula" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20531" />
            <display value="Ankle">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Cheville" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20532" />
            <display value="Foot">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Pied" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20533" />
            <display value="Toe">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Orteil" />
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              </extension>
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          </valueCoding>
        </answerOption>
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      <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://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
              <code value="push-button" />
              <display value="Push Button" />
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        </extension>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="style">
            <valueString value="font-weight:bold;" />
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          <extension url="sameLine">
            <valueBoolean value="false" />
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          <extension url="quoteAnswer">
            <valueBoolean value="false" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
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        <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_shoulder" />
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          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
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            <extension url="content">
              <valueString value="Épaule :" />
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        <type value="choice" />
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          <operator value="=" />
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20519" />
            <display value="Shoulder">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Épaule" />
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              </extension>
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        <enableBehavior value="all" />
        <required value="true" />
        <repeats value="false" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21321" />
            <display value="Left">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Gauche" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21322" />
            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Droite" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21323" />
            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Bilatéral" />
                </extension>
              </extension>
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          </valueCoding>
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        <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://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
              <code value="push-button" />
              <display value="Push Button" />
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        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="style">
            <valueString value="font-weight:bold;" />
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          <extension url="sameLine">
            <valueBoolean value="false" />
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          <extension url="quoteAnswer">
            <valueBoolean value="false" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
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        <linkId value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea_humerus" />
        <text value="Humerus:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Humérus :" />
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          </extension>
        </text>
        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_MRI_musculoskeletal_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20520" />
            <display value="Humerus">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Humérus" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <enableBehavior value="all" />
        <required value="true" />
        <repeats value="false" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21321" />
            <display value="Left">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Gauche" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21322" />
            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Droite" />
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      <text value="Osteoarthritis - Quality Standards


  
    MRI is not routinely indicated. Avoid advanced imaging (MRI)
    in arthritic joints.
  



  
    People who have persistent, atraumatic, movement-related joint pain
    or aching, and/or morning stiffness lasting less than 30 minutes,
    are diagnosed with osteoarthritis based on clinical assessment.
    Radiological imaging is not required to make a diagnosis in people
    aged 40 years or older if their symptoms are typical of osteoarthritis.
  


Symptoms typical  of osteoarthritis: Persistent atraumatic movement-related joint pain, aching, stiffness, and/or swelling. Morning stiffness lasting less than 30 minutes may or may not be present. Symptoms may affect one or a few joints. 
Atypical features: A recent history of injury, joint locking, prolonged morning joint-related stiffness, rapid onset of symptoms, the presence of a hot swollen joint, fever, chills, sweats, or feeling generally unwell. Atypical features usually indicate the need for further investigations to identify possible additional or alternative diagnoses, including loose body, meniscal injury, gout, or other inflammatory arthritides, such as rheumatoid arthritis, septic arthritis, and malignancy (if bone or soft tissue pain are present).




  
    Source: Ontario Health. Quality Standards – Osteoarthritis:
    Care for Adults with Osteoarthritis of the Knee, Hip, Hands,
    or Shoulder; 2024.">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
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<p>
  <b>
    MRI is not routinely indicated. Avoid advanced imaging (MRI)
    in arthritic joints.
  </b>
</p>

<p>
  <b>
    People who have persistent, atraumatic, movement-related joint pain
    or aching, and/or morning stiffness lasting less than 30 minutes,
    are diagnosed with osteoarthritis based on clinical assessment.
    Radiological imaging is not required to make a diagnosis in people
    aged 40 years or older if their symptoms are typical of osteoarthritis.
  </b>
</p>

<p>Symptoms <b>typical </b> of osteoarthritis: Persistent atraumatic movement-related joint pain, aching, stiffness, and/or swelling. Morning stiffness lasting less than 30 minutes may or may not be present. Symptoms may affect one or a few joints. </p>
<p><b>Atypical </b>features: A recent history of injury, joint locking, prolonged morning joint-related stiffness, rapid onset of symptoms, the presence of a hot swollen joint, fever, chills, sweats, or feeling generally unwell. Atypical features usually indicate the need for further investigations to identify possible additional or alternative diagnoses, including loose body, meniscal injury, gout, or other inflammatory arthritides, such as rheumatoid arthritis, septic arthritis, and malignancy (if bone or soft tissue pain are present).
</p>


<p>
  <i><sub>
    Source: Ontario Health. Quality Standards – Osteoarthritis:
    Care for Adults with Osteoarthritis of the Knee, Hip, Hands,
    or Shoulder; 2024.
 </sub> </i>
</p>" />
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21321" />
            <display value="Left">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Gauche" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21322" />
            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Droite" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21323" />
            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Bilatéral" />
                </extension>
              </extension>
            </display>
          </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://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
              <code value="push-button" />
              <display value="Push Button" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <linkId value="medicalImaging_examRequest_MRI_angiographyl_specificarea_lower_specify" />
        <text value="Specify Lower Extremity Angiography">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préciser l'angiographie des membres inférieurs" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_MRI_angiographyarterial_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20546" />
            <display value="Lower Extremity Angiography">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Angiographie des membres inférieurs" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <required value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21321" />
            <display value="Left">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Gauche" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21322" />
            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Droite" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21323" />
            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Bilatéral" />
                </extension>
              </extension>
            </display>
          </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>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_MRI_breast" />
      <text value="Breast">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Sein" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20476" />
          <display value="Breast">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Sein" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_MRI_breast_group" />
      <prefix value="Breast">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Sein" />
          </extension>
        </extension>
      </prefix>
      <type value="group" />
      <enableWhen>
        <question value="medicalImaging_examRequest_MRI_breast" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </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://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="text">
            <valueString value="Specific area of interest" />
          </extension>
          <extension url="listSeparator">
            <valueString value="," />
          </extension>
          <extension url="lastSeparator">
            <valueString value="and" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_MRI_breast_specificarea" />
        <text value="Specific area of interest">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Région d'intérêt précise" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <required value="true" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20554" />
            <display value="Diagnostic">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Diagnostique" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20555" />
            <display value="Implant">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Implant" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Other specific area of interest" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_MRI_breast_specificarea_other" />
        <text value="Specify Other">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préciser (autre)" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_MRI_breast_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </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/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
        </extension>
        <linkId value="medicalImaging_examRequest_MRI_breast_specificarea_diagnostic" />
        <text value="Diagnostic">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Diagnostique" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_MRI_breast_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20554" />
            <display value="Diagnostic">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Diagnostique" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <required value="true" />
        <repeats value="false" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21321" />
            <display value="Left">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Gauche" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21322" />
            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Droite" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21323" />
            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Bilatéral" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </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/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
        </extension>
        <linkId value="medicalImaging_examRequest_MRI_breast_specificarea_breastimplant" />
        <text value="Breast Implant:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Implant mammaire :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_MRI_breast_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20555" />
            <display value="Implant">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Implant" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <required value="true" />
        <repeats value="false" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21321" />
            <display value="Left">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Gauche" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21322" />
            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Droite" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21323" />
            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Bilatéral" />
                </extension>
              </extension>
            </display>
          </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>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_MRI_cardiac" />
      <text value="Cardiac">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Cardiaque" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20477" />
          <display value="Cardiac">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Cardiaque" />
              </extension>
            </extension>
          </display>
        </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>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="true" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <linkId value="medicalImaging_examRequest_MRI_other" />
      <text value="Other">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Autre" />
          </extension>
        </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">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Autre" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="font-weight:bold;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="true" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_MRI_other_specify" />
      <text value="Specify">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Préciser" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <enableWhen>
        <question value="medicalImaging_examRequest_MRI_other" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </enableWhen>
      <enableBehavior value="all" />
      <required value="true" />
    </item>
  </item>
  <item>
    <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info">
      <extension url="style">
        <valueString value="font-weight:bold;" />
      </extension>
      <extension url="groupItems">
        <valueBoolean value="false" />
      </extension>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
      <valueString value="border-style:solid;" />
    </extension>
    <linkId value="medicalImaging_MRI_clinicalindication_MRIrefnote" />
    <text value="MRI Request: Clinical History / Indication">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="font-weight:bold;" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Demande d'IRM : antécédents cliniques / indication" />
        </extension>
      </extension>
    </text>
    <type value="group" />
    <enableWhen>
      <question value="medicalImaging_examRequest" />
      <operator value="=" />
      <answerCoding>
        <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
        <code value="20391" />
        <display value="MRI Requisition">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Demande d'IRM" />
            </extension>
          </extension>
        </display>
      </answerCoding>
    </enableWhen>
    <enableBehavior value="all" />
    <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="<br/>" />
            </extension>
          </valueString>
        </extension>
      </extension>
      <linkId value="medicalImaging_MRI_clinicalindication_text" />
      <text value="Reason for exam (please also include presenting symptom(s), relevant underlying diagnosis and therapies, where applicable)">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Motif de l'examen (veuillez aussi indiquer le ou les symptômes présents, le diagnostic sous-jacent pertinent et les traitements, le cas échéant)" />
          </extension>
        </extension>
      </text>
      <type value="text" />
      <required value="true" />
    </item>
  </item>
  <item>
    <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info">
      <extension url="text">
        <valueString value="X-Ray Exam/Region(s) of Interest:" />
      </extension>
      <extension url="style">
        <valueString value="font-weight:bold;text-decoration:underline;" />
      </extension>
      <extension url="groupItems">
        <valueBoolean value="false" />
      </extension>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
      <valueString value="border-style:solid;" />
    </extension>
    <linkId value="medicalImaging_examRequest_XRAY_group_XRAYrefnote" />
    <text value="Select X-Ray Exam/Region(s) of Interest:">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="font-weight:bold;" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Sélectionner l'examen/la ou les régions de radiographie d'intérêt :" />
        </extension>
      </extension>
    </text>
    <type value="group" />
    <enableWhen>
      <question value="medicalImaging_examRequest" />
      <operator value="=" />
      <answerCoding>
        <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
        <code value="20392" />
        <display value="X-Ray Requisition">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Demande de radiographie" />
            </extension>
          </extension>
        </display>
      </answerCoding>
    </enableWhen>
    <enableBehavior value="all" />
    <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>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_XRAY_chest" />
      <text value="Chest (default Chest 2 views)">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Thorax (par défaut : thorax, 2 incidences)" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20556" />
          <display value="Chest (default Chest 2 views)">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Thorax (par défaut : thorax, 2 incidences)" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_XRAY_chest_group" />
      <prefix value="Chest exams:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Examens du thorax :" />
          </extension>
        </extension>
      </prefix>
      <type value="group" />
      <enableWhen>
        <question value="medicalImaging_examRequest_XRAY_chest" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </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://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="text">
            <valueString value="Specific area of interest" />
          </extension>
          <extension url="listSeparator">
            <valueString value="," />
          </extension>
          <extension url="lastSeparator">
            <valueString value="and" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_XRAY_chest_specificarea" />
        <text value="Chest exams:">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Examens du thorax :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20566" />
            <display value="One view (PA)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Une incidence (PA)" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20567" />
            <display value="Two Views (PA, Lat)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Deux incidences (PA, latérale)" />
                </extension>
              </extension>
            </display>
          </valueCoding>
          <initialSelected value="true" />
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20568" />
            <display value="Three views (PA inspiration, PA expiration, Lat)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Trois incidences (PA en inspiration, PA en expiration, latérale)" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20569" />
            <display value="Sternum">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Sternum" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20570" />
            <display value="Ribs">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Côtes" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20571" />
            <display value="Thoracic inlet">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Orifice supérieur du thorax" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20572" />
            <display value="Sternoclavicular Joints">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Articulations sternoclaviculaires" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Other specific area of interest" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_XRAY_chest_specificarea_other" />
        <text value="Specify Other">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préciser (autre)" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_XRAY_chest_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <required value="true" />
      </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://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="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
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          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </extension>
        <linkId value="medicalImaging_examRequest_XRAY_chest_ribs" />
        <text value="Ribs:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Côtes :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_XRAY_chest_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20570" />
            <display value="Ribs">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Côtes" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <enableBehavior value="all" />
        <required value="true" />
        <repeats value="false" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21321" />
            <display value="Left">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Gauche" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21322" />
            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Droite" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21323" />
            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Bilatéral" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
    </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" />
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      </extension>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
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        <extension url="sameLine">
          <valueBoolean value="false" />
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        <extension url="quoteAnswer">
          <valueBoolean value="false" />
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      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_XRAY_abdomen" />
      <text value="Abdomen">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Abdomen" />
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        </extension>
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      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20557" />
          <display value="Abdomen">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Abdomen" />
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            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_XRAY_abdomen_group" />
      <prefix value="Abdomen exams:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Examens de l'abdomen :" />
          </extension>
        </extension>
      </prefix>
      <type value="group" />
      <enableWhen>
        <question value="medicalImaging_examRequest_XRAY_abdomen" />
        <operator value="exists" />
        <answerBoolean value="true" />
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      <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://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="text">
            <valueString value="Specific area of interest" />
          </extension>
          <extension url="listSeparator">
            <valueString value="," />
          </extension>
          <extension url="lastSeparator">
            <valueString value="and" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_XRAY_abdomen_specifcarea" />
        <text value="Abdomen exams:">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Examens de l'abdomen :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20573" />
            <display value="One view (Supine)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Une incidence (décubitus dorsal)" />
                </extension>
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    People with acute low back pain do not receive diagnostic imaging
    tests unless they present with red flags that suggest serious
    pathological disease.
  


Red flag signs or symptoms include:


  
    Neurological disorders: diffuse or substantial motor/sensory loss,
    progressive neurological deficits, cauda equina syndrome. Infection:
    fever, history of IV drug use, immunosuppression
  
  
    Fracture: trauma, osteoporosis risk/fragility fracture
  
  
    Tumour: history of cancer, unexplained weight loss, significant
    unexpected night pain, severe fatigue
  
  
    Inflammation: chronic low back pain for more than 3 months,
    age of onset less than 45 years, morning stiffness for more than
    30 minutes, improvement with exercise, disproportionate night pain
  



  
    Source: Health Quality Ontario. Quality Standards – Low Back Pain:
    Care for Adults with Acute Low Back Pain; 2019.">
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<p>
  <b>
    People with acute low back pain do not receive diagnostic imaging
    tests unless they present with red flags that suggest serious
    pathological disease.
  </b>
</p>

<p><b>Red flag signs or symptoms include:</b></p>

<span style="text-decoration: underline;">
  <li>
    Neurological disorders: diffuse or substantial motor/sensory loss,
    progressive neurological deficits, cauda equina syndrome. Infection:
    fever, history of IV drug use, immunosuppression
  </li>
  <li>
    Fracture: trauma, osteoporosis risk/fragility fracture
  </li>
  <li>
    Tumour: history of cancer, unexplained weight loss, significant
    unexpected night pain, severe fatigue
  </li>
  <li>
    Inflammation: chronic low back pain for more than 3 months,
    age of onset less than 45 years, morning stiffness for more than
    30 minutes, improvement with exercise, disproportionate night pain
  </li>
</span>

<p>
  <i>
    Source: Health Quality Ontario. Quality Standards – Low Back Pain:
    Care for Adults with Acute Low Back Pain; 2019.
  </i>
</p>" />
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            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_XRAY_head_specifcarea" />
        <text value="Head and Neck exams:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Examens de la tête et du cou :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20585" />
            <display value="Skull">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Crâne" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20586" />
            <display value="Orbits">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Orbites" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20587" />
            <display value="Neck for soft tissue">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Cou – tissus mous" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20588" />
            <display value="Mastoids">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Mastoïdes" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20589" />
            <display value="Nasal bones">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Os nasaux" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20590" />
            <display value="Facal bones">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Os de la face" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20591" />
            <display value="Mandible">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Mandibule" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20592" />
            <display value="Temporomandibular joints">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Articulations temporomandibulaires" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20593" />
            <display value="Sinus">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Sinus" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Other specific area of interest" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_XRAY_head_specifcarea_other" />
        <text value="Specify Other">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préciser (autre)" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_XRAY_head_specifcarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <required 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://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="listSeparator">
            <valueString value="," />
          </extension>
          <extension url="lastSeparator">
            <valueString value="and" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </extension>
        <linkId value="medicalImaging_examRequest_XRAY_head_specifcarea_orbit" />
        <text value="Orbits exams:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Examens des orbites :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_XRAY_head_specifcarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20586" />
            <display value="Orbits">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Orbites" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <enableBehavior value="all" />
        <required value="true" />
        <repeats value="false" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20594" />
            <display value="Trauma or injury">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Traumatisme ou blessure" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20595" />
            <display value="Eye for foreign body">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Œil – recherche de corps étranger" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </extension>
        <linkId value="Sinus_Exams_Display" />
        <text value="Sinus x-rays are not covered by OHIP and are not recommended in adults with sinus disease.">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<p>Sinus x-rays are <b>not covered by OHIP </b>and are <b>not recommended</b> in adults with sinus disease.</p>" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="font-weight:bold;color:#AA0000;" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Les radiographies des sinus ne sont pas couvertes par l'OHIP et ne sont pas recommandées chez les adultes atteints d'une affection sinusienne." />
            </extension>
          </extension>
        </text>
        <type value="display" />
        <enableWhen>
          <question value="medicalImaging_examRequest_XRAY_head_specifcarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20593" />
            <display value="Sinus">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Sinus" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <enableBehavior value="all" />
      </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="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_XRAY_upperextremities" />
      <text value="Upper Extremities">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Membres supérieurs" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20560" />
          <display value="Upper Extremities">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Membres supérieurs" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_XRAY_upperextremities_group" />
      <prefix value="Upper Extremities exams:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Examens des membres supérieurs :" />
          </extension>
        </extension>
      </prefix>
      <type value="group" />
      <enableWhen>
        <question value="medicalImaging_examRequest_XRAY_upperextremities" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </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://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="text">
            <valueString value="Specific area of interest" />
          </extension>
          <extension url="listSeparator">
            <valueString value="," />
          </extension>
          <extension url="lastSeparator">
            <valueString value="and" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_XRAY_upperextremities_specifcarea" />
        <text value="Upper Extremities exams:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Examens des membres supérieurs :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20596" />
            <display value="Shoulder">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Épaule" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20597" />
            <display value="Clavicle">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Clavicule" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20598" />
            <display value="Acromioclavicular joints">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Articulations acromioclaviculaires" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20572" />
            <display value="Sternoclavicular Joints">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Articulations sternoclaviculaires" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20599" />
            <display value="Scapula">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Scapula" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20600" />
            <display value="Humerus">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Humérus" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20601" />
            <display value="Elbow">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Coude" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20602" />
            <display value="Forearm">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Avant-bras" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20603" />
            <display value="Wrist">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Poignet" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20604" />
            <display value="Scaphoid">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Scaphoïde" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20605" />
            <display value="Hand">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Main" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20606" />
            <display value="Finger">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Doigt" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Other specific area of interest" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
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        </extension>
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      <text value="Osteoarthritis - Quality Standards

X-ray is not routinely indicated


  People who have persistent, atraumatic, movement-related joint pain
  or aching, and/or morning stiffness lasting less than 30 minutes,
  are diagnosed with osteoarthritis based on clinical assessment.
  Radiological imaging is not required to make a diagnosis in people
  aged 40 years or older if their symptoms are typical of osteoarthritis.



  For X-Ray Hip or Shoulder:
  Plain radiographs (non-weight bearing for hip and AP view for shoulder)
  are required within the 6-month period prior to the patient’s first
  appointment with a surgeon.


Symptoms typical of osteoarthritis:


  
    Persistent atraumatic movement-related joint pain, aching,
    stiffness, and/or swelling
  
  
    Morning stiffness lasting less than 30 minutes may or may not be present
  
  
    Symptoms may affect one or a few joints
  


Atypical features:


  Recent history of injury
  Joint locking
  Prolonged morning joint-related stiffness
  Rapid onset of symptoms
  Presence of a hot swollen joint
  Fever, chills, sweats, or feeling generally unwell



  Atypical features usually indicate the need for further investigation
  to identify possible additional or alternative diagnoses, including
  loose body, meniscal injury, gout, or other inflammatory arthritides
  such as rheumatoid arthritis, septic arthritis, and malignancy
  (if bone or soft tissue pain are present).



  
    Source: Ontario Health. Quality Standards – Osteoarthritis:
    Care for Adults with Osteoarthritis of the Knee, Hip, Hands,
    or Shoulder; 2024.">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
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<p><b>X-ray is not routinely indicated</b></p>

<p>
  People who have persistent, atraumatic, movement-related joint pain
  or aching, and/or morning stiffness lasting less than 30 minutes,
  are diagnosed with osteoarthritis based on clinical assessment.
  Radiological imaging is not required to make a diagnosis in people
  aged 40 years or older if their symptoms are typical of osteoarthritis.
</p>

<p>
  <b>For X-Ray Hip or Shoulder:</b>
  Plain radiographs (non-weight bearing for hip and AP view for shoulder)
  are required within the 6-month period prior to the patient’s first
  appointment with a surgeon.
</p>

<p><b>Symptoms typical of osteoarthritis:</b></p>

<span style="text-decoration: underline;">
  <li>
    Persistent atraumatic movement-related joint pain, aching,
    stiffness, and/or swelling
  </li>
  <li>
    Morning stiffness lasting less than 30 minutes may or may not be present
  </li>
  <li>
    Symptoms may affect one or a few joints
  </li>
</span>

<p><b>Atypical features:</b></p>

<span style="text-decoration: underline;">
  <li>Recent history of injury</li>
  <li>Joint locking</li>
  <li>Prolonged morning joint-related stiffness</li>
  <li>Rapid onset of symptoms</li>
  <li>Presence of a hot swollen joint</li>
  <li>Fever, chills, sweats, or feeling generally unwell</li>
</span>

<p>
  Atypical features usually indicate the need for further investigation
  to identify possible additional or alternative diagnoses, including
  loose body, meniscal injury, gout, or other inflammatory arthritides
  such as rheumatoid arthritis, septic arthritis, and malignancy
  (if bone or soft tissue pain are present).
</p>

<p>
  <i>
    Source: Ontario Health. Quality Standards – Osteoarthritis:
    Care for Adults with Osteoarthritis of the Knee, Hip, Hands,
    or Shoulder; 2024.
  </i>
</p>" />
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      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
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          <extension url="lang">
            <valueCode value="fr" />
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            <valueString value="Examens des membres inférieurs :" />
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              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
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            <valueString value="and" />
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            <extension url="lang">
              <valueCode value="fr" />
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            <extension url="content">
              <valueString value="Examens des membres inférieurs :" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
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                <extension url="lang">
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                <extension url="lang">
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                <extension url="lang">
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                <extension url="lang">
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                <extension url="lang">
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                  <valueString value="Cheville" />
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                <extension url="lang">
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                  <valueString value="Pied" />
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                <extension url="lang">
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                  <valueString value="Calcanéus" />
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                <extension url="lang">
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                  <valueString value="Orteil" />
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                <extension url="lang">
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                <extension url="lang">
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                <extension url="lang">
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                <extension url="lang">
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      <text value="Osteoarthritis - Quality Standards

X-ray is not routinely indicated


  People who have persistent, atraumatic, movement-related joint pain
  or aching, and/or morning stiffness lasting less than 30 minutes,
  are diagnosed with osteoarthritis based on clinical assessment.
  Radiological imaging is not required to make a diagnosis in people
  aged 40 years or older if their symptoms are typical of osteoarthritis.


For X-Ray Knee:

  Weight-bearing images are required within the 6-month period prior to
  the patient’s first appointment with a surgeon.


For X-Ray Hip or Shoulder:

  Plain radiographs (non-weight bearing for hip, and AP view for shoulder)
  are required within the 6-month period prior to the patient’s first
  appointment with a surgeon.


Symptoms typical of osteoarthritis:

  Persistent atraumatic movement-related joint pain, aching, stiffness,
  and/or swelling. Morning stiffness lasting less than 30 minutes may or
  may not be present. Symptoms may affect one or a few joints.


Atypical features:

  Recent history of injury, joint locking, prolonged morning joint-related
  stiffness, rapid onset of symptoms, presence of a hot swollen joint,
  fever, chills, sweats, or feeling generally unwell.



  Atypical features usually indicate the need for further investigation
  to identify possible additional or alternative diagnoses, including
  loose body, meniscal injury, gout, or other inflammatory arthritis
  such as rheumatoid arthritis, septic arthritis, and malignancy
  (if bone or soft tissue pain are present).



  
    Source: Ontario Health. Quality Standards – Osteoarthritis:
    Care for Adults with Osteoarthritis of the Knee, Hip, Hands,
    or Shoulder; 2024.">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
          <valueString value="<p><b>Osteoarthritis - Quality Standards</b></p>

<p><b>X-ray is not routinely indicated</b></p>

<p>
  People who have persistent, atraumatic, movement-related joint pain
  or aching, and/or morning stiffness lasting less than 30 minutes,
  are diagnosed with osteoarthritis based on clinical assessment.
  Radiological imaging is not required to make a diagnosis in people
  aged 40 years or older if their symptoms are typical of osteoarthritis.
</p>

<p><b>For X-Ray Knee:</b></p>
<p>
  Weight-bearing images are required within the 6-month period prior to
  the patient’s first appointment with a surgeon.
</p>

<p><b>For X-Ray Hip or Shoulder:</b></p>
<p>
  Plain radiographs (non-weight bearing for hip, and AP view for shoulder)
  are required within the 6-month period prior to the patient’s first
  appointment with a surgeon.
</p>

<p><b>Symptoms typical of osteoarthritis:</b></p>
<p>
  Persistent atraumatic movement-related joint pain, aching, stiffness,
  and/or swelling. Morning stiffness lasting less than 30 minutes may or
  may not be present. Symptoms may affect one or a few joints.
</p>

<p><b>Atypical features:</b></p>
<p>
  Recent history of injury, joint locking, prolonged morning joint-related
  stiffness, rapid onset of symptoms, presence of a hot swollen joint,
  fever, chills, sweats, or feeling generally unwell.
</p>

<p>
  Atypical features usually indicate the need for further investigation
  to identify possible additional or alternative diagnoses, including
  loose body, meniscal injury, gout, or other inflammatory arthritis
  such as rheumatoid arthritis, septic arthritis, and malignancy
  (if bone or soft tissue pain are present).
</p>

<p>
  <i>
    Source: Ontario Health. Quality Standards – Osteoarthritis:
    Care for Adults with Osteoarthritis of the Knee, Hip, Hands,
    or Shoulder; 2024.
  </i>
</p>" />
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        <question value="medicalImaging_XRAY_lower_CDS_Osteoarthritis_enabled" />
        <operator value="=" />
        <answerBoolean value="true" />
      </enableWhen>
      <enableBehavior value="any" />
    </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="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_XRAY_mammogram" />
      <text value="Mammogram (Non-OBSP)">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Mammographie (non-OBSP)" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20562" />
          <display value="Mammogram (Non-OBSP)">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Mammographie (non-OBSP)" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <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="listSeparator">
            <valueString value="," />
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          <extension url="lastSeparator">
            <valueString value="and" />
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          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
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          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </extension>
        <linkId value="medicalImaging_examRequest_XRAY_mammogram_specifcarea" />
        <text value="Mammogram:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Mammographie :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_XRAY_mammogram" />
          <operator value="exists" />
          <answerBoolean value="true" />
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        <enableBehavior value="all" />
        <required value="true" />
        <repeats value="false" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21321" />
            <display value="Left">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Gauche" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21322" />
            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Droite" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21323" />
            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Bilatéral" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
    </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>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
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        <extension url="sameLine">
          <valueBoolean value="false" />
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        <extension url="quoteAnswer">
          <valueBoolean value="false" />
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      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
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      <linkId value="medicalImaging_examRequest_XRAY_boneage" />
      <text value="Bone Age">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Âge osseux" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20563" />
          <display value="Bone Age">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Âge osseux" />
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            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
        <valueCode value="horizontal" />
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        <valueCodeableConcept>
          <coding>
            <system value="http://hl7.org/fhir/questionnaire-item-control" />
            <code value="check-box" />
            <display value="Check-box" />
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        </valueCodeableConcept>
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      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
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        <extension url="sameLine">
          <valueBoolean value="false" />
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        <extension url="quoteAnswer">
          <valueBoolean value="false" />
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      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
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      <linkId value="medicalImaging_examRequest_XRAY_survey" />
      <text value="Survey">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
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          <extension url="content">
            <valueString value="Sondage" />
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        </extension>
      </text>
      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20564" />
          <display value="Survey">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Sondage" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
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      <linkId value="medicalImaging_examRequest_XRAY_survey_group" />
      <prefix value="Survey">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Sondage" />
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        </extension>
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      <type value="group" />
      <enableWhen>
        <question value="medicalImaging_examRequest_XRAY_survey" />
        <operator value="exists" />
        <answerBoolean value="true" />
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      <enableBehavior value="all" />
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
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          <valueCodeableConcept>
            <coding>
              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
              <code value="push-button" />
              <display value="Push Button" />
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        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Specific area of interest" />
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          <extension url="listSeparator">
            <valueString value="," />
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          <extension url="lastSeparator">
            <valueString value="and" />
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          <extension url="style">
            <valueString value="font-weight:bold;" />
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          <extension url="sameLine">
            <valueBoolean value="true" />
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          <extension url="quoteAnswer">
            <valueBoolean value="false" />
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        <linkId value="medicalImaging_examRequest_XRAY_survey_specificarea" />
        <text value="Survey">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
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            <extension url="content">
              <valueString value="Sondage" />
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        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20618" />
            <display value="Metabolic">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Métabolique" />
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              </extension>
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          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20619" />
            <display value="Metastatic">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Métastatique" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20620" />
            <display value="Rheumatoid">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Rhumatoïde" />
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20621" />
            <display value="Babygram">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Babygramme" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20617" />
            <display value="Leg length">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Longueur des jambes" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
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      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Other specific area of interest" />
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          <extension url="style">
            <valueString value="font-weight:bold;" />
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          <extension url="sameLine">
            <valueBoolean value="false" />
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          <extension url="quoteAnswer">
            <valueBoolean value="false" />
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        <linkId value="medicalImaging_examRequest_XRAY_survey_specificarea_other" />
        <text value="Specify Other">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
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          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
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            <extension url="content">
              <valueString value="Préciser (autre)" />
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        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_XRAY_survey_specificarea" />
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            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
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            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Autre" />
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        <required value="true" />
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        <valueCode value="horizontal" />
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        <valueCodeableConcept>
          <coding>
            <system value="http://hl7.org/fhir/questionnaire-item-control" />
            <code value="check-box" />
            <display value="Check-box" />
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      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
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        <extension url="sameLine">
          <valueBoolean value="false" />
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        <extension url="quoteAnswer">
          <valueBoolean value="false" />
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        <valueString value="border-style:solid;" />
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      <linkId value="medicalImaging_examRequest_XRAY_gastric" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
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      <repeats value="true" />
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          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20565" />
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            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Imagerie gastrique et fluoroscopique" />
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      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
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          <extension url="lang">
            <valueCode value="fr" />
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          <extension url="content">
            <valueString value="Examens d'imagerie gastrique et fluoroscopique :" />
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        <answerBoolean value="true" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
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          <valueCodeableConcept>
            <coding>
              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
              <code value="push-button" />
              <display value="Push Button" />
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        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Specific area of interest" />
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          <extension url="listSeparator">
            <valueString value="," />
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          <extension url="lastSeparator">
            <valueString value="and" />
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          <extension url="style">
            <valueString value="font-weight:bold;" />
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          <extension url="sameLine">
            <valueBoolean value="true" />
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          <extension url="quoteAnswer">
            <valueBoolean value="false" />
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        <linkId value="medicalImaging_examRequest_XRAY_gastric_specifcarea" />
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          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Examens d'imagerie gastrique et fluoroscopique :" />
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        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20622" />
            <display value="Gastrointestinal tract">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Tractus gastro-intestinal" />
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              </extension>
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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            <display value="Retrograde urethrogram">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Urétrographie rétrograde" />
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        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20624" />
            <display value="Cystourethrogram">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Cysto-urétrographie" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20625" />
            <display value="Hysterosalpingogram">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Hystérosalpingographie" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20626" />
            <display value="Sinogram">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Sinographie" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20627" />
            <display value="Musculoskeletal injections">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Injections musculosquelettiques" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Other specific area of interest" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_XRAY_gastric_specifcarea_other" />
        <text value="Specify Other">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préciser (autre)" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_XRAY_gastric_specifcarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <required 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://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="border-style:solid;" />
        </extension>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="listSeparator">
            <valueString value="," />
          </extension>
          <extension url="lastSeparator">
            <valueString value="and" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_XRAY_gastric_specifcarea_gastro" />
        <text value="Gastrointestinal tract exams:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Examens du tractus gastro-intestinal :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_XRAY_gastric_specifcarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20622" />
            <display value="Gastrointestinal tract">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Tractus gastro-intestinal" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20629" />
            <display value="Barium swallow">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Gorgée barytée" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20628" />
            <display value="Modified barium swallow (Video fluoroscope swallowing exam)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Gorgée barytée modifiée (examen vidéofluoroscopique de la déglutition)" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20630" />
            <display value="Upper GI series (Esophagus, stomach and duodenum)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Examen du tractus gastro-intestinal supérieur (œsophage, estomac et duodénum)" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20631" />
            <display value="Small bowel follow through">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Transit du grêle" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20632" />
            <display value="Barium enema">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Lavement baryté" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Other specific area of interest" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_XRAY_gastric_specifcarea_gastro_other" />
        <text value="Specify Other">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préciser (autre)" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_XRAY_gastric_specifcarea_gastro" />
          <operator value="=" />
          <answerCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <required 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://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="border-style:solid;" />
        </extension>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="listSeparator">
            <valueString value="," />
          </extension>
          <extension url="lastSeparator">
            <valueString value="and" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_XRAY_gastric_specifcarea_cysto" />
        <text value="Cystourethrogram:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Cysto-urétrographie :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_XRAY_gastric_specifcarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20624" />
            <display value="Cystourethrogram">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Cysto-urétrographie" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <repeats value="false" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20633" />
            <display value="Stress">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="À l'effort" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20634" />
            <display value="Voiding">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Mictionnel" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </extension>
        <linkId value="medicalImaging_examRequest_XRAY_gastric_specifcarea_sinogram" />
        <text value="Sinogram: specify">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Sinographie : préciser" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_XRAY_gastric_specifcarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20626" />
            <display value="Sinogram">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Sinographie" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <required value="true" />
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </extension>
        <linkId value="medicalImaging_examRequest_XRAY_gastric_specifcarea_musculoskeletal" />
        <text value="Musculoskeletal injection: specify">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Injection musculosquelettique : préciser" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_XRAY_gastric_specifcarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20627" />
            <display value="Musculoskeletal injections">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Injections musculosquelettiques" />
                </extension>
              </extension>
            </display>
          </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://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_XRAY_other" />
      <text value="Other">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Autre" />
          </extension>
        </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">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Autre" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </extension>
        <linkId value="medicalImaging_examRequest_XRAY_other_specify" />
        <text value="Other:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Autre :" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_XRAY_other" />
          <operator value="exists" />
          <answerBoolean value="true" />
        </enableWhen>
        <enableBehavior value="all" />
        <required value="true" />
      </item>
    </item>
  </item>
  <item>
    <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info">
      <extension url="style">
        <valueString value="font-weight:bold;" />
      </extension>
      <extension url="groupItems">
        <valueBoolean value="false" />
      </extension>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
      <valueString value="border-style:solid;" />
    </extension>
    <linkId value="medicalImaging_XRAY_clinicalindication_XRAYrefnote" />
    <text value="X-Ray Request: Clinical History / Indication">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="font-weight:bold;" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Demande de radiographie : antécédents cliniques / indication" />
        </extension>
      </extension>
    </text>
    <type value="group" />
    <enableWhen>
      <question value="medicalImaging_examRequest" />
      <operator value="=" />
      <answerCoding>
        <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
        <code value="20392" />
        <display value="X-Ray Requisition">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Demande de radiographie" />
            </extension>
          </extension>
        </display>
      </answerCoding>
    </enableWhen>
    <enableBehavior value="all" />
    <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="<br/>" />
            </extension>
          </valueString>
        </extension>
      </extension>
      <linkId value="medicalImaging_XRAY_clinicalindication_text" />
      <text value="Reason for exam (please also include presenting symptom(s), relevant underlying diagnosis and therapies, where applicable)">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Motif de l'examen (veuillez aussi indiquer le ou les symptômes présents, le diagnostic sous-jacent pertinent et les traitements, le cas échéant)" />
          </extension>
        </extension>
      </text>
      <type value="text" />
      <required value="true" />
    </item>
    <item>
      <linkId value="medicalImaging_XRAY_clinicalindication_views" />
      <text value="Additional relevant information (e.g. request specific views)">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Renseignements pertinents supplémentaires (p. ex. demander des incidences précises)" />
          </extension>
        </extension>
      </text>
      <type value="string" />
    </item>
  </item>
  <item>
    <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info">
      <extension url="text">
        <valueString value="Ultrasound Exam/Region(s) of Interest:" />
      </extension>
      <extension url="style">
        <valueString value="font-weight:bold;text-decoration:underline;" />
      </extension>
      <extension url="groupItems">
        <valueBoolean value="false" />
      </extension>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
      <valueString value="border-style:solid;" />
    </extension>
    <linkId value="medicalImaging_examRequest_US_group_USrefnote" />
    <text value="Select Ultrasound Exam/Region(s) of Interest:">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="font-weight:bold;" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Sélectionner l'examen/la ou les régions d'échographie d'intérêt :" />
        </extension>
      </extension>
    </text>
    <type value="group" />
    <enableWhen>
      <question value="medicalImaging_examRequest" />
      <operator value="=" />
      <answerCoding>
        <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
        <code value="20393" />
        <display value="Ultrasound Requisition">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Demande d'échographie" />
            </extension>
          </extension>
        </display>
      </answerCoding>
    </enableWhen>
    <enableBehavior value="all" />
    <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>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_US_abdomen" />
      <text value="Abdomen">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Abdomen" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20635" />
          <display value="Abdomen">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Abdomen" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_US_abdomen_group" />
      <prefix value="Abdomen:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Abdomen :" />
          </extension>
        </extension>
      </prefix>
      <type value="group" />
      <enableWhen>
        <question value="medicalImaging_examRequest_US_abdomen" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </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://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="text">
            <valueString value="Specific area of interest" />
          </extension>
          <extension url="listSeparator">
            <valueString value="," />
          </extension>
          <extension url="lastSeparator">
            <valueString value="and" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_US_abdomen_specificarea" />
        <text value="Abdomen:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Abdomen :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20643" />
            <display value="Complete abdomen">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Abdomen complet" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20644" />
            <display value="Appendix">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Appendice" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20645" />
            <display value="Gallbladder">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Vésicule biliaire" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20646" />
            <display value="Kidney Ureters Bladder">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Reins, uretères et vessie" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20647" />
            <display value="Liver">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Foie" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20648" />
            <display value="Liver elastography">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Élastographie hépatique" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20649" />
            <display value="Pancreas">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Pancréas" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20650" />
            <display value="Portal hypertension">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Hypertension portale" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20651" />
            <display value="Renal">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Rénal" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20652" />
            <display value="Right upper quadrant">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Quadrant supérieur droit" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20653" />
            <display value="Spleen">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Rate" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20654" />
            <display value="Abdomen contrast">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Abdomen avec contraste" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20655" />
            <display value="Abdominal wall">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Paroi abdominale" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Other specific area of interest" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_US_abdomen_specificarea_other" />
        <text value="Specify:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préciser :" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_abdomen_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </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>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_US_pelvis" />
      <text value="Pelvis">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Pelvis" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20636" />
          <display value="Pelvis">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Pelvis" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_US_pelvis_group" />
      <prefix value="Pelvis:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Pelvis :" />
          </extension>
        </extension>
      </prefix>
      <type value="group" />
      <enableWhen>
        <question value="medicalImaging_examRequest_US_pelvis" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </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://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="text">
            <valueString value="Specific area of interest" />
          </extension>
          <extension url="listSeparator">
            <valueString value="," />
          </extension>
          <extension url="lastSeparator">
            <valueString value="and" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_US_pelvis_specificarea" />
        <text value="Pelvis:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Pelvis :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20656" />
            <display value="Complete pelvis">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Pelvis complet" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20657" />
            <display value="Pelvis transabdominal">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Pelvis (transabdominale)" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20658" />
            <display value="Female pelvis (transvaginal)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Pelvis féminin (transvaginale)" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20659" />
            <display value="Follicular monitoring">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Monitorage folliculaire" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20660" />
            <display value="Limited non-pregnancy (for IUD insertion placement check)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Examen limité (hors grossesse) (pour vérifier la mise en place d'un stérilet)" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20661" />
            <display value="Saline Infusion Sonohysterography">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Sonohystérographie avec perfusion de solution saline" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20662" />
            <display value="Male pelvis (Transrectal)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Pelvis masculin (transrectale)" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20663" />
            <display value="Prostate">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Prostate" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20664" />
            <display value="Penile">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Pénien" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20665" />
            <display value="Testicles/Scrotum">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Testicules / scrotum" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20666" />
            <display value="Bladder">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Vessie" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20667" />
            <display value="Groin">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Aine" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Other specific area of interest" />
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          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_US_pelvis_specificarea_other" />
        <text value="Specify:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préciser :" />
            </extension>
          </extension>
        </text>
        <type value="string" />
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          <question value="medicalImaging_examRequest_US_pelvis_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
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              </extension>
            </display>
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        </enableWhen>
        <enableBehavior value="all" />
        <required value="true" />
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      <item>
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          <extension url="style">
            <valueString value="font-weight:bold;" />
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          <extension url="sameLine">
            <valueBoolean value="false" />
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          <extension url="quoteAnswer">
            <valueBoolean value="false" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
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        <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" />
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        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
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        <linkId value="medicalImaging_examRequest_US_pelvis_specificarea_groin" />
        <text value="Groin:">
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            <extension url="lang">
              <valueCode value="fr" />
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            <extension url="content">
              <valueString value="Aine :" />
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          </extension>
        </text>
        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_pelvis_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20667" />
            <display value="Groin">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Aine" />
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        <enableBehavior value="all" />
        <required value="true" />
        <repeats value="false" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21321" />
            <display value="Left">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Gauche" />
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              </extension>
            </display>
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        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21322" />
            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Droite" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21323" />
            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Bilatéral" />
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        </answerOption>
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    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
        <valueCode value="horizontal" />
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        <valueCodeableConcept>
          <coding>
            <system value="http://hl7.org/fhir/questionnaire-item-control" />
            <code value="check-box" />
            <display value="Check-box" />
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      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
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        <extension url="sameLine">
          <valueBoolean value="false" />
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        <extension url="quoteAnswer">
          <valueBoolean value="false" />
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      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
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      <linkId value="medicalImaging_examRequest_US_obstetrical" />
      <text value="Obstetrical">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
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          <extension url="content">
            <valueString value="Obstétrical" />
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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="20637" />
          <display value="Obstetrical">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Obstétrical" />
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            </extension>
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        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
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          <extension url="content">
            <valueString value="Obstétrical :" />
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      <type value="group" />
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        <operator value="exists" />
        <answerBoolean value="true" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
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          <valueCodeableConcept>
            <coding>
              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
              <code value="push-button" />
              <display value="Push Button" />
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          <extension url="sameLine">
            <valueBoolean value="true" />
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            <valueBoolean value="false" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
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          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
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            <extension url="content">
              <valueString value="Type de grossesse :" />
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        <type value="choice" />
        <required value="true" />
        <repeats value="false" />
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20668" />
            <display value="Singleton">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Grossesse unique" />
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          <initialSelected value="true" />
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20669" />
            <display value="Twins">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Jumeaux" />
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              </extension>
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          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20670" />
            <display value="Triplets">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Triplés" />
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        <answerOption>
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20671" />
            <display value="Unknown">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Inconnu" />
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        <answerOption>
          <valueCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Autre" />
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        </answerOption>
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        <linkId value="medicalImaging_examRequest_US_obstetrical_pregnancytype_other" />
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            <extension url="lang">
              <valueCode value="fr" />
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            <extension url="content">
              <valueString value="Préciser :" />
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        <type value="string" />
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            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Autre" />
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        <enableBehavior value="all" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
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            <coding>
              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
              <code value="push-button" />
              <display value="Push Button" />
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        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Specific area of interest" />
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          <extension url="listSeparator">
            <valueString value="," />
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          <extension url="lastSeparator">
            <valueString value="and" />
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          <extension url="style">
            <valueString value="font-weight:bold;" />
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          <extension url="sameLine">
            <valueBoolean value="true" />
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          <extension url="quoteAnswer">
            <valueBoolean value="false" />
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        <linkId value="medicalImaging_examRequest_US_obstetrical_specificarea" />
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          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
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        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20672" />
            <display value="Dating (<16 weeks)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Datation (< 16 semaines)" />
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Dépistage prénatal (clarté nucale/eFTS) 11-14 semaines" />
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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            <display value="Anatomy (20 week scan)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Anatomie (échographie de 20 semaines)" />
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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            <display value="2nd or 3rd trimester scan">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Échographie du 2e ou 3e trimestre" />
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20676" />
            <display value="Biophysical profile">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Profil biophysique" />
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20677" />
            <display value="Growth">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Croissance" />
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              </extension>
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20678" />
            <display value="Cervical length">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Longueur du col utérin" />
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20679" />
            <display value="Multi-gestational study">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Étude de grossesse multiple" />
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20680" />
            <display value="High risk pregnancy">
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Grossesse à risque élevé" />
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20681" />
            <display value="Uterine artery doppler studies">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Études Doppler de l'artère utérine" />
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Études Doppler de l'artère ombilicale" />
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        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20683" />
            <display value="Fetal doppler">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Doppler fœtal" />
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              </extension>
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          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20745" />
            <display value="With transvaginal">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Avec transvaginale" />
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              </extension>
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        <answerOption>
          <valueCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
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              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Other specific area of interest" />
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          <extension url="style">
            <valueString value="font-weight:bold;" />
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          <extension url="sameLine">
            <valueBoolean value="false" />
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          <extension url="quoteAnswer">
            <valueBoolean value="false" />
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        </extension>
        <linkId value="medicalImaging_examRequest_US_obstetrical_specificarea_other" />
        <text value="Specify:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préciser :" />
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        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_obstetrical_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
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              </extension>
            </display>
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        </enableWhen>
        <enableBehavior value="all" />
        <required value="true" />
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      <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" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </extension>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="answerStyle">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_US_obstetrical_specificarea_anatomy" />
        <text value="Anatomy (20 week scan) additional option:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Anatomie (échographie de 20 semaines), option supplémentaire :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_obstetrical_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20674" />
            <display value="Anatomy (20 week scan)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Anatomie (échographie de 20 semaines)" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <enableBehavior value="all" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20684" />
            <display value="Report sex">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Indiquer le sexe du fœtus" />
                </extension>
              </extension>
            </display>
          </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://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="border-style:solid;" />
        </extension>
        <linkId value="medicalImaging_examRequest_US_obstetrical_specificarea_highrisk" />
        <text value="High-Risk Pregnancy Trimester:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Trimestre de la grossesse à risque élevé :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_obstetrical_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20680" />
            <display value="High risk pregnancy">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Grossesse à risque élevé" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <enableBehavior value="all" />
        <required value="true" />
        <repeats value="false" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20685" />
            <display value="1st Trimester">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="1er trimestre" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20686" />
            <display value="2nd and 3rd Trimester">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="2e et 3e trimestre" />
                </extension>
              </extension>
            </display>
          </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>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_US_neonatal" />
      <text value="Neonatal and Paediatric">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Néonatal et pédiatrique" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20638" />
          <display value="Neonatal and Paediatric">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Néonatal et pédiatrique" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_US_neonatal_group" />
      <prefix value="Neonatal and paediatric:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Néonatal et pédiatrique :" />
          </extension>
        </extension>
      </prefix>
      <type value="group" />
      <enableWhen>
        <question value="medicalImaging_examRequest_US_neonatal" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </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://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="text">
            <valueString value="Specific area of interest" />
          </extension>
          <extension url="listSeparator">
            <valueString value="," />
          </extension>
          <extension url="lastSeparator">
            <valueString value="and" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_US_neonatal_specificarea" />
        <text value="Neonatal and paediatric:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Néonatal et pédiatrique :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20689" />
            <display value="Brain">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Cerveau" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20688" />
            <display value="Spine">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Colonne vertébrale" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20691" />
            <display value="Pylorus and Hypertrophic Pyloric Stenosis">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Pylore et sténose hypertrophique du pylore" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20692" />
            <display value="Bowel">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Intestin" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20644" />
            <display value="Appendix">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Appendice" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20690" />
            <display value="Hips">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Hanches" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Other specific area of interest" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_US_neonatal_specificarea_other" />
        <text value="Specify:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préciser :" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_neonatal_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </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>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_US_musculoskeletal" />
      <text value="Musculoskeletal">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Musculosquelettique" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20639" />
          <display value="Musculoskeletal">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Musculosquelettique" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_US_musculoskeletal_group" />
      <prefix value="Musculoskeletal">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Musculosquelettique" />
          </extension>
        </extension>
      </prefix>
      <type value="group" />
      <enableWhen>
        <question value="medicalImaging_examRequest_US_musculoskeletal" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </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://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="text">
            <valueString value="Specific area of interest" />
          </extension>
          <extension url="listSeparator">
            <valueString value="," />
          </extension>
          <extension url="lastSeparator">
            <valueString value="and" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea" />
        <prefix value="Musculoskeletal:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Musculosquelettique :" />
            </extension>
          </extension>
        </prefix>
        <type value="choice" />
        <required value="true" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20712" />
            <display value="Shoulders">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Épaule" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20713" />
            <display value="Rotator cuff">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Coiffe des rotateurs" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20710" />
            <display value="Biceps">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Biceps" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20711" />
            <display value="Triceps">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Triceps" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20709" />
            <display value="Elbow">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Coude" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20707" />
            <display value="Carpal tunnel">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Canal carpien" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20706" />
            <display value="Wrist">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Poignet" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20705" />
            <display value="Hand">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Main" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20715" />
            <display value="Finger(s)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Doigt(s)" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20704" />
            <display value="Gluteal region">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Région fessière" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Hanche" />
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        </answerOption>
        <answerOption>
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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            <display value="Thigh/Hamstrings">
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Cuisse / ischio-jambiers" />
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              </extension>
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          </valueCoding>
        </answerOption>
        <answerOption>
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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            <display value="Quadriceps tendon">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Tendon quadricipital" />
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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            <display value="Patellar tendon">
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Tendon rotulien" />
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        </answerOption>
        <answerOption>
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20698" />
            <display value="Knee">
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Genou" />
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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            <display value="Popliteal fossa">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Creux poplité" />
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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            <display value="Calf/Lower leg/Gastrocnemius">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Mollet / jambe / gastrocnémien" />
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Tendon d'Achille" />
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Cheville" />
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Pied" />
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Fascia plantaire" />
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Orteil(s)" />
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Masses palpables" />
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                  <valueString value="Corps étranger" />
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Avant-bras" />
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          <valueCode value="horizontal" />
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              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
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            <extension url="lang">
              <valueCode value="fr" />
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              <valueString value="Épaule :" />
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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                <extension url="lang">
                  <valueCode value="fr" />
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              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Gauche" />
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Droite" />
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Bilatéral" />
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              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
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            <extension url="lang">
              <valueCode value="fr" />
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                <extension url="lang">
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                <extension url="lang">
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                <extension url="lang">
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                <extension url="lang">
                  <valueCode value="fr" />
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            <extension url="lang">
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                <extension url="lang">
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="lang">
                  <valueCode value="fr" />
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            <extension url="lang">
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                <extension url="lang">
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                <extension url="lang">
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                <extension url="lang">
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                <extension url="lang">
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            <extension url="lang">
              <valueCode value="fr" />
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        <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" />
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        </extension>
        <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_finger_right" />
        <text value="Right digit(s):">
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            <extension url="lang">
              <valueCode value="fr" />
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              <valueString value="Doigt(s) droit(s) :" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Droite" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Bilatéral" />
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              <extension url="lang">
                <valueCode value="fr" />
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                <valueString value="1" />
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          <valueString value="2">
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              <extension url="lang">
                <valueCode value="fr" />
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              <extension url="lang">
                <valueCode value="fr" />
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              <extension url="lang">
                <valueCode value="fr" />
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              <extension url="lang">
                <valueCode value="fr" />
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              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
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          <valueString value="border-style:solid;" />
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            <extension url="lang">
              <valueCode value="fr" />
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              <valueString value="Région fessière :" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Gauche" />
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            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Droite" />
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        <answerOption>
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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            <display value="Bilateral">
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Bilatéral" />
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            <extension url="lang">
              <valueCode value="fr" />
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              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
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              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Gauche" />
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            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Droite" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                  <valueString value="Bilatéral" />
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              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
              <code value="push-button" />
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          <valueString value="border-style:solid;" />
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            <extension url="lang">
              <valueCode value="fr" />
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            <extension url="content">
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              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
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                <extension url="lang">
                  <valueCode value="fr" />
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                  <valueString value="Gauche" />
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                  <valueString value="Droite" />
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                  <valueCode value="fr" />
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                  <valueString value="Bilatéral" />
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            <extension url="lang">
              <valueCode value="fr" />
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                <extension url="lang">
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              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                  <valueString value="Gauche" />
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              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                  <valueString value="Droite" />
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                <extension url="lang">
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          <valueString value="border-style:solid;" />
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          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
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            <extension url="content">
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              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Gauche" />
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        <answerOption>
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            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Droite" />
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Bilatéral" />
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          </valueCoding>
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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="drop-down" />
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        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="style">
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        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
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        <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_knee" />
        <text value="Knee:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
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            <extension url="content">
              <valueString value="Genou :" />
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        <type value="choice" />
        <enableWhen>
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          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20698" />
            <display value="Knee">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Genou" />
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              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <enableBehavior value="all" />
        <required value="true" />
        <repeats value="false" />
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              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Droite" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21323" />
            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Bilatéral" />
                </extension>
              </extension>
            </display>
          </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" />
              <display value="Drop down" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </extension>
        <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_toe" />
        <text value="Toe:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Orteil :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20714" />
            <display value="Toe(s)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Orteil(s)" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <enableBehavior value="all" />
        <required value="true" />
        <repeats value="false" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21321" />
            <display value="Left">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Gauche" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21322" />
            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Droite" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21323" />
            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Bilatéral" />
                </extension>
              </extension>
            </display>
          </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>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </extension>
        <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_toe_left" />
        <text value="Left digit(s):">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Doigt(s)/orteil(s) gauche(s) :" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea_toe" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21321" />
            <display value="Left">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Gauche" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <enableWhen>
          <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea_toe" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21323" />
            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Bilatéral" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <enableBehavior value="any" />
        <required value="true" />
        <repeats value="true" />
        <answerOption>
          <valueString value="1">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="1" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
        <answerOption>
          <valueString value="2">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="2" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
        <answerOption>
          <valueString value="3">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="3" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
        <answerOption>
          <valueString value="4">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="4" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
        <answerOption>
          <valueString value="5">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="5" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
      </item>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </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="medicalImaging_examRequest_US_musculoskeletal_specificarea_toe_right" />
        <text value="Right digits(s):">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Doigt(s) droit(s) :" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea_toe" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21322" />
            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Droite" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <enableWhen>
          <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea_toe" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21323" />
            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Bilatéral" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <enableBehavior value="any" />
        <required value="true" />
        <repeats value="true" />
        <answerOption>
          <valueString value="1">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="1" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
        <answerOption>
          <valueString value="2">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="2" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
        <answerOption>
          <valueString value="3">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="3" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
        <answerOption>
          <valueString value="4">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="4" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
        <answerOption>
          <valueString value="5">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="5" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
      </item>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </extension>
        <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_palpablemass" />
        <text value="Palpable masses specify:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Masses palpables, préciser :" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20716" />
            <display value="Palpable masses">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Masses palpables" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <enableBehavior value="all" />
        <required value="true" />
      </item>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </extension>
        <linkId value="medicalImaging_examRequest_US_musculoskeletal_specificarea_foreignbody" />
        <text value="Foreign body specify:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Corps étranger, préciser :" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_musculoskeletal_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20717" />
            <display value="Foreign body">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Corps étranger" />
                </extension>
              </extension>
            </display>
          </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>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_US_vascular" />
      <text value="Vascular">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Vasculaire" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20640" />
          <display value="Vascular">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Vasculaire" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_US_vascular_group" />
      <prefix value="Vascular:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Vasculaire :" />
          </extension>
        </extension>
      </prefix>
      <type value="group" />
      <enableWhen>
        <question value="medicalImaging_examRequest_US_vascular" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </enableWhen>
      <enableBehavior value="all" />
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
        </extension>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Specific area of interest" />
          </extension>
          <extension url="listSeparator">
            <valueString value="," />
          </extension>
          <extension url="lastSeparator">
            <valueString value="and" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </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="medicalImaging_examRequest_US_vascular_specificarea" />
        <text value="Vascular:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Vasculaire :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20718" />
            <display value="Upper extremity arterial">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Artériel des membres supérieurs" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20719" />
            <display value="Upper extremity venous">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Veineux des membres supérieurs" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20720" />
            <display value="Lower extremity arterial">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Artériel des membres inférieurs" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20721" />
            <display value="Lower extremity venous thrombosis">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Thrombose veineuse des membres inférieurs" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20722" />
            <display value="Lower extremity venous reflux">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Reflux veineux des membres inférieurs" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20723" />
            <display value="Abdominal aortic aneurysm screen">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Dépistage de l'anévrisme de l'aorte abdominale" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20724" />
            <display value="Ankle brachial index" />
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20725" />
            <display value="Arterial venous fistula">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Fistule artérioveineuse" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20726" />
            <display value="Carotid">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Carotide" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20727" />
            <display value="Inferior vena cava">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Veine cave inférieure" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20728" />
            <display value="Portal vein">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Veine porte" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20729" />
            <display value="Renal arteries">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Artères rénales" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20730" />
            <display value="Superior mesenteric artery (SMA)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Artère mésentérique supérieure (AMS)" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20731" />
            <display value="Temporal arteries">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Artères temporales" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21375" />
            <display value="Thoracic outlet syndrome">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Syndrome du défilé thoracobrachial" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20732" />
            <display value="Venous mapping">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Cartographie veineuse" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Other specific area of interest" />
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          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_US_vascular_specificarea_other" />
        <text value="Specify:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préciser :" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_vascular_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <enableBehavior value="all" />
        <required value="true" />
      </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://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
              <code value="push-button" />
              <display value="Push Button" />
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        </extension>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="style">
            <valueString value="font-weight:bold;" />
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          <extension url="sameLine">
            <valueBoolean value="false" />
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          <extension url="quoteAnswer">
            <valueBoolean value="false" />
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        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </extension>
        <linkId value="medicalImaging_examRequest_US_vascular_specificarea_uea" />
        <text value="Upper extremity arterial ultrasound:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Échographie artérielle des membres supérieurs :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_vascular_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20718" />
            <display value="Upper extremity arterial">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Artériel des membres supérieurs" />
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              </extension>
            </display>
          </answerCoding>
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        <enableBehavior value="all" />
        <required value="true" />
        <repeats value="false" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21321" />
            <display value="Left">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Gauche" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21322" />
            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Droite" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21323" />
            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Bilatéral" />
                </extension>
              </extension>
            </display>
          </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://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="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </extension>
        <linkId value="medicalImaging_examRequest_US_vascular_specificarea_uev" />
        <text value="Upper extremity venous ultrasound:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Échographie veineuse des membres supérieurs :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_vascular_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20719" />
            <display value="Upper extremity venous">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Veineux des membres supérieurs" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <enableBehavior value="all" />
        <required value="true" />
        <repeats value="false" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21321" />
            <display value="Left">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Gauche" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21322" />
            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Droite" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21323" />
            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Bilatéral" />
                </extension>
              </extension>
            </display>
          </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://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="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </extension>
        <linkId value="medicalImaging_examRequest_US_vascular_specificarea_lea" />
        <text value="Lower extremity arterial ultrasound:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Échographie artérielle des membres inférieurs :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_vascular_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20720" />
            <display value="Lower extremity arterial">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Artériel des membres inférieurs" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <enableBehavior value="all" />
        <required value="true" />
        <repeats value="false" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21321" />
            <display value="Left">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Gauche" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21322" />
            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Droite" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21323" />
            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Bilatéral" />
                </extension>
              </extension>
            </display>
          </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://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
              <code value="push-button" />
              <display value="Push Button" />
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        </extension>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
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          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </extension>
        <linkId value="medicalImaging_examRequest_US_vascular_specificarea_lev" />
        <text value="Lower extremity venous thrombosis ultrasound:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Échographie de la thrombose veineuse des membres inférieurs :" />
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          </extension>
        </text>
        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_vascular_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20721" />
            <display value="Lower extremity venous thrombosis">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Thrombose veineuse des membres inférieurs" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <enableBehavior value="all" />
        <required value="true" />
        <repeats value="false" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21321" />
            <display value="Left">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Gauche" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21322" />
            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Droite" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21323" />
            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Bilatéral" />
                </extension>
              </extension>
            </display>
          </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://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
              <code value="push-button" />
              <display value="Push Button" />
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        </extension>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="style">
            <valueString value="font-weight:bold;" />
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          <extension url="sameLine">
            <valueBoolean value="false" />
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          <extension url="quoteAnswer">
            <valueBoolean value="false" />
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        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </extension>
        <linkId value="medicalImaging_examRequest_US_vascular_specificarea_levr" />
        <text value="Lower extremity venous reflux ultrasound:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Échographie du reflux veineux des membres inférieurs :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_vascular_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20722" />
            <display value="Lower extremity venous reflux">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Reflux veineux des membres inférieurs" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <enableBehavior value="all" />
        <required value="true" />
        <repeats value="false" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21321" />
            <display value="Left">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Gauche" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21322" />
            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Droite" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21323" />
            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Bilatéral" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </extension>
        <linkId value="medicalImaging_examRequest_US_vascular_specificarea_ankle" />
        <text value="Specify extremity:" />
        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_vascular_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20724" />
            <display value="Ankle brachial index">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Indice de pression systolique cheville-bras" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <enableBehavior value="all" />
        <required 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://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="border-style:solid;" />
        </extension>
        <linkId value="medicalImaging_examRequest_US_vascular_specificside_avf" />
        <text value="AVF specify side:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="FAV, préciser le côté :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_vascular_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20725" />
            <display value="Arterial venous fistula">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Fistule artérioveineuse" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <enableBehavior value="all" />
        <required value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21321" />
            <display value="Left">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Gauche" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21322" />
            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Droite" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21323" />
            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Bilatéral" />
                </extension>
              </extension>
            </display>
          </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://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
              <code value="push-button" />
              <display value="Push Button" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <linkId value="medicalImaging_examRequest_US_vascular_specificarea_avf" />
        <text value="AVF specify area:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="FAV, préciser la région :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_vascular_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20725" />
            <display value="Arterial venous fistula">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Fistule artérioveineuse" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <required value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21378" />
            <display value="Arm">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Bras" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21379" />
            <display value="Leg">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Jambe" />
                </extension>
              </extension>
            </display>
          </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://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
              <code value="push-button" />
              <display value="Push Button" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <linkId value="medicalImaging_examRequest_US_vascular_specificarea_sma" />
        <text value="SMA specify:" />
        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_vascular_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20730" />
            <display value="Superior mesenteric artery (SMA)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Artère mésentérique supérieure (AMS)" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <required value="true" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21381" />
            <display value="Fasting">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="À jeun" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21382" />
            <display value="Post-prandial">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Postprandial" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </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/questionnaire-choiceOrientation">
          <valueCode value="horizontal" />
        </extension>
        <linkId value="medicalImaging_examRequest_US_vascular_specificarea_temporal" />
        <text value="Temporal arteries:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Artères temporales :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_vascular_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20731" />
            <display value="Temporal arteries">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Artères temporales" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <enableBehavior value="all" />
        <required value="true" />
        <repeats value="false" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21321" />
            <display value="Left">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Gauche" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21322" />
            <display value="Right">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Droite" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21323" />
            <display value="Bilateral">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Bilatéral" />
                </extension>
              </extension>
            </display>
          </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://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
              <code value="push-button" />
              <display value="Push Button" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <linkId value="medicalImaging_examRequest_US_vascular_specificarea_thoracicoutlet" />
        <text value="Thoracic outlet syndrome:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Syndrome du défilé thoracobrachial :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_vascular_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21375" />
            <display value="Thoracic outlet syndrome">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Syndrome du défilé thoracobrachial" />
                </extension>
              </extension>
            </display>
          </answerCoding>
        </enableWhen>
        <required value="true" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21376" />
            <display value="Arterial">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Artériel" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="21377" />
            <display value="Venous">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Veineux" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </extension>
        <linkId value="medicalImaging_examRequest_US_vascular_specificarea_venous" />
        <text value="Venous mapping: Specify extremity">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Cartographie veineuse : préciser le membre" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_vascular_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20732" />
            <display value="Venous mapping">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Cartographie veineuse" />
                </extension>
              </extension>
            </display>
          </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>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_US_head" />
      <text value="Head and Neck">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Tête et cou" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20641" />
          <display value="Head and Neck">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Tête et cou" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_examRequest_US_head_group" />
      <prefix value="Head and Neck">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Tête et cou" />
          </extension>
        </extension>
      </prefix>
      <type value="group" />
      <enableWhen>
        <question value="medicalImaging_examRequest_US_head" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </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://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="text">
            <valueString value="Specific area of interest" />
          </extension>
          <extension url="listSeparator">
            <valueString value="," />
          </extension>
          <extension url="lastSeparator">
            <valueString value="and" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="true" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_US_head_specificarea" />
        <text value="Head and Neck:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Tête et cou :" />
            </extension>
          </extension>
        </text>
        <type value="choice" />
        <repeats value="true" />
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20733" />
            <display value="Neck/Salivary gland">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Cou / glande salivaire" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20734" />
            <display value="Lymph nodes">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Ganglions lymphatiques" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20735" />
            <display value="Thyroid">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Thyroïde" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
        <answerOption>
          <valueCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
            <code value="OTH" />
            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Autre" />
                </extension>
              </extension>
            </display>
          </valueCoding>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
            <valueString value="Other specific area of interest" />
          </extension>
          <extension url="style">
            <valueString value="font-weight:bold;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="medicalImaging_examRequest_US_head_specificarea_other" />
        <text value="Specify:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préciser :" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_head_specificarea" />
          <operator value="=" />
          <answerCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
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              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Autre" />
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              </extension>
            </display>
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        <required value="true" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
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        <linkId value="medicalImaging_examRequest_US_head_specificarea_neck" />
        <text value="Neck/Salivary gland: Specify">
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            <extension url="lang">
              <valueCode value="fr" />
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            <extension url="content">
              <valueString value="Cou / glande salivaire : préciser" />
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        </text>
        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_examRequest_US_head_specificarea" />
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          <answerCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20733" />
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              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Cou / glande salivaire" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
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            <extension url="lang">
              <valueCode value="fr" />
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            <extension url="content">
              <valueString value="Ganglions lymphatiques :" />
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          </extension>
        </text>
        <type value="string" />
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                  <valueCode value="fr" />
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        <valueCode value="horizontal" />
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        <valueCodeableConcept>
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            <system value="http://hl7.org/fhir/questionnaire-item-control" />
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          <extension url="lang">
            <valueCode value="fr" />
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            <valueString value="Sein et aisselle" />
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              <extension url="lang">
                <valueCode value="fr" />
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                <valueString value="Sein et aisselle" />
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      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
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          <extension url="lang">
            <valueCode value="fr" />
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            <valueString value="Sein et aisselle" />
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          <valueCode value="horizontal" />
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              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
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              <display value="Push Button" />
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            <valueString value="and" />
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            <valueString value="font-weight:bold;" />
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            <valueBoolean value="true" />
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            <extension url="lang">
              <valueCode value="fr" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Sein" />
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Aisselle" />
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        <answerOption>
          <valueCoding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                  <valueString value="Autre" />
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            <valueString value="font-weight:bold;" />
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            <extension url="lang">
              <valueCode value="fr" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Autre" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
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              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
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            <extension url="lang">
              <valueCode value="fr" />
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              <valueString value="Sein :" />
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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                <extension url="lang">
                  <valueCode value="fr" />
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Gauche" />
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        <answerOption>
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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            <display value="Right">
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Droite" />
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        <answerOption>
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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                <extension url="lang">
                  <valueCode value="fr" />
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              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
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            <extension url="lang">
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="lang">
                  <valueCode value="fr" />
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          <extension url="lang">
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            <extension url="lang">
              <valueCode value="fr" />
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          <extension url="lang">
            <valueCode value="fr" />
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            <valueString value="Divers" />
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            <coding>
              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
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            <extension url="lang">
              <valueCode value="fr" />
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            <extension url="content">
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Thorax" />
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        <answerOption>
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            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Paroi thoracique (masse)" />
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        <answerOption>
          <valueCoding>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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            <display value="Soft tissue">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Tissus mous" />
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        <answerOption>
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            <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
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            <display value="Other">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
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                <extension url="content">
                  <valueString value="Autre" />
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        </answerOption>
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      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="text">
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    <linkId value="bmd_ordering_guidelines" />
    <text value="BMD Ordering Guidelines

Baseline test:
Once per lifetime

Low Risk Patients:

(FRAX or equivalent fracture risk <10%)
Subsequent test: every 60 months


Medium Risk Patients:

(FRAX or equivalent fracture risk 10-15%)
Subsequent test: every 60 months


High Risk Patients or therapy monitoring or risk factor for secondary osteoporosis:

(FRAX or equivalent fracture risk>15%)
Subsequent test: every 36 months
Therapy monitoring is limited to:
1 test ≥36 months after initiating pharmacotherapy; and/or
1 test ≥36 months after stopping bisphosphonate therapy




Hypercortisolism/Cushing's syndrome or receiving high-dose glucocorticoid therapy of <20 mg Prednisone equivalent per day
Additional test: every 12 months



Source: Ontario Ministry of Health, Schedule of Benefits for Physician Services (Diagnostic Radiology – BMD Measurement), updated March 9, 2026, effective April 1, 2026.">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
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<p><b>Baseline test:</b></p>
<p>Once per lifetime</p>

<p><b>Low Risk Patients:</b></p>
<p>
(FRAX or equivalent fracture risk &lt;10%)
Subsequent test: every 60 months
</p>

<p><b>Medium Risk Patients:</b></p>
<p>
(FRAX or equivalent fracture risk 10-15%)
Subsequent test: every 60 months
</p>

<p><b>High Risk Patients or therapy monitoring or risk factor for secondary osteoporosis:</b></p>
<p>
(FRAX or equivalent fracture risk&gt;15%)
Subsequent test: every 36 months
Therapy monitoring is limited to:
1 test ≥36 months after initiating pharmacotherapy; and/or
1 test ≥36 months after stopping bisphosphonate therapy

</p>

<p>
<b>Hypercortisolism/Cushing's syndrome </b>or receiving <b>high-dose glucocorticoid therapy</b> of &lt;20 mg Prednisone equivalent per day
Additional test: every 12 months
</p>

<p>
Source: Ontario Ministry of Health, Schedule of Benefits for Physician Services (Diagnostic Radiology – BMD Measurement), updated March 9, 2026, effective April 1, 2026.
</p>" />
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    <required value="true" />
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        <code value="20742" />
        <display value="Low Risk">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Risque faible" />
            </extension>
          </extension>
        </display>
      </answerCoding>
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    <enableWhen>
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              <valueCode value="fr" />
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            <extension url="content">
              <valueString value="Risque élevé" />
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    <enableBehavior value="any" />
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  <item>
    <linkId value="medicalImaging_examRequest_BMD_previous_date" />
    <text value="Date of most recent BMD (Year and Month if known):">
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Date de la plus récente ostéodensitométrie (année et mois, si connus) :" />
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    <type value="string" />
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        <code value="20742" />
        <display value="Low Risk">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Risque faible" />
            </extension>
          </extension>
        </display>
      </answerCoding>
    </enableWhen>
    <enableWhen>
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      <answerCoding>
        <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
        <code value="20743" />
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          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Risque élevé" />
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          </extension>
        </display>
      </answerCoding>
    </enableWhen>
    <enableBehavior value="any" />
  </item>
  <item>
    <linkId value="medicalImaging_examRequest_BMD_previous_location" />
    <text value="Location of most recent BMD:">
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Lieu de la plus récente ostéodensitométrie :" />
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      </extension>
    </text>
    <type value="string" />
    <enableWhen>
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        <code value="20742" />
        <display value="Low Risk">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Risque faible" />
            </extension>
          </extension>
        </display>
      </answerCoding>
    </enableWhen>
    <enableWhen>
      <question value="medicalImaging_examRequest_BMD_group_BMDrefnote" />
      <operator value="=" />
      <answerCoding>
        <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
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          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
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            <extension url="content">
              <valueString value="Risque élevé" />
            </extension>
          </extension>
        </display>
      </answerCoding>
    </enableWhen>
    <enableBehavior value="any" />
  </item>
  <item>
    <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info">
      <extension url="style">
        <valueString value="font-weight:bold;" />
      </extension>
      <extension url="groupItems">
        <valueBoolean value="false" />
      </extension>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
      <valueString value="border-style:solid;" />
    </extension>
    <linkId value="medicalImaging_BMD_clinicalindication_BMDrefnote" />
    <text value="BMD Request: Clinical History / Indication">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="font-weight:bold;" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Demande d'ostéodensitométrie : antécédents cliniques / indication" />
        </extension>
      </extension>
    </text>
    <type value="group" />
    <enableWhen>
      <question value="medicalImaging_examRequest" />
      <operator value="=" />
      <answerCoding>
        <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
        <code value="20394" />
        <display value="Bone Mineral Density Requisition">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Demande d'ostéodensitométrie" />
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          </extension>
        </display>
      </answerCoding>
    </enableWhen>
    <enableBehavior value="all" />
    <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="<br/>" />
            </extension>
          </valueString>
        </extension>
      </extension>
      <linkId value="medicalImaging_BMD_clinicalindication_text" />
      <text value="Reason for exam (please also include presenting symptom(s), relevant underlying diagnosis and therapies, where applicable)">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Motif de l'examen (veuillez aussi indiquer le ou les symptômes présents, le diagnostic sous-jacent pertinent et les traitements, le cas échéant)" />
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        </extension>
      </text>
      <type value="text" />
    </item>
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  <item>
    <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info">
      <extension url="enableWhenExpression">
        <valueExpression>
          <language value="text/fhirpath" />
          <expression value="false" />
        </valueExpression>
      </extension>
    </extension>
    <linkId value="medicalImaging_examRequest_BMD_Display" />
    <text value="Patient risk factor screening questionnaire will be provided by the imaging facility before or on the day of the exam" />
    <type value="display" />
    <enableWhen>
      <question value="medicalImaging_examRequest" />
      <operator value="=" />
      <answerCoding>
        <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
        <code value="20394" />
        <display value="Bone Mineral Density Requisition">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Demande d'ostéodensitométrie" />
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          </extension>
        </display>
      </answerCoding>
    </enableWhen>
    <enableBehavior value="any" />
  </item>
  <item>
    <linkId value="medicalImaging_examRequest_BMD_Previous_group" />
    <text value="Previous Relevant BMD">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="font-weight:bold;" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Ostéodensitométrie antérieure pertinente" />
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      </extension>
    </text>
    <type value="group" />
    <enableWhen>
      <question value="medicalImaging_examRequest" />
      <operator value="=" />
      <answerCoding>
        <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
        <code value="20394" />
        <display value="Bone Mineral Density Requisition">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Demande d'ostéodensitométrie" />
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          </extension>
        </display>
      </answerCoding>
    </enableWhen>
    <enableBehavior value="any" />
    <item>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="sameLine">
          <valueBoolean value="true" />
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        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <linkId value="medicalImaging_examRequest_BMD_Previous_Date" />
      <text value="Date of most recent BMD (Year and Month if known):">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Date de la plus récente ostéodensitométrie (année et mois, si connus) :" />
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        </extension>
      </text>
      <type value="string" />
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    <item>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="sameLine">
          <valueBoolean value="true" />
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        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <linkId value="medicalImaging_examRequest_BMD_Previous_Location" />
      <text value="Location of most recent BMD:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Lieu de la plus récente ostéodensitométrie :" />
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        </extension>
      </text>
      <type value="string" />
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    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/mimeType">
        <valueCode value="application/pdf" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/maxSize">
        <valueDecimal value="0" />
      </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="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="image/tiff" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/mimeType">
        <valueCode value="application/vnd.wordperfect" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/mimeType">
        <valueCode value="text/plain" />
      </extension>
      <linkId value="medicalImaging_examRequest_BMD_Previous_Attachment" />
      <text value="Add Attachments" />
      <type value="attachment" />
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  </item>
  <item>
    <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info">
      <extension url="style">
        <valueString value="font-weight:bold;text-decoration:underline;" />
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      <extension url="groupItems">
        <valueBoolean value="false" />
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    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
      <valueString value="border-style:solid;" />
    </extension>
    <linkId value="medicalImaging_MRIsafety_group_MRIrefnote" />
    <text value="MRI Safety Screening">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="font-weight:bold;" />
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      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Dépistage de sécurité pour l'IRM" />
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      </extension>
    </text>
    <type value="group" />
    <enableWhen>
      <question value="medicalImaging_examRequest" />
      <operator value="=" />
      <answerCoding>
        <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
        <code value="20391" />
        <display value="MRI Requisition">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Demande d'IRM" />
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          </extension>
        </display>
      </answerCoding>
    </enableWhen>
    <enableBehavior value="all" />
    <required value="true" />
    <item>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info">
        <extension url="enableWhenExpression">
          <valueExpression>
            <language value="text/fhirpath" />
            <expression value="false" />
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        </extension>
      </extension>
      <linkId value="MRI_safety_screening_display" />
      <text value="To prevent delays in scheduling, please provide all relevant information. *">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Pour éviter les retards de planification, veuillez fournir tous les renseignements pertinents. *" />
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        </extension>
      </text>
      <type value="display" />
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    <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>
      <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="<br/>" />
            </extension>
          </valueString>
        </extension>
      </extension>
      <linkId value="medicalImaging_MRIsafety_metalfragments" />
      <text value="Has metal fragments in eye(s)/body">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Présence de fragments métalliques dans les yeux ou le corps" />
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        </extension>
      </text>
      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21296" />
          <display value="Has metal fragments in eye(s)/body">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Présence de fragments métalliques dans les yeux ou le corps" />
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            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
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      <linkId value="medicalImaging_MRIsafety_attachxray" />
      <text value="Attach x-ray reports post injury, if available">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
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          <extension url="content">
            <valueString value="Joindre les comptes rendus de radiographie post-traumatiques, s'ils sont disponibles" />
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        </extension>
      </text>
      <type value="display" />
      <enableWhen>
        <question value="medicalImaging_MRIsafety_metalfragments" />
        <operator value="exists" />
        <answerBoolean value="true" />
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      <enableBehavior value="all" />
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    <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>
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            <system value="http://hl7.org/fhir/questionnaire-item-control" />
            <code value="check-box" />
            <display value="Check-box" />
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      </extension>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="text">
          <valueString value="Has active electronic implants">
            <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
              <valueString value="<br/>" />
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          </valueString>
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
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        <extension url="quoteAnswer">
          <valueBoolean value="false" />
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      <linkId value="medicalImaging_MRIsafety_electronicimplant" />
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          <valueString value="display:none;" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
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          <extension url="content">
            <valueString value="Porte des implants électroniques actifs (p. ex. dispositif cardiaque électronique implantable, neurostimulateur, implant cochléaire, etc.) ou des éléments résiduels (p. ex. sondes, etc.) :" />
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      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21297" />
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            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
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              <extension url="content">
                <valueString value="Porte des implants électroniques actifs (p. ex. dispositif cardiaque électronique implantable, neurostimulateur, implant cochléaire, pompe à médicaments, etc.) ou des éléments résiduels (p. ex. sondes, etc.) :" />
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    <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://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
            <code value="push-button" />
            <display value="Push Button" />
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      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="text">
          <valueString value="Specify" />
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        <extension url="listSeparator">
          <valueString value="," />
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        <extension url="lastSeparator">
          <valueString value="and" />
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        <extension url="style">
          <valueString value="font-weight:bold;" />
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        <extension url="sameLine">
          <valueBoolean value="false" />
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        <extension url="quoteAnswer">
          <valueBoolean value="false" />
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      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
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      <linkId value="medicalImaging_MRIsafety_electronicimplant_specify" />
      <text value="What implants does the patient have:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
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          <extension url="content">
            <valueString value="Quels implants le patient porte-t-il :" />
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      <type value="choice" />
      <enableWhen>
        <question value="medicalImaging_MRIsafety_electronicimplant" />
        <operator value="exists" />
        <answerBoolean value="true" />
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      <enableBehavior value="all" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21299" />
          <display value="CIED">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
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              <extension url="content">
                <valueString value="CIED" />
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      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21300" />
          <display value="Neurostimulator">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
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              <extension url="content">
                <valueString value="Neurostimulateur" />
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      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21301" />
          <display value="Cochlear Implant">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
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              <extension url="content">
                <valueString value="Implant cochléaire" />
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        </valueCoding>
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      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21302" />
          <display value="Medication Pump">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
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              <extension url="content">
                <valueString value="Pompe à médicaments" />
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      <answerOption>
        <valueCoding>
          <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
          <code value="OTH" />
          <display value="Other">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
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              <extension url="content">
                <valueString value="Autre" />
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            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <linkId value="medicalImaging_MRIsafety_electronicimplant_otherspecify" />
      <text value="Specify">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
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          <extension url="content">
            <valueString value="Préciser" />
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      <type value="string" />
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        <operator value="=" />
        <answerCoding>
          <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
          <code value="OTH" />
          <display value="Other">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
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              <extension url="content">
                <valueString value="Autre" />
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          </display>
        </answerCoding>
      </enableWhen>
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      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="text">
          <valueString value="Implant details" />
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        <extension url="style">
          <valueString value="font-weight:bold;" />
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        <extension url="sameLine">
          <valueBoolean value="false" />
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        <extension url="quoteAnswer">
          <valueBoolean value="false" />
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      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
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      <linkId value="medicalImaging_MRIsafety_electronicimplant_implantdetails" />
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        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
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          <extension url="content">
            <valueString value="Détails de l'implant, y compris la marque, le modèle, l'établissement et la date (si connus). Joindre le compte rendu pertinent, s'il est disponible." />
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      <type value="text" />
      <enableWhen>
        <question value="medicalImaging_MRIsafety_electronicimplant_specify" />
        <operator value="exists" />
        <answerBoolean value="true" />
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        <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" />
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      </extension>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="text">
          <valueString value="Has other metal containing devices">
            <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
              <valueString value="<br/>" />
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          </valueString>
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        <extension url="sameLine">
          <valueBoolean value="false" />
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        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <linkId value="medicalImaging_MRIsafety_metaldevices" />
      <text value="Has other metal containing devices (e.g. Aneurysm clip, IUD, Tissue expander, Stent, Coil,etc.), metal foreign bodies (Shrapnel, Bullets Etc), or Large orthopedic device greater than 10cm in length:">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Porte d'autres dispositifs contenant du métal (p. ex. clip d'anévrisme, stérilet, expanseur tissulaire, endoprothèse, spire d'embolisation, etc.), des corps étrangers métalliques (éclats, balles, etc.) ou un gros dispositif orthopédique de plus de 10 cm de longueur :" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21298" />
          <display value="Has other metal containing devices (e.g. Aneurysm Clip, IUD, Tissue Expander, Shunt, Stent, Coil, Traction Device, Glucose Monitor, etc.), metal foreign bodies (Shrapnel, Bullets, Subdermal Piercings, Etc), or orthopedic device:">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Porte d'autres dispositifs contenant du métal (p. ex. clip d'anévrisme, stérilet, expanseur tissulaire, dérivation, endoprothèse, spire d'embolisation, dispositif de traction, capteur de glycémie, etc.), des corps étrangers métalliques (éclats, balles, piercings sous-cutanés, etc.) ou un dispositif orthopédique :" />
              </extension>
            </extension>
          </display>
        </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://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="text">
          <valueString value="Specify" />
        </extension>
        <extension url="listSeparator">
          <valueString value="," />
        </extension>
        <extension url="lastSeparator">
          <valueString value="and" />
        </extension>
        <extension url="style">
          <valueString value="font-weight:bold;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_MRIsafety_metaldevices_specify" />
      <text value="What implants does the patient have:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Quels implants le patient porte-t-il :" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <enableWhen>
        <question value="medicalImaging_MRIsafety_metaldevices" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </enableWhen>
      <enableBehavior value="all" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21303" />
          <display value="Aneurysm Clip">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Clip d'anévrisme" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21304" />
          <display value="Coil">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Spire d'embolisation" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21305" />
          <display value="Glucose Monitor">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Capteur de glycémie" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21306" />
          <display value="Heart Valve">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Valve cardiaque" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21307" />
          <display value="Copper or Stainless Steel IUD">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Stérilet en cuivre ou en acier inoxydable" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21308" />
          <display value="Orthopedic Devices">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Dispositifs orthopédiques" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21309" />
          <display value="Pessary">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Pessaire" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21310" />
          <display value="Prosthesis">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Prothèse" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21311" />
          <display value="Shunt">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Dérivation" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21312" />
          <display value="Stent">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Endoprothèse" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21313" />
          <display value="Subdermal Piercings">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Piercings sous-cutanés" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21314" />
          <display value="Tissue Expander">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Expanseur tissulaire" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21315" />
          <display value="Traction Device">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Dispositif de traction" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
          <code value="OTH" />
          <display value="Other">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Autre" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21399" />
          <display value="None of the above">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Aucune de ces réponses" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <linkId value="medicalImaging_MRIsafety_metaldevices_otherspecify" />
      <text value="Specify">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Préciser" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <enableWhen>
        <question value="medicalImaging_MRIsafety_metaldevices_specify" />
        <operator value="=" />
        <answerCoding>
          <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
          <code value="OTH" />
          <display value="Other">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Autre" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
    </item>
    <item>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="text">
          <valueString value="Implant details" />
        </extension>
        <extension url="style">
          <valueString value="font-weight:bold;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="MRI_safety_implantDetails" />
      <text value="Implant details including make, model, institution and date (if known). Attach relevant report if available.">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Détails de l'implant, y compris la marque, le modèle, l'établissement et la date (si connus). Joindre le compte rendu pertinent, s'il est disponible." />
          </extension>
        </extension>
      </text>
      <type value="text" />
      <enableWhen>
        <question value="medicalImaging_MRIsafety_metaldevices" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </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://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <linkId value="MRI_safety_none" />
      <text value="None of the above">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Aucune de ces réponses" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <repeats value="false" />
      <answerOption>
        <valueString value="None of the above">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Aucune de ces réponses" />
            </extension>
          </extension>
        </valueString>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_MRIsafety_previoussurgeries_MRIrefnote" />
      <text value="Previous surgeries:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Chirurgies antérieures :" />
          </extension>
        </extension>
      </text>
      <type value="text" />
    </item>
  </item>
  <item>
    <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="groupItems">
        <valueBoolean value="false" />
      </extension>
    </extension>
    <linkId value="medicalImaging_patientsafety_group" />
    <text value="Patient Safety Screening
 Select where applicable">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
        <valueString value="<p><b> Patient Safety Screening</b></p>
<p> Select where applicable </p>">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="<p><b> Dépistage relatif à la sécurité du patient</b></p>
<p> Sélectionner s'il y a lieu </p>" />
            </extension>
          </extension>
        </valueString>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Dépistage relatif à la sécurité du patient
 Sélectionner s'il y a lieu" />
        </extension>
      </extension>
    </text>
    <type value="group" />
    <enableWhen>
      <question value="medicalImaging_examRequest" />
      <operator value="exists" />
      <answerBoolean value="true" />
    </enableWhen>
    <enableBehavior value="any" />
    <item>
      <linkId value="medicalImaging_patientsafety_cardiac_section" />
      <type value="group" />
      <enableWhen>
        <question value="medicalImaging_examRequest_CT_cardiac_specificarea" />
        <operator value="=" />
        <answerCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20464" />
          <display value="Cardiac CT">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="TDM cardiaque" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableWhen>
        <question value="medicalImaging_examRequest_CT_cardiac_specificarea" />
        <operator value="=" />
        <answerCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20465" />
          <display value="Coronary Angiography (CCTA)">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Angiographie coronarienne par TDM (CCTA)" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableBehavior value="any" />
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="enableWhenExpression">
            <valueExpression>
              <language value="text/fhirpath" />
              <expression value="false" />
            </valueExpression>
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </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="medicalImaging_patientsafety_cardiac_cds" />
        <text value="Heart Rate and Beta-Blocker Information for Cardiac CT Exams">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Renseignements sur la fréquence cardiaque et les bêtabloquants pour les examens de TDM cardiaque" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <answerOption>
          <valueString value="Hide">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Masquer" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
        <answerOption>
          <valueString value="Show">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Afficher" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info">
          <extension url="enableWhenExpression">
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              <language value="text/fhirpath" />
              <expression value="false" />
            </valueExpression>
          </extension>
        </extension>
        <linkId value="medicalImaging_patientsafety_cardiac_cds_display" />
        <text value="To support optimal Cardiac CT imaging, a
  
  
    heart rate of less than 65 beats per minute (bpm)
  
  
  is required. Beta-blockers should be prescribed to achieve adequate heart rate control.
  
  
    Premedication before the exam is expected and is the most effective approach
  
  . While beta-blockers may be given on the day of the exam, this approach is less effective and will prolong the patient's overall exam duration.




  
    For patients already on beta-blockers
  
  
  Adjust as per clinical judgment.
  
  If the patient’s heart rate is >65 bpm, consider increasing the beta-blocker dose the day before and on the day of the CT scan.
  
  If the patient’s intrinsic heart rate is <65 bpm, no beta-blocker is required.




  
    Beta-blocker premedication
  
  
  For beta-blocker naive patients, Metoprolol may be used to target a heart rate of less than 65 bpm. Dosing may vary based on baseline heart rate, blood pressure, and body size. For example:




  

  
    50 mg the day before at 16:00 (4:00 PM)
  
  

  
    50 mg the night before the scan
  
  

  
    50 mg one hour before the scan
  
  





  Dosing may need to be modified if the patient is receiving concomitant AV nodal blocking agents.
  
  
  Please advise patients to avoid caffeine intake within 24 hours of the CT exam.">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<p>
  To support optimal Cardiac CT imaging, a
  <span/>
  <b>
    heart rate of less than 65 beats per minute (bpm)
  </b>
  <span/>
  is required. Beta-blockers should be prescribed to achieve adequate heart rate control.
  <span/>
  <b>
    Premedication before the exam is expected and is the most effective approach
  </b>
  . While beta-blockers may be given on the day of the exam, this approach is less effective and will prolong the patient's overall exam duration.
</p>


<p>
  <b>
    For patients already on beta-blockers
  </b>
  <br/>
  Adjust as per clinical judgment.
  <br/>
  If the patient’s heart rate is &gt;65 bpm, consider increasing the beta-blocker dose the day before and on the day of the CT scan.
  <br/>
  If the patient’s intrinsic heart rate is &lt;65 bpm, no beta-blocker is required.
</p>


<p>
  <b>
    Beta-blocker premedication
  </b>
  <br/>
  For beta-blocker naive patients, Metoprolol may be used to target a heart rate of less than 65 bpm. Dosing may vary based on baseline heart rate, blood pressure, and body size. For example:
</p>


<span style="text-decoration: underline;">
  

  <li>
    50 mg the day before at 16:00 (4:00 PM)
  </li>
  

  <li>
    50 mg the night before the scan
  </li>
  

  <li>
    50 mg one hour before the scan
  </li>
  

</span>


<p>
  Dosing may need to be modified if the patient is receiving concomitant AV nodal blocking agents.
  <br/>
  <br/>
  Please advise patients to avoid caffeine intake within 24 hours of the CT exam.
</p>" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Pour favoriser une imagerie optimale" />
            </extension>
          </extension>
        </text>
        <type value="display" />
        <enableWhen>
          <question value="medicalImaging_patientsafety_cardiac_cds" />
          <operator value="=" />
          <answerString value="Show" />
        </enableWhen>
      </item>
      <item>
        <linkId value="medicalImaging_patientsafety_cardiac_restingHR" />
        <text value="What is the patient's current resting heart rate (bpm)?">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Quelle est la fréquence cardiaque au repos actuelle du patient (bpm)?" />
            </extension>
          </extension>
        </text>
        <type value="integer" />
        <repeats value="false" />
      </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="medicalImaging_patientsafety_cardiac_known_contraindications_Nitro" />
        <text value="Known contraindications to Nitroglycerin: (e.g., allergy, on PDE inhibitor such as Viagra® or Cialis®)">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Contre-indications connues à la nitroglycérine : (p. ex. allergie, prise d'un inhibiteur de la PDE tel que Viagra® ou Cialis®)" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <required value="true" />
        <answerOption>
          <valueString value="No">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Non" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
        <answerOption>
          <valueString value="Yes">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Oui" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
      </item>
      <item>
        <linkId value="medicalImaging_patientsafety_cardiac_known_contraindications_Nitro_yes" />
        <text value="If the patient is taking phosphodiesterase type 5 (PDE‑5) inhibitors, hold the medication for 48 hours prior to the CT scan.">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Si le patient prend des inhibiteurs de la phosphodiestérase de type 5 (PDE‑5), cesser ce médicament pendant les 48 heures précédant la TDM." />
            </extension>
          </extension>
        </text>
        <type value="display" />
        <enableWhen>
          <question value="medicalImaging_patientsafety_cardiac_known_contraindications_Nitro" />
          <operator value="=" />
          <answerString value="Yes" />
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      </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="medicalImaging_patientsafety_cardiac_on_betaBlockers" />
        <text value="Is the patient currently on beta-blockers?">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Le patient prend-il actuellement des bêtabloquants?" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <required value="true" />
        <repeats value="false" />
        <answerOption>
          <valueString value="No">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Non" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
        <answerOption>
          <valueString value="Yes">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Oui" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
      </item>
      <item>
        <linkId value="medicalImaging_patientsafety_cardiac_betaBlockers_cds" />
        <text value="Beta-blockers are usually required for a Cardiac CT to slow the  heart rate to <65 beats per minute (bpm). Please review Heart Rate and Beta Blocker Information for Cardiac CT Exams above.">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
            <valueString value="<p> Beta-blockers are usually required for a Cardiac CT to slow the <b> heart rate to &lt;65 beats per minute (bpm). </b>Please review Heart Rate and Beta Blocker Information for Cardiac CT Exams above. </p>">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="<p> Les bêtabloquants sont habituellement requis pour une TDM cardiaque afin de ralentir la <b> fréquence cardiaque à moins de 65 battements par minute (bpm). </b>Veuillez consulter les renseignements sur la fréquence cardiaque et les bêtabloquants pour les examens de TDM cardiaque ci-dessus. </p>" />
                </extension>
              </extension>
            </valueString>
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Les bêtabloquants sont habituellement requis pour une TDM cardiaque afin de ralentir la fréquence cardiaque à moins de 65 battements par minute (bpm). Veuillez consulter les renseignements sur la fréquence cardiaque et les bêtabloquants pour les examens de TDM cardiaque ci-dessus." />
            </extension>
          </extension>
        </text>
        <type value="display" />
        <enableWhen>
          <question value="medicalImaging_patientsafety_cardiac_on_betaBlockers" />
          <operator value="=" />
          <answerString value="No" />
        </enableWhen>
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="listSeparator">
            <valueString value="," />
          </extension>
          <extension url="lastSeparator">
            <valueString value="and" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
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        </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" />
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          </valueCodeableConcept>
        </extension>
        <linkId value="medicalImaging_patientsafety_cardiac_betaBlocker_concerns" />
        <text value="Concerns for beta-blockers use:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préoccupations concernant l'utilisation de bêtabloquants :" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <enableWhen>
          <question value="medicalImaging_patientsafety_cardiac_on_betaBlockers" />
          <operator value="=" />
          <answerString value="No" />
        </enableWhen>
        <repeats value="true" />
        <answerOption>
          <valueString value="Severe/critical aortic stenosis">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Sténose aortique grave/critique" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
        <answerOption>
          <valueString value="Severe symptomatic aortic insufficiency">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Insuffisance aortique grave symptomatique" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
        <answerOption>
          <valueString value="Decompensated congestive heart failure">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Insuffisance cardiaque congestive décompensée" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
        <answerOption>
          <valueString value="Allergy to Beta-blockers">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Allergie aux bêtabloquants" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
        <answerOption>
          <valueString value="Prior hospitalization for lung disease">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Hospitalisation antérieure pour une maladie pulmonaire" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
        <answerOption>
          <valueString value="Active bronchospasm">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Bronchospasme actif" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
        <answerOption>
          <valueString value="2nd or 3rd degree heart block, or 1st degree with PR>0.42s">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Bloc cardiaque du 2e ou 3e degré, ou du 1er degré avec PR > 0,42 s" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
      </item>
      <item>
        <linkId value="medicalImaging_patientsafety_cardiac_betaBlocker_Ivabradine" />
        <text value="If beta-blockers are contraindicated, Ivabradine (e.g., Lancora) should be considered.
  




   A recommended protocol is as follows:




   Ivabradine 7.5 mg PO BID for 1 week until the day of the CT study">
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            <valueString value="<p>
  <b>
    If&#xa0;beta-blockers&#xa0;are&#xa0;contraindicated,&#xa0;Ivabradine&#xa0;(e.g.,&#xa0;Lancora)&#xa0;should&#xa0;be&#xa0;considered.
  </b>
</p>


<p>
  &#xa0;A&#xa0;recommended&#xa0;protocol&#xa0;is&#xa0;as&#xa0;follows:
</p>


<p>
  &#xa0;Ivabradine&#xa0;7.5&#xa0;mg&#xa0;PO&#xa0;BID&#xa0;for&#xa0;1&#xa0;week&#xa0;until&#xa0;the&#xa0;day&#xa0;of&#xa0;the&#xa0;CT&#xa0;study
</p>" />
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          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Si les bêtabloquants sont contre-indiqués" />
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        </text>
        <type value="display" />
        <enableWhen>
          <question value="medicalImaging_patientsafety_cardiac_betaBlocker_concerns" />
          <operator value="exists" />
          <answerBoolean value="true" />
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      <item>
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          <valueCodeableConcept>
            <coding>
              <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/item-controls" />
              <code value="push-button" />
              <display value="Push Button" />
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          </valueCodeableConcept>
        </extension>
        <linkId value="medicalImaging_patientsafety_cardiac_betaBlockerRx" />
        <text value="Will the patient be prescribed a beta-blocker?">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Prescrira-t-on un bêtabloquant au patient?" />
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          </extension>
        </text>
        <type value="string" />
        <required value="true" />
        <repeats value="false" />
        <answerOption>
          <valueString value="No">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
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              <extension url="content">
                <valueString value="Non" />
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          </valueString>
        </answerOption>
        <answerOption>
          <valueString value="Yes">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Oui" />
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            </extension>
          </valueString>
        </answerOption>
      </item>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
        <valueCode value="horizontal" />
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        <valueCodeableConcept>
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            <display value="Push Button" />
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      <linkId value="medicalImaging_patientsafety_renal" />
      <text value="Renal Assessment Questions:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
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          <extension url="content">
            <valueString value="Questions d'évaluation rénale :" />
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        </extension>
      </text>
      <type value="choice" />
      <enableWhen>
        <question value="medicalImaging_examRequest" />
        <operator value="=" />
        <answerCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20390" />
          <display value="CT Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Demande de TDM" />
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          </display>
        </answerCoding>
      </enableWhen>
      <enableWhen>
        <question value="medicalImaging_examRequest" />
        <operator value="=" />
        <answerCoding>
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          <code value="20391" />
          <display value="MRI Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
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              <extension url="content">
                <valueString value="Demande d'IRM" />
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      <enableBehavior value="any" />
      <repeats value="false" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21283" />
          <display value="No known kidney issues">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Aucun problème rénal connu" />
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      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21316" />
          <display value="Patient has impaired renal function or a history of renal transplant">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Le patient présente une insuffisance rénale ou des antécédents de greffe rénale" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info">
        <extension url="enableWhenExpression">
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            <expression value="false" />
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        </extension>
        <extension url="groupItems">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_patientsafety_mri_note" />
      <text value="MRI Note">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
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          <extension url="content">
            <valueString value="Note IRM" />
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      </text>
      <type value="group" />
      <enableWhen>
        <question value="medicalImaging_examRequest" />
        <operator value="=" />
        <answerCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20391" />
          <display value="MRI Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
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              <extension url="content">
                <valueString value="Demande d'IRM" />
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      <enableBehavior value="all" />
      <item>
        <linkId value="medicalImaging_patientsafety_MRI_screeningForRenalFunction" />
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              <valueCode value="fr" />
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            <extension url="content">
              <valueString value="Note IRM" />
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          </extension>
        </text>
        <type value="display" />
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    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_patientsafety_recentegfr" />
      <text value="Recent (within 6 months) estimated Glomerular Filtration Rate (eGFR):">
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          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Débit de filtration glomérulaire estimé (DFGe) récent (dans les 6 derniers mois) :" />
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        </extension>
      </text>
      <type value="group" />
      <enableWhen>
        <question value="medicalImaging_patientsafety_renal" />
        <operator value="=" />
        <answerCoding>
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          <code value="21316" />
          <display value="Patient has impaired renal function or a history of renal transplant">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
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              <extension url="content">
                <valueString value="Le patient présente une insuffisance rénale ou des antécédents de greffe rénale" />
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          </display>
        </answerCoding>
      </enableWhen>
      <enableBehavior value="all" />
      <item>
        <linkId value="medicalImaging_patientsafety_eGFR_display" />
        <text value="Recent (within 6 months) estimated Glomerular Filtration Rate (eGFR):">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
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            <extension url="content">
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          </extension>
        </text>
        <type value="display" />
      </item>
      <item>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info">
          <extension url="enableWhenExpression">
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              <language value="text/fhirpath" />
              <expression value="false" />
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          </extension>
        </extension>
        <linkId value="medicalImaging_patientsafety_eGFR_display2" />
        <text value="Note: if eGFR is not available at the time of referral, please ensure it is available prior to exam date.">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="font-weight:bold;color:#AA0000;" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Remarque : si le DFGe n'est pas disponible au moment de la demande, veuillez vous assurer qu'il le soit avant la date de l'examen." />
            </extension>
          </extension>
        </text>
        <type value="display" />
      </item>
      <item>
        <linkId value="medicalImaging_patientsafety_eGFR_result" />
        <code>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21285" />
        </code>
        <text value="eGFR result:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Résultat du DFGe :" />
            </extension>
          </extension>
        </text>
        <type value="integer" />
      </item>
      <item>
        <linkId value="medicalImaging_patientsafety_eGFR_date" />
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          <code value="21316" />
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            <extension url="lang">
              <valueCode value="fr" />
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              <valueString value="Directives sur l'insuffisance rénale aiguë associée au produit de contraste" />
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                <valueString value="Afficher" />
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        <linkId value="medicalImaging_patientsafety_contrastguidance_display" />
        <text value="For non-emergent presentation of stable outpatients,
  inpatients, and emergency patients when eGFR is available:



  
    If eGFR >30 mL/min/1.73 m2 and no signs and
    symptoms of acute kidney injury (AKI), then proceed with an indicated
    contrast imaging study.
  

  
    Imaging with ICM can be performed in patients on peritoneal or
    hemodialysis regardless of residual urine output and no change in
    dialysis schedule is required.
  



  
    Macdonald DB, Hurrell C, Costa AF, et al. Canadian Association of
    Radiologists Guidance on Contrast Associated Acute Kidney Injury.
    Can Assoc Radiol J. 2022;73(3):499-514.
    doi:10.1177/08465371221083970">
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  For <b>non-emergent presentation</b> of stable outpatients,
  inpatients, and emergency patients when eGFR is available:
</p>

<span style="text-decoration: underline;">
  <li>
    If eGFR &gt;30&#xa0;mL/min/1.73&#xa0;m<sup>2</sup> and no signs and
    symptoms of acute kidney injury (AKI), then proceed with an indicated
    contrast imaging study.
  </li>

  <li>
    Imaging with ICM can be performed in patients on peritoneal or
    hemodialysis regardless of residual urine output and no change in
    dialysis schedule is required.
  </li>
</span>

<p>
  <i>
    Macdonald DB, Hurrell C, Costa AF, et al. Canadian Association of
    Radiologists Guidance on Contrast Associated Acute Kidney Injury.
    Can Assoc Radiol J. 2022;73(3):499-514.
    doi:10.1177/08465371221083970
  </i>
</p>" />
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        <code value="21288" />
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      <text value="Known hypersensitivity to contrast agents:">
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          <extension url="lang">
            <valueCode value="fr" />
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          <extension url="content">
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          <code value="20391" />
          <display value="MRI Requisition">
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      <required value="true" />
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          <valueString value="border-style:solid;" />
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        <linkId value="medicalImaging_patientsafety_knownhypersensitivity_reaction_contrastAgent" />
        <text value="Name of contrast agent causing hypersensitivity (if known):">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
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              <valueCode value="fr" />
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            <extension url="lang">
              <valueCode value="fr" />
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    <item>
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            <code value="push-button" />
            <display value="Push Button" />
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        </valueCodeableConcept>
      </extension>
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      <text value="Contrast Hypersensitivity Pre-Medication Guidance">
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          <extension url="lang">
            <valueCode value="fr" />
          </extension>
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      <type value="string" />
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              <valueCode value="fr" />
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            <extension url="content">
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            </extension>
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        <initialSelected value="true" />
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            </extension>
          </extension>
        </valueString>
      </answerOption>
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    <item>
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      <linkId value="medicalImaging_patientsafety_contrastHypersensitivity_guidance" />
      <text value="For mild to moderate hypersensitivity reactions, the referring provider can provide the following for the patient to bring to their appointment:


    Oral second-generation antihistamine at least 1 hour before exam (optional)
    
    Steroid premedication is not recommended

Second/third generation antihistamines include Bilastine, Cetirizine, Desloratadine, Fexofenadine, Levocetirizine, Loratadine, and Rupatadine.




Sources:

    Byrne A, Macdonald DB, Kirkpatrick IDC, Pham M, Green CR, Copaescu AM et al. CAR/CSACI Practice Guidance for Contrast Media Hypersensitivity. Can Assoc Radiol J. 2025 Jan 11. Available from: https://doi.org/10.1177/08465371241311253
    
    Wang C, Ramsey A, Lang D, Copaescu AM, Krishnan P, Kuruvilla M, et al. Management and Prevention of Hypersensitivity Reactions to Radiocontrast Media: A Consensus Statement from the American College of Radiology and the American Academy of Allergy, Asthma & Immunology. Radiology. 2025 May 1;315(2). Available from: https://doi.org/10.1148/radiol.240100">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
          <valueString value="<p>For mild to moderate hypersensitivity reactions, the <b>referring provider</b> can provide the following for the patient to bring to their appointment:
</p>
<span style="text-decoration: underline;">
    <li><b>Oral second-generation antihistamine at least 1 hour before exam (optional)</b>
    </li>
    <li>Steroid premedication is <b>not</b> recommended</li>
</span>
<p>Second/third generation antihistamines include Bilastine, Cetirizine, Desloratadine, Fexofenadine, Levocetirizine, Loratadine, and Rupatadine.
</p>
<p/>
<p><img 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<p><sub>Sources:</sub></p>
<span style="text-decoration: underline;">
    <li><sub>Byrne A, Macdonald DB, Kirkpatrick IDC, Pham M, Green CR, Copaescu AM et al. CAR/CSACI Practice Guidance for Contrast Media Hypersensitivity. Can Assoc Radiol J. 2025 Jan 11. Available from: https://doi.org/10.1177/08465371241311253</sub>
    </li>
    <li><sub>Wang C, Ramsey A, Lang D, Copaescu AM, Krishnan P, Kuruvilla M, et al. Management and Prevention of Hypersensitivity Reactions to Radiocontrast Media: A Consensus Statement from the American College of Radiology and the American Academy of Allergy, Asthma &amp; Immunology. Radiology. 2025 May 1;315(2). Available from: https://doi.org/10.1148/radiol.240100</sub>
    </li>
</span>" />
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        <question value="medicalImaging_patientsafety_contrastHypersensitivity" />
        <operator value="=" />
        <answerString value="Show" />
      </enableWhen>
    </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="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_patientsafety_currentlypregnant" />
      <text value="Currently Pregnant">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Enceinte actuellement" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <enableWhen>
        <question value="medicalImaging_examRequest" />
        <operator value="=" />
        <answerCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20390" />
          <display value="CT Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Demande de TDM" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableWhen>
        <question value="medicalImaging_examRequest" />
        <operator value="=" />
        <answerCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20391" />
          <display value="MRI Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Demande d'IRM" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableWhen>
        <question value="medicalImaging_examRequest" />
        <operator value="=" />
        <answerCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20392" />
          <display value="X-Ray Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Demande de radiographie" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableWhen>
        <question value="medicalImaging_examRequest" />
        <operator value="=" />
        <answerCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20394" />
          <display value="Bone Mineral Density Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Demande d'ostéodensitométrie" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableBehavior value="any" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21261" />
          <display value="Currently Pregnant">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Enceinte actuellement" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_patientsafety_currentlypregnant_sub" />
      <text>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
      </text>
      <type value="group" />
      <enableWhen>
        <question value="medicalImaging_patientsafety_currentlypregnant" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </enableWhen>
      <enableWhen>
        <question value="medicalImaging_examRequest_US_obstetrical" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </enableWhen>
      <enableBehavior value="any" />
      <item>
        <linkId value="medicalImaging_patientsafety_estimateddelivery" />
        <code>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21291" />
        </code>
        <text value="Estimated Date of Delivery:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Date prévue de l'accouchement :" />
            </extension>
          </extension>
        </text>
        <type value="date" />
      </item>
      <item>
        <linkId value="medicalImaging_patientsafety_lastmenstrualdate" />
        <code>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21292" />
        </code>
        <text value="Last Menstrual Period:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Date des dernières menstruations :" />
            </extension>
          </extension>
        </text>
        <type value="date" />
      </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="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_patientsafety_breastfeeding" />
      <text value="Currently breastfeeding">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Allaite actuellement" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <enableWhen>
        <question value="medicalImaging_examRequest" />
        <operator value="=" />
        <answerCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20390" />
          <display value="CT Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Demande de TDM" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableWhen>
        <question value="medicalImaging_examRequest" />
        <operator value="=" />
        <answerCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20391" />
          <display value="MRI Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Demande d'IRM" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableBehavior value="any" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21293" />
          <display value="Currently breastfeeding">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Allaite actuellement" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="true" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </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="medicalImaging_patientsafety_reliable" />
      <text value="Patient cannot provide reliable medical history or provide consent to contrast injections (where applicable)">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Le patient ne peut pas fournir d'antécédents médicaux fiables ni consentir aux injections de produit de contraste (le cas échéant)" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <enableWhen>
        <question value="medicalImaging_examRequest" />
        <operator value="=" />
        <answerCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20390" />
          <display value="CT Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Demande de TDM" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableWhen>
        <question value="medicalImaging_examRequest" />
        <operator value="=" />
        <answerCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20391" />
          <display value="MRI Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Demande d'IRM" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableBehavior value="any" />
      <repeats value="true" />
      <answerOption>
        <valueString value="Patient cannot provide reliable medical history or provide consent to contrast injections (where applicable)">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Le patient ne peut pas fournir d'antécédents médicaux fiables ni consentir aux injections de produit de contraste (le cas échéant)" />
            </extension>
          </extension>
        </valueString>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_patientsafety_SDM" />
      <text value="Please notify the Substitute Decision Maker (SDM) or Power of Attorney (POA) to attend the scheduled appointment with the patient. They may be required to provide pertinent medical history or assist in obtaining such information from appropriate parties.">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
          <valueString value="<p>Please notify the <b>Substitute Decision Maker (SDM)</b> or <b>Power of Attorney (POA)</b> to attend the scheduled appointment with the patient. They may be required to provide pertinent medical history or assist in obtaining such information from appropriate parties.
</p>" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="SDM" />
          </extension>
        </extension>
      </text>
      <type value="display" />
      <enableWhen>
        <question value="medicalImaging_patientsafety_reliable" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </enableWhen>
    </item>
    <item>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </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="medicalImaging_patientsafety_accessibility" />
      <text value="Accessibility concerns or disability:">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Préoccupations liées à l'accessibilité ou incapacité :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <repeats value="true" />
      <answerOption>
        <valueString value="Accessibility concerns or disability">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Préoccupations liées à l'accessibilité ou incapacité" />
            </extension>
          </extension>
        </valueString>
      </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://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="listSeparator">
          <valueString value="," />
        </extension>
        <extension url="lastSeparator">
          <valueString value="and" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <linkId value="medicalImaging_patientsafety_accessibility_specify" />
      <text>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
      </text>
      <type value="choice" />
      <enableWhen>
        <question value="medicalImaging_patientsafety_accessibility" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </enableWhen>
      <enableBehavior value="all" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21270" />
          <display value="Falls risk">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Risque de chute" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21272" />
          <display value="Patient requires lift">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Le patient nécessite un lève-personne" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21274" />
          <display value="Wheelchair">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Fauteuil roulant" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21271" />
          <display value="Hearing impaired">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Malentendant" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
          <code value="OTH" />
          <display value="Other">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Autre" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <linkId value="medicalImaging_patientsafety_accessibility_specify_other" />
      <text value="Specify">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Préciser" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <enableWhen>
        <question value="medicalImaging_patientsafety_accessibility_specify" />
        <operator value="=" />
        <answerCoding>
          <system value="http://terminology.hl7.org/CodeSystem/v3-NullFlavor" />
          <code value="OTH" />
          <display value="Other">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Autre" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableBehavior value="all" />
      <required 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>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <linkId value="medicalImaging_patientsafety_claustrophobia" />
      <text value="Claustrophobia">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Claustrophobie" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <enableWhen>
        <question value="medicalImaging_examRequest" />
        <operator value="=" />
        <answerCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20390" />
          <display value="CT Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Demande de TDM" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableWhen>
        <question value="medicalImaging_examRequest" />
        <operator value="=" />
        <answerCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20391" />
          <display value="MRI Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Demande d'IRM" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableBehavior value="any" />
      <repeats value="false" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21294" />
          <display value="Claustrophobia">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Claustrophobie" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/display-note-info">
        <extension url="enableWhenExpression">
          <valueExpression>
            <language value="text/fhirpath" />
            <expression value="false" />
          </valueExpression>
        </extension>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </extension>
      <linkId value="medicalImaging_patientsafety_requiresedation_claustrophobia" />
      <text value="For patients with claustrophobia requiring oral sedation, the referring clinician is responsible for prescribing the medications. Patients taking oral sedation must not drive and should arrange alternative transportation.">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
          <valueString value="<p> For patients with claustrophobia requiring <b>oral sedation</b>, the <b>referring clinician</b> is responsible for prescribing the medications. Patients taking oral sedation must not drive and should arrange alternative transportation. </p>">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="<p> Pour les patients claustrophobes nécessitant une <b>sédation orale</b>, le <b>clinicien traitant</b> est responsable de prescrire les médicaments. Les patients sous sédation orale ne doivent pas conduire et devraient prévoir un autre moyen de transport. </p>" />
              </extension>
            </extension>
          </valueString>
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Pour les patients claustrophobes nécessitant une sédation orale, le médecin traitant ou l'infirmier praticien est responsable de prescrire les médicaments. Les patients sous sédation orale ne doivent pas conduire et devraient prévoir un autre moyen de transport." />
          </extension>
        </extension>
      </text>
      <type value="display" />
      <enableWhen>
        <question value="medicalImaging_patientsafety_claustrophobia" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </enableWhen>
      <enableBehavior value="any" />
    </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="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <linkId value="medicalImaging_patientsafety_anesthesia" />
      <text value="Require general anesthesia">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="display:none;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Nécessite une anesthésie générale" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <enableWhen>
        <question value="medicalImaging_examRequest" />
        <operator value="=" />
        <answerCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20390" />
          <display value="CT Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Demande de TDM" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableWhen>
        <question value="medicalImaging_examRequest" />
        <operator value="=" />
        <answerCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20391" />
          <display value="MRI Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Demande d'IRM" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableBehavior value="any" />
      <repeats value="false" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21295" />
          <display value="Require general anesthesia">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Nécessite une anesthésie générale" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-choiceOrientation">
        <valueCode value="horizontal" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="border-style:solid;" />
      </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="medicalImaging_patientsafety_piccporta" />
      <text value="Existing vascular access:" />
      <type value="choice" />
      <enableWhen>
        <question value="medicalImaging_examRequest" />
        <operator value="=" />
        <answerCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20390" />
          <display value="CT Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Demande de TDM" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableWhen>
        <question value="medicalImaging_examRequest" />
        <operator value="=" />
        <answerCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="20391" />
          <display value="MRI Requisition">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Demande d'IRM" />
              </extension>
            </extension>
          </display>
        </answerCoding>
      </enableWhen>
      <enableBehavior value="any" />
      <repeats value="true" />
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21383" />
          <display value="Existing PICC line">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Cathéter central à insertion périphérique (PICC) en place" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21384" />
          <display value="Existing Port-a-Cath">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Port-a-Cath en place" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
    <item>
      <linkId value="medicalImaging_patientsafety_requiresedation_rationale" />
      <text value="Rationale:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Justification :" />
          </extension>
        </extension>
      </text>
      <type value="text" />
      <enableWhen>
        <question value="medicalImaging_patientsafety_anesthesia" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </enableWhen>
      <enableBehavior value="all" />
      <required value="true" />
    </item>
    <item>
      <linkId value="medicalImaging_weight_height" />
      <text value="Patient Weight and Height">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="font-weight:bold;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Poids et taille du patient" />
          </extension>
        </extension>
      </text>
      <type value="group" />
      <enableWhen>
        <question value="medicalImaging_weightHeightRequirement" />
        <operator value="!=" />
        <answerString value="HIDE" />
      </enableWhen>
      <enableBehavior value="any" />
      <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="medicalImaging_weight_height_units" />
        <text value="Units:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Unités :" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <enableBehavior value="any" />
        <repeats value="false" />
        <answerOption>
          <valueString value="Imperial (ft.in/lbs)">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Système impérial (pi.po/lb)" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
        <answerOption>
          <valueString value="Metric (cm/kgs)">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Système métrique (cm/kg)" />
              </extension>
            </extension>
          </valueString>
          <initialSelected value="true" />
        </answerOption>
      </item>
      <item>
        <linkId value="medicalImaging_weight_height_group" />
        <text value="Imperial height and weight required">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Taille et poids requis en unités impériales" />
            </extension>
          </extension>
        </text>
        <type value="group" />
        <enableWhen>
          <question value="medicalImaging_weight_height_units" />
          <operator value="=" />
          <answerString value="Imperial (ft.in/lbs)" />
        </enableWhen>
        <enableWhen>
          <question value="medicalImaging_weightHeightRequirement" />
          <operator value="=" />
          <answerString value="MRI_HEIGHT_WEIGHT_REQUIRED" />
        </enableWhen>
        <enableBehavior value="all" />
        <item>
          <linkId value="medicalImaging_weight_height_lb" />
          <code>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20918" />
            <display value="Weight (lbs)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Poids (lb)" />
                </extension>
              </extension>
            </display>
          </code>
          <text value="Weight (lbs):">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Poids (lb) :" />
              </extension>
            </extension>
          </text>
          <type value="integer" />
          <enableBehavior value="any" />
          <required value="true" />
        </item>
        <item>
          <linkId value="medicalImaging_weight_height_ft" />
          <code>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20916" />
            <display value="Height (ft)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Taille (pi)" />
                </extension>
              </extension>
            </display>
          </code>
          <text value="Height (ft):">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Taille (pi) :" />
              </extension>
            </extension>
          </text>
          <type value="decimal" />
          <enableBehavior value="any" />
          <required value="true" />
        </item>
        <item>
          <linkId value="medicalImaging_weight_height_in" />
          <code>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20917" />
            <display value="Height (in)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Taille (po)" />
                </extension>
              </extension>
            </display>
          </code>
          <text value="Height (in):">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Taille (po) :" />
              </extension>
            </extension>
          </text>
          <type value="decimal" />
          <enableBehavior value="any" />
        </item>
      </item>
      <item>
        <linkId value="medicalImaging_weight_height_req" />
        <text value="Imperial weight required">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Poids requis en unités impériales" />
            </extension>
          </extension>
        </text>
        <type value="group" />
        <enableWhen>
          <question value="medicalImaging_weight_height_units" />
          <operator value="=" />
          <answerString value="Imperial (ft.in/lbs)" />
        </enableWhen>
        <enableWhen>
          <question value="medicalImaging_weightHeightRequirement" />
          <operator value="=" />
          <answerString value="CT_WEIGHT_REQUIRED" />
        </enableWhen>
        <enableBehavior value="all" />
        <item>
          <linkId value="medicalImaging_weight_height_required_lb" />
          <code>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20918" />
            <display value="Weight (lbs)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Poids (lb)" />
                </extension>
              </extension>
            </display>
          </code>
          <text value="Weight (lbs):">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Poids (lb) :" />
              </extension>
            </extension>
          </text>
          <type value="decimal" />
          <enableBehavior value="any" />
          <required value="true" />
        </item>
        <item>
          <linkId value="medicalImaging_weight_height_required_ft" />
          <code>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20916" />
            <display value="Height (ft)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Taille (pi)" />
                </extension>
              </extension>
            </display>
          </code>
          <text value="Height (ft):">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Taille (pi) :" />
              </extension>
            </extension>
          </text>
          <type value="decimal" />
          <enableBehavior value="any" />
        </item>
        <item>
          <linkId value="medicalImaging_weight_height_required_in" />
          <code>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20917" />
            <display value="Height (in)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Taille (po)" />
                </extension>
              </extension>
            </display>
          </code>
          <text value="Height (in):">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Taille (po) :" />
              </extension>
            </extension>
          </text>
          <type value="decimal" />
          <enableBehavior value="any" />
        </item>
      </item>
      <item>
        <linkId value="medicalImaging_weight_height_notrequired" />
        <text value="Imperial not required">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Unités impériales non requises" />
            </extension>
          </extension>
        </text>
        <type value="group" />
        <enableWhen>
          <question value="medicalImaging_weight_height_units" />
          <operator value="=" />
          <answerString value="Imperial (ft.in/lbs)" />
        </enableWhen>
        <enableWhen>
          <question value="medicalImaging_weightHeightRequirement" />
          <operator value="=" />
          <answerString value="BMD_HEIGHT_WEIGHT_OPTIONAL" />
        </enableWhen>
        <enableBehavior value="all" />
        <item>
          <linkId value="medicalImaging_weight_height_notrequired_lb" />
          <code>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20918" />
            <display value="Weight (lbs)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Poids (lb)" />
                </extension>
              </extension>
            </display>
          </code>
          <text value="Weight (lbs):">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Poids (lb) :" />
              </extension>
            </extension>
          </text>
          <type value="decimal" />
          <enableBehavior value="any" />
        </item>
        <item>
          <linkId value="medicalImaging_weight_height_notrequired_ft" />
          <code>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20916" />
            <display value="Height (ft)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Taille (pi)" />
                </extension>
              </extension>
            </display>
          </code>
          <text value="Height (ft):">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Taille (pi) :" />
              </extension>
            </extension>
          </text>
          <type value="decimal" />
          <enableBehavior value="any" />
        </item>
        <item>
          <linkId value="medicalImaging_weight_height_notrequired_in" />
          <code>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20917" />
            <display value="Height (in)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Taille (po)" />
                </extension>
              </extension>
            </display>
          </code>
          <text value="Height (in):">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Taille (po) :" />
              </extension>
            </extension>
          </text>
          <type value="decimal" />
          <enableBehavior value="any" />
        </item>
      </item>
      <item>
        <linkId value="medicalImaging_weight_height_required_metric" />
        <text value="Metric height and weight required">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Taille et poids requis en unités métriques" />
            </extension>
          </extension>
        </text>
        <type value="group" />
        <enableWhen>
          <question value="medicalImaging_weight_height_units" />
          <operator value="=" />
          <answerString value="Metric (cm/kgs)" />
        </enableWhen>
        <enableWhen>
          <question value="medicalImaging_weightHeightRequirement" />
          <operator value="=" />
          <answerString value="MRI_HEIGHT_WEIGHT_REQUIRED" />
        </enableWhen>
        <enableBehavior value="all" />
        <item>
          <linkId value="medicalImaging_weight_height_required_metric_kg" />
          <code>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20823" />
            <display value="Weight (kg)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Poids (kg)" />
                </extension>
              </extension>
            </display>
          </code>
          <text value="Weight (kgs):">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Poids (kg) :" />
              </extension>
            </extension>
          </text>
          <type value="decimal" />
          <required value="true" />
        </item>
        <item>
          <linkId value="medicalImaging_weight_height_required_metric_cm" />
          <code>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20822" />
            <display value="Height (cm)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Taille (cm)" />
                </extension>
              </extension>
            </display>
          </code>
          <text value="Height (cm):">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Taille (cm) :" />
              </extension>
            </extension>
          </text>
          <type value="decimal" />
          <enableBehavior value="all" />
          <required value="true" />
        </item>
      </item>
      <item>
        <linkId value="medicalImaging_weight_required_metric" />
        <text value="Metric weight required">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Poids requis en unités métriques" />
            </extension>
          </extension>
        </text>
        <type value="group" />
        <enableWhen>
          <question value="medicalImaging_weight_height_units" />
          <operator value="=" />
          <answerString value="Metric (cm/kgs)" />
        </enableWhen>
        <enableWhen>
          <question value="medicalImaging_weightHeightRequirement" />
          <operator value="=" />
          <answerString value="CT_WEIGHT_REQUIRED" />
        </enableWhen>
        <enableBehavior value="all" />
        <item>
          <linkId value="medicalImaging_weight_required_metric_kg" />
          <code>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20823" />
            <display value="Weight (kg)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Poids (kg)" />
                </extension>
              </extension>
            </display>
          </code>
          <text value="Weight (kgs):">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Poids (kg) :" />
              </extension>
            </extension>
          </text>
          <type value="decimal" />
          <required value="true" />
        </item>
        <item>
          <linkId value="medicalImaging_weight_required_metric_cm" />
          <code>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20822" />
            <display value="Height (cm)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Taille (cm)" />
                </extension>
              </extension>
            </display>
          </code>
          <text value="Height (cm):">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Taille (cm) :" />
              </extension>
            </extension>
          </text>
          <type value="decimal" />
          <enableBehavior value="all" />
        </item>
      </item>
      <item>
        <linkId value="medicalImaging_weight_notrequired_metric" />
        <text value="Metric not required">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Unités métriques non requises" />
            </extension>
          </extension>
        </text>
        <type value="group" />
        <enableWhen>
          <question value="medicalImaging_weight_height_units" />
          <operator value="=" />
          <answerString value="Metric (cm/kgs)" />
        </enableWhen>
        <enableWhen>
          <question value="medicalImaging_weightHeightRequirement" />
          <operator value="=" />
          <answerString value="BMD_HEIGHT_WEIGHT_OPTIONAL" />
        </enableWhen>
        <enableBehavior value="all" />
        <item>
          <linkId value="medicalImaging_weight_notrequired_metric_kg" />
          <code>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20823" />
            <display value="Weight (kg)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Poids (kg)" />
                </extension>
              </extension>
            </display>
          </code>
          <text value="Weight (kgs):">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Poids (kg) :" />
              </extension>
            </extension>
          </text>
          <type value="decimal" />
        </item>
        <item>
          <linkId value="medicalImaging_weight_notrequired_metric_cm" />
          <code>
            <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
            <code value="20822" />
            <display value="Height (cm)">
              <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Taille (cm)" />
                </extension>
              </extension>
            </display>
          </code>
          <text value="Height (cm):">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Taille (cm) :" />
              </extension>
            </extension>
          </text>
          <type value="decimal" />
          <enableBehavior value="all" />
        </item>
      </item>
      <item>
        <linkId value="medicalImaging_weight_height_date" />
        <text value="Date of Weight/Height:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Date de la mesure du poids/de la taille :" />
            </extension>
          </extension>
        </text>
        <type value="date" />
        <enableWhen>
          <question value="medicalImaging_weight_height_units" />
          <operator value="exists" />
          <answerBoolean value="true" />
        </enableWhen>
      </item>
    </item>
  </item>
  <item>
    <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="groupItems">
        <valueBoolean value="false" />
      </extension>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
      <valueString value="border-style:solid;" />
    </extension>
    <linkId value="medicalImaging_scheduling_" />
    <text value="Scheduling">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="font-weight:bold;" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Planification" />
        </extension>
      </extension>
    </text>
    <type value="group" />
    <enableWhen>
      <question value="medicalImaging_examRequest" />
      <operator value="exists" />
      <answerBoolean value="true" />
    </enableWhen>
    <enableBehavior value="any" />
    <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="medicalImaging_scheduling" />
      <text value="Request specific appointment date or time interval based on:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Demander une date de rendez-vous précise ou un intervalle de temps en fonction de :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <repeats value="true" />
      <answerOption>
        <valueString value="Clinical Reasons">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Raisons cliniques" />
            </extension>
          </extension>
        </valueString>
      </answerOption>
      <answerOption>
        <valueString value="Other Considerations">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Autres considérations" />
            </extension>
          </extension>
        </valueString>
      </answerOption>
    </item>
    <item>
      <linkId value="medicalImaging_scheduling_clinicalreasons_other" />
      <text value="Specify Timeframe:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Préciser le délai :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <enableWhen>
        <question value="medicalImaging_scheduling" />
        <operator value="exists" />
        <answerBoolean value="true" />
      </enableWhen>
      <required value="true" />
    </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>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="style">
          <valueString value="display:none;" />
        </extension>
        <extension url="sameLine">
          <valueBoolean value="false" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <linkId value="medicalImaging_scheduling_clinicalreasons" />
      <text value="Clinical Reasons:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Raisons cliniques :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <enableWhen>
        <question value="medicalImaging_scheduling" />
        <operator value="=" />
        <answerString value="Clinical Reasons" />
      </enableWhen>
      <repeats value="false" />
      <answerOption>
        <valueString value="Timed follow-up (eg,. 6 months interval study)">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Suivi programmé (p. ex. examen à 6 mois d'intervalle)" />
            </extension>
          </extension>
        </valueString>
      </answerOption>
      <answerOption>
        <valueString value="Procedural (eg., pre/post op)">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Intervention (p. ex. pré/postopératoire)" />
            </extension>
          </extension>
        </valueString>
      </answerOption>
      <answerOption>
        <valueString value="Patient navigation (eg., Before a specialist appointment)">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Accompagnement du patient (p. ex. avant un rendez-vous avec un spécialiste)" />
            </extension>
          </extension>
        </valueString>
      </answerOption>
      <answerOption>
        <valueString value="Other clinical reasons">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Autres raisons cliniques" />
            </extension>
          </extension>
        </valueString>
      </answerOption>
    </item>
    <item>
      <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
        <extension url="sameLine">
          <valueBoolean value="true" />
        </extension>
        <extension url="quoteAnswer">
          <valueBoolean value="false" />
        </extension>
      </extension>
      <linkId value="medicalImaging_scheduling_clinicalreasons_rationale" />
      <text value="Specify Rationale:" />
      <type value="string" />
      <enableWhen>
        <question value="medicalImaging_scheduling_clinicalreasons" />
        <operator value="=" />
        <answerString value="Other clinical reasons" />
      </enableWhen>
      <required value="true" />
    </item>
    <item>
      <linkId value="medicalImaging_scheduling_nonclinical" />
      <text value="Non-Clinical Considerations:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Considérations non cliniques :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <enableWhen>
        <question value="medicalImaging_scheduling" />
        <operator value="=" />
        <answerString value="Other Considerations" />
      </enableWhen>
    </item>
  </item>
  <item>
    <linkId value="pref_consultant_group" />
    <type value="group" />
    <enableWhen>
      <question value="medicalImaging_examRequest" />
      <operator value="=" />
      <answerCoding>
        <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
        <code value="20390" />
        <display value="CT Requisition">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Demande de TDM" />
            </extension>
          </extension>
        </display>
      </answerCoding>
    </enableWhen>
    <enableWhen>
      <question value="medicalImaging_examRequest" />
      <operator value="=" />
      <answerCoding>
        <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
        <code value="20391" />
        <display value="MRI Requisition">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Demande d'IRM" />
            </extension>
          </extension>
        </display>
      </answerCoding>
    </enableWhen>
    <enableWhen>
      <question value="medicalImaging_examRequest" />
      <operator value="=" />
      <answerCoding>
        <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
        <code value="20392" />
        <display value="X-Ray Requisition">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Demande de radiographie" />
            </extension>
          </extension>
        </display>
      </answerCoding>
    </enableWhen>
    <enableBehavior value="any" />
    <item>
      <linkId value="preferredconsultlocation_header" />
      <text value="Preferred Consultant or Location">
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="font-weight:bold;" />
        </extension>
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Consultant ou lieu préféré" />
          </extension>
        </extension>
      </text>
      <type value="group" />
      <item>
        <linkId value="preferredconsultlocation_display" />
        <text value="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/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Tous les patients seront orientés vers le délai d'attente le plus court, à moins qu'un consultant ou un lieu préféré ne soit indiqué." />
            </extension>
          </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" />
              <display value="Check-box" />
            </coding>
          </valueCodeableConcept>
        </extension>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="style">
            <valueString value="display:none;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="preferredconsultlocation_selector" />
        <text value="Preferred consultant or location">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Consultant ou lieu préféré" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <repeats value="false" />
        <answerOption>
          <valueString value="Preferred consultant or location">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Consultant ou lieu préféré" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
      </item>
      <item>
        <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
          <valueString value="border-style:solid;" />
        </extension>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/group-note-info">
          <extension url="enableWhenExpression">
            <valueExpression>
              <language value="text/fhirpath" />
              <expression value="false" />
            </valueExpression>
          </extension>
          <extension url="groupItems">
            <valueBoolean value="false" />
          </extension>
        </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 url="http://hl7.org/fhir/StructureDefinition/translation">
                <extension url="lang">
                  <valueCode value="fr" />
                </extension>
                <extension url="content">
                  <valueString value="Veuillez préciser un consultant ou un lieu <b>préféré</b> :" />
                </extension>
              </extension>
            </valueString>
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Veuillez préciser un consultant préféré ou un lieu préféré :" />
            </extension>
          </extension>
        </text>
        <type value="group" />
        <enableWhen>
          <question value="preferredconsultlocation_selector" />
          <operator value="exists" />
          <answerBoolean value="true" />
        </enableWhen>
        <item>
          <linkId value="preferredconsultlocation_consultant" />
          <text value="Consultant:">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Consultant :" />
              </extension>
            </extension>
          </text>
          <type value="string" />
        </item>
        <item>
          <linkId value="preferredconsultlocation_location" />
          <text value="Location:">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Lieu :" />
              </extension>
            </extension>
          </text>
          <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>
        <extension url="http://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
          <extension url="style">
            <valueString value="display:none;" />
          </extension>
          <extension url="sameLine">
            <valueBoolean value="false" />
          </extension>
          <extension url="quoteAnswer">
            <valueBoolean value="false" />
          </extension>
        </extension>
        <linkId value="preferredconsultlocation_willingtotravel" />
        <text value="Patient willing to travel for shorter wait time">
          <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
            <valueString value="display:none;" />
          </extension>
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Le patient est prêt à se déplacer pour obtenir un délai d'attente plus court" />
            </extension>
          </extension>
        </text>
        <type value="string" />
        <repeats value="false" />
        <answerOption>
          <valueString value="Patient willing to travel for shorter wait time">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Le patient est prêt à se déplacer pour obtenir un délai d'attente plus court" />
              </extension>
            </extension>
          </valueString>
        </answerOption>
      </item>
      <item>
        <linkId value="preferredconsultlocation_otherconsiderations" />
        <text value="Other considerations:">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Autres considérations :" />
            </extension>
          </extension>
        </text>
        <type value="string" />
      </item>
    </item>
  </item>
  <item>
    <linkId value="supportingDocumentation_header" />
    <text value="Supporting Documentation">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="font-weight:bold;" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Documents à l'appui" />
        </extension>
      </extension>
    </text>
    <type value="group" />
    <enableWhen>
      <question value="medicalImaging_examRequest" />
      <operator value="=" />
      <answerCoding>
        <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
        <code value="20390" />
        <display value="CT Requisition">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Demande de TDM" />
            </extension>
          </extension>
        </display>
      </answerCoding>
    </enableWhen>
    <enableWhen>
      <question value="medicalImaging_examRequest" />
      <operator value="=" />
      <answerCoding>
        <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
        <code value="20391" />
        <display value="MRI Requisition">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Demande d'IRM" />
            </extension>
          </extension>
        </display>
      </answerCoding>
    </enableWhen>
    <enableWhen>
      <question value="medicalImaging_examRequest" />
      <operator value="=" />
      <answerCoding>
        <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
        <code value="20392" />
        <display value="X-Ray Requisition">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Demande de radiographie" />
            </extension>
          </extension>
        </display>
      </answerCoding>
    </enableWhen>
    <enableWhen>
      <question value="medicalImaging_examRequest" />
      <operator value="=" />
      <answerCoding>
        <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
        <code value="20394" />
        <display value="Bone Mineral Density Requisition">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="Demande d'ostéodensitométrie" />
            </extension>
          </extension>
        </display>
      </answerCoding>
    </enableWhen>
    <enableBehavior value="any" />
    <item>
      <linkId value="supportingDocumentation_relevant_imaging" />
      <text value="Previous Relevant Imaging (if applicable)">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Imagerie antérieure pertinente (le cas échéant)" />
          </extension>
        </extension>
      </text>
      <type value="string" />
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/mimeType">
        <valueCode value="application/pdf" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/maxSize">
        <valueDecimal value="5000000" />
      </extension>
      <linkId value="supportingDocumentation_attachment" />
      <text value="Add attachments">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Ajouter des pièces jointes" />
          </extension>
        </extension>
      </text>
      <type value="attachment" />
    </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://ontariohealth.ca/fhir/eforms/StructureDefinition/question-note-info">
      <extension url="style">
        <valueString value="display:none;" />
      </extension>
      <extension url="sameLine">
        <valueBoolean value="false" />
      </extension>
      <extension url="quoteAnswer">
        <valueBoolean value="false" />
      </extension>
    </extension>
    <linkId value="657300800304" />
    <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-style">
        <valueString value="display:none;" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Des renseignements personnels sur la santé qui sont pertinents sur le plan médical n'ont pas été divulgués à la demande du patient." />
        </extension>
      </extension>
    </text>
    <type value="string" />
    <repeats value="false" />
    <answerOption>
      <valueString 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/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Des renseignements personnels sur la santé qui sont pertinents sur le plan médical n'ont pas été divulgués à la demande du patient." />
          </extension>
        </extension>
      </valueString>
    </answerOption>
  </item>
  <item>
    <linkId value="feedbacksurvey_MI" />
    <text value="Click here to provide feedback on this form">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-xhtml">
        <valueString value="<p>
  <a href="https://www.surveymonkey.com/r/MISRF">
    Click here to provide feedback on this form
  </a>
</p>">
          <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
              <valueCode value="fr" />
            </extension>
            <extension url="content">
              <valueString value="<p>
  <a href="https://www.surveymonkey.com/r/MISRF">
    Cliquez ici pour donner votre avis sur ce formulaire
  </a>
</p>" />
            </extension>
          </extension>
        </valueString>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Sondage de rétroaction : imagerie médicale" />
        </extension>
      </extension>
    </text>
    <type value="display" />
  </item>
  <item>
    <linkId value="602618746069" />
    <text value="Referrer's Information">
      <extension url="http://hl7.org/fhir/StructureDefinition/rendering-style">
        <valueString value="font-weight:bold;" />
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="Renseignements sur le demandeur" />
        </extension>
      </extension>
    </text>
    <type value="group" />
    <item>
      <linkId value="referrer_sitename" />
      <text value="Site Name:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Nom de l'établissement :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
    </item>
    <item>
      <linkId value="referrer_address_line1" />
      <text value="Address (Line 1):">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Adresse (ligne 1) :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <required value="true" />
    </item>
    <item>
      <linkId value="referrer_address_line2" />
      <text value="Address (Line 2):">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Adresse (ligne 2) :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
    </item>
    <item>
      <linkId value="referrer_address_city" />
      <text value="City:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Ville :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <required value="true" />
    </item>
    <item>
      <linkId value="referrer_address_province" />
      <text value="Province:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Province :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
      <required value="true" />
      <maxLength value="2" />
    </item>
    <item>
      <linkId value="referrer_address_postalcode" />
      <text value="Postal Code:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Code postal :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint">
        <extension url="key">
          <valueId value="phone4" />
        </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="Please enter a valid north-american phone number.  e.g. XXX-XXX-XXXX." />
        </extension>
      </extension>
      <linkId value="referrer_phone" />
      <text value="Phone #:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="N° de téléphone :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
    </item>
    <item>
      <extension url="http://hl7.org/fhir/StructureDefinition/targetConstraint">
        <extension url="key">
          <valueId value="phone5" />
        </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="Please enter a valid north-american phone number.  e.g. XXX-XXX-XXXX." />
        </extension>
      </extension>
      <linkId value="referrer_fax" />
      <text value="Fax #:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="N° de télécopieur :" />
          </extension>
        </extension>
      </text>
      <type value="string" />
    </item>
    <item>
      <linkId value="referrer_billing" />
      <text value="Billing Number:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Numéro de facturation :" />
          </extension>
        </extension>
      </text>
      <type value="integer" />
    </item>
    <item>
      <linkId value="referrer_professionalid" />
      <text value="Professional ID:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="N° d'identification professionnel :" />
          </extension>
        </extension>
      </text>
      <type value="integer" />
    </item>
    <item>
      <linkId value="referrer_signature" />
      <text value="Signed:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Signé :" />
          </extension>
        </extension>
      </text>
      <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:">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
          <extension url="lang">
            <valueCode value="fr" />
          </extension>
          <extension url="content">
            <valueString value="Rôle :" />
          </extension>
        </extension>
      </text>
      <type value="choice" />
      <answerOption>
        <valueCoding>
          <system value="http://snomed.info/sct" />
          <code value="309398001" />
          <display value="Allied Health Professional">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Professionnel paramédical" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21276" />
          <display value="Family Physician">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Médecin de famille" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://snomed.info/sct" />
          <code value="449161006" />
          <display value="Physician Assistant">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Adjoint au médecin" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://snomed.info/sct" />
          <code value="398130009" />
          <display value="Medical Student">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Étudiant en médecine" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://snomed.info/sct" />
          <code value="106292003" />
          <display value="Nurse">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Infirmier" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://snomed.info/sct" />
          <code value="224571005" />
          <display value="Nurse Practitioner">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Infirmier praticien" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21281" />
          <display value="Resident">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Résident" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21282" />
          <display value="Specialist">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Spécialiste" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
      <answerOption>
        <valueCoding>
          <system value="http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes" />
          <code value="21402" />
          <display value="Other">
            <extension url="http://hl7.org/fhir/StructureDefinition/translation">
              <extension url="lang">
                <valueCode value="fr" />
              </extension>
              <extension url="content">
                <valueString value="Autre" />
              </extension>
            </extension>
          </display>
        </valueCoding>
      </answerOption>
    </item>
  </item>
  <item>
    <extension url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden">
      <valueBoolean value="true" />
    </extension>
    <extension url="http://hl7.org/fhir/uv/sdc/StructureDefinition/sdc-questionnaire-calculatedExpression">
      <valueExpression>
        <language value="text/fhirpath" />
        <expression value="(   iif(%resource.item.repeat(item).where(linkId='medicalImaging_examRequest')         .answer.where(valueCoding.code = '20390').exists(), 'CT', {}) |   iif(%resource.item.repeat(item).where(linkId='medicalImaging_examRequest')         .answer.where(valueCoding.code = '20391').exists(), 'MRI', {}) |   iif(%resource.item.repeat(item).where(linkId='medicalImaging_examRequest')         .answer.where(valueCoding.code = '20392').exists(), 'X_RAY', {}) |   iif(%resource.item.repeat(item).where(linkId='medicalImaging_examRequest')         .answer.where(valueCoding.code = '20393').exists(), 'ULTRASOUND', {}) |   iif(%resource.item.repeat(item).where(linkId='medicalImaging_examRequest')         .answer.where(valueCoding.code = '20394').exists(), 'BONE_MINERAL_DENSITY', {}) ).join(' | ')" />
      </valueExpression>
    </extension>
    <linkId value="referralService" />
    <text value="referralService">
      <extension url="http://hl7.org/fhir/StructureDefinition/translation">
        <extension url="lang">
          <valueCode value="fr" />
        </extension>
        <extension url="content">
          <valueString value="referralService" />
        </extension>
      </extension>
    </text>
    <type value="string" />
  </item>
</Questionnaire>