{ "resourceType": "QuestionnaireResponse", "id": "questionnaire-response-02", "text": { "status": "generated", "div": "

Generated Narrative: QuestionnaireResponse questionnaire-response-02

\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
LinkIDTextDefinitionAnswer\"doco\"
\"\"\"\" questionnaire-response-02Questionnaire:urn:uuid:1b12e576-c039-4395-ad20-2d7e8633fe70|0.0.1
\"\"\"\"\"\" questionnaire-response-02 / patient_headerPatient Information
\"\"\"\"\"\"\"\" questionnaire-response-02 / patient_header / patient_surnameSurname:Patel
\"\"\"\"\"\"\"\" questionnaire-response-02 / patient_header / patient_firstnameFirst Name:Alisha
\"\"\"\"\"\"\"\" questionnaire-response-02 / patient_header / patient_date_of_birthDOB:1987-04-12
\"\"\"\"\"\"\"\" questionnaire-response-02 / patient_header / patient_genderGender:AdministrativeGender: female (Female)
\"\"\"\"\"\"\"\" questionnaire-response-02 / patient_header / patient_hc_numberHN:1234567890
\"\"\"\"\"\"\"\" questionnaire-response-02 / patient_header / patient_hc_vcHN VC:AB
\"\"\"\"\"\"\"\" questionnaire-response-02 / patient_header / patient_address_line1Address (Line 1):2453 Dundas St W
\"\"\"\"\"\"\"\" questionnaire-response-02 / patient_header / patient_address_line2Address (Line 2):Apt 708
\"\"\"\"\"\"\"\" questionnaire-response-02 / patient_header / patient_address_cityCity:Toronto
\"\"\"\"\"\"\"\" questionnaire-response-02 / patient_header / patient_address_provinceProvince:ON
\"\"\"\"\"\"\"\" questionnaire-response-02 / patient_header / patient_address_postalcodePostal Code:M6P 1X3
\"\"\"\"\"\"\"\" questionnaire-response-02 / patient_header / patient_phone_mobileMobile #:416-555-0198
\"\"\"\"\"\"\"\" questionnaire-response-02 / patient_header / patient_phone_homeHome #:416-555-0131
\"\"\"\"\"\"\"\" questionnaire-response-02 / patient_header / patient_emailEmail:alisha.patel87@example.com
\"\"\"\"\"\" questionnaire-response-02 / additionalinfo_header[Optional] Additional Patient Information
\"\"\"\"\"\"\"\" questionnaire-response-02 / additionalinfo_header / additionalinfo_sexassignedatbirthSex assigned at birth:LOINC: LA3-6 (Female)
\"\"\"\"\"\"\"\" questionnaire-response-02 / additionalinfo_header / additionalinfo_pronounsPronouns:LOINC: LA29519-8 (she/her/her/hers/herself)
\"\"\"\"\"\"\"\" questionnaire-response-02 / additionalinfo_header / additionalinfo_preferredlanguagePreferred language:Other
\"\"\"\"\"\"\"\" questionnaire-response-02 / additionalinfo_header / additionalinfo_preferredlanguage_specifySpecify:Urdu
\"\"\"\"\"\"\"\" questionnaire-response-02 / additionalinfo_header / additionalinfo_preferredlanguage_translatorrequiredTranslator requiredTranslator Required
\"\"\"\"\"\"\"\" questionnaire-response-02 / additionalinfo_header / additionalinfo_bestmethodofcontactBest method of contact:ContactPointSystem: phone (Phone)
\"\"\"\"\"\"\"\" questionnaire-response-02 / additionalinfo_header / additionalinfo_bestmethodofcontact_voicemailsVoicemails acceptableVoicemails acceptable
\"\"\"\"\"\"\"\" questionnaire-response-02 / additionalinfo_header / additionalinfo_alternatecontact_selectAlternate contactAlternate contact
\"\"\"\"\"\"\"\" questionnaire-response-02 / additionalinfo_header / additionalinfo_alternatecontact_nameName:Imran Patel
\"\"\"\"\"\"\"\" questionnaire-response-02 / additionalinfo_header / additionalinfo_alternatecontact_phoneAlternate contact phone #:416-555-0144
\"\"\"\"\"\"\"\" questionnaire-response-02 / additionalinfo_header / additionalinfo_alternatecontact_relationshipRelationship:Spouse
\"\"\"\"\"\"\"\" questionnaire-response-02 / additionalinfo_header / additionalinfo_alternatecontact_bookingcontactIs Alternate contact the appointment booking contact?:Yes
\"\"\"\"\"\"\"\" questionnaire-response-02 / additionalinfo_header / additionalinfo_accessibilityconcernsordisability_selecttAccessibility concerns or disabilityAccessibility concerns or disability
\"\"\"\"\"\"\"\" questionnaire-response-02 / additionalinfo_header / additionalinfo_accessibilityconcernsordisabilityAccessibility concerns OptionsSNOMED CT: 105503008 (Dependence on wheelchair)
\"\"\"\"\"\"\"\" questionnaire-response-02 / additionalinfo_header / additionalinfo_specialconsiderations_selectSpecial considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)
\"\"\"\"\"\"\"\" questionnaire-response-02 / additionalinfo_header / additionalinfo_specialconsiderationsDetails of special considerations:Patient has significant anxiety in medical settings. Please explain steps in advance; prefers a quiet waiting area when possible.
\"\"\"\"\"\"\"\" questionnaire-response-02 / additionalinfo_header / additionalinfo_sendcopiestoadditionalprovidersSend copies of reports to additional providersSend copies of reports to additional providers
\"\"\"\"\"\"\"\" questionnaire-response-02 / additionalinfo_header / additionalinfo_sendcopiestoadditionalproviders_namesName(s):Dr. Farah Alvi (Endocrinology)
\"\"\"\"\"\"\"\" questionnaire-response-02 / additionalinfo_header / additionalinfo_sendcopiestoadditionalproviders_contactinfoContact information:Fax 416-555-0187
\"\"\"\"\"\" questionnaire-response-02 / 274716928898Referral Details
\"\"\"\"\"\"\"\" questionnaire-response-02 / 274716928898 / 836886186557Triage Considerations
\"\"\"\"\"\"\"\"\"\" questionnaire-response-02 / 274716928898 / 836886186557 / referral_requestedpriorityRequested Priority:RequestPriority: urgent (Urgent)
\"\"\"\"\"\"\"\"\"\" questionnaire-response-02 / 274716928898 / 836886186557 / referral_requestedpriority_urgentreasonReason for urgent triage:Progressive exertional chest tightness with reduced exercise tolerance over the past 3 weeks.
\"\"\"\"\"\"\"\" questionnaire-response-02 / 274716928898 / 200848944281Name of the suspected diagnosis/problem triggering referral:New exertional chest tightness; rule out stable angina / ischemic heart disease.
\"\"\"\"\"\"\"\" questionnaire-response-02 / 274716928898 / 602158378622Brief Description of Referral, History, Management, and Investigations38F with 3-month history of exertional substernal chest tightness when climbing stairs, relieved by rest in 3–5 minutes. No syncope. Occasional palpitations. Risk factors: type 2 diabetes (A1c 7.6%), hypertension, dyslipidemia, strong family history (father MI at 52). Vitals today: BP 146/92, HR 82. Physical exam unremarkable. Baseline ECG in clinic: normal sinus rhythm, no acute ischemic changes. Started ASA 81 mg daily and optimized statin (rosuvastatin 20 mg).
\"\"\"\"\"\" questionnaire-response-02 / preferredconsultlocation_headerPreferred Consultant or Location All patients will be triaged to the shortest wait time unless a preferred consultant or location is entered.
\"\"\"\"\"\"\"\" questionnaire-response-02 / preferredconsultlocation_header / preferredconsultlocation_selectorPreferred consultant or locationPreferred consultant or location
\"\"\"\"\"\"\"\" questionnaire-response-02 / preferredconsultlocation_header / preferredconsultlocation_specifyPlease specify either a preferred consultant or location
\"\"\"\"\"\"\"\"\"\" questionnaire-response-02 / preferredconsultlocation_header / preferredconsultlocation_specify / preferredconsultlocation_consultantConsultant:Dr. Samantha Chen
\"\"\"\"\"\"\"\"\"\" questionnaire-response-02 / preferredconsultlocation_header / preferredconsultlocation_specify / preferredconsultlocation_locationLocation:Toronto General Hospital – Cardiology Clinic
\"\"\"\"\"\"\"\" questionnaire-response-02 / preferredconsultlocation_header / preferredconsultlocation_willingtotravelPatient willing to travel for shorter wait timePatient willing to travel for shorter wait time
\"\"\"\"\"\"\"\" questionnaire-response-02 / preferredconsultlocation_header / preferredconsultlocation_otherconsiderationsOther considerations:Prefers weekday mornings; relies on translator services.
\"\"\"\"\"\" questionnaire-response-02 / referrer_headerReferrer's Information
\"\"\"\"\"\"\"\" questionnaire-response-02 / referrer_header / referrer_sitenameSite Name:Parkdale Family Health Team
\"\"\"\"\"\"\"\" questionnaire-response-02 / referrer_header / referrer_address_line1Address (Line 1):123 Brock Ave
\"\"\"\"\"\"\"\" questionnaire-response-02 / referrer_header / referrer_address_line2Address (Line 2):Suite 401
\"\"\"\"\"\"\"\" questionnaire-response-02 / referrer_header / referrer_address_cityCity:Toronto
\"\"\"\"\"\"\"\" questionnaire-response-02 / referrer_header / referrer_address_provinceProvince:ON
\"\"\"\"\"\"\"\" questionnaire-response-02 / referrer_header / referrer_address_postalcodePostal Code:M6K 2L5
\"\"\"\"\"\"\"\" questionnaire-response-02 / referrer_header / referrer_phonePhone #:416-555-0101
\"\"\"\"\"\"\"\" questionnaire-response-02 / referrer_header / referrer_faxFax #:416-555-0102
\"\"\"\"\"\"\"\" questionnaire-response-02 / referrer_header / referrer_professionalidProfessional ID:7654321
\"\"\"\"\"\"\"\" questionnaire-response-02 / referrer_header / referrer_signatureSigned:Dr. Nadia Rahman, MD CCFP
\"\"\"\"\"\"\"\" questionnaire-response-02 / referrer_header / referrer_roleRole:SNOMED CT: 449161006 (Physician assistant)

\"doco\" Documentation for this format
" }, "questionnaire": "urn:uuid:1b12e576-c039-4395-ad20-2d7e8633fe70|0.0.1", "status": "completed", "subject": { "reference": "Patient/patient-01", "display": "MOMO ABBAS" }, "authored": "2026-01-08T19:01:48.738Z", "author": { "reference": "PractitionerRole/practitioner-role-01", "type": "PractitionerRole", "display": "Susan Clark" }, "item": [ { "linkId": "patient_header", "text": "Patient Information", "item": [ { "linkId": "patient_surname", "text": "Surname:", "answer": [ { "valueString": "Patel" } ] }, { "linkId": "patient_firstname", "text": "First Name:", "answer": [ { "valueString": "Alisha" } ] }, { "linkId": "patient_date_of_birth", "text": "DOB:", "answer": [ { "valueDate": "1987-04-12" } ] }, { "linkId": "patient_gender", "text": "Gender:", "answer": [ { "valueCoding": { "system": "http://hl7.org/fhir/administrative-gender", "code": "female", "display": "Female" } } ] }, { "linkId": "patient_hc_number", "text": "HN:", "answer": [ { "valueString": "1234567890" } ] }, { "linkId": "patient_hc_vc", "text": "HN VC:", "answer": [ { "valueString": "AB" } ] }, { "linkId": "patient_address_line1", "text": "Address (Line 1):", "answer": [ { "valueString": "2453 Dundas St W" } ] }, { "linkId": "patient_address_line2", "text": "Address (Line 2):", "answer": [ { "valueString": "Apt 708" } ] }, { "linkId": "patient_address_city", "text": "City:", "answer": [ { "valueString": "Toronto" } ] }, { "linkId": "patient_address_province", "text": "Province:", "answer": [ { "valueString": "ON" } ] }, { "linkId": "patient_address_postalcode", "text": "Postal Code:", "answer": [ { "valueString": "M6P 1X3" } ] }, { "linkId": "patient_phone_mobile", "text": "Mobile #:", "answer": [ { "valueString": "416-555-0198" } ] }, { "linkId": "patient_phone_home", "text": "Home #:", "answer": [ { "valueString": "416-555-0131" } ] }, { "linkId": "patient_email", "text": "Email:", "answer": [ { "valueString": "alisha.patel87@example.com" } ] } ] }, { "linkId": "additionalinfo_header", "text": "[Optional] Additional Patient Information", "item": [ { "linkId": "additionalinfo_sexassignedatbirth", "text": "Sex assigned at birth:", "answer": [ { "valueCoding": { "system": "http://loinc.org", "code": "LA3-6", "display": "Female" } } ] }, { "linkId": "additionalinfo_pronouns", "text": "Pronouns:", "answer": [ { "valueCoding": { "system": "http://loinc.org", "code": "LA29519-8", "display": "she/her/her/hers/herself" } } ] }, { "linkId": "additionalinfo_preferredlanguage", "text": "Preferred language:", "answer": [ { "valueString": "Other" } ] }, { "linkId": "additionalinfo_preferredlanguage_specify", "text": "Specify:", "answer": [ { "valueString": "Urdu" } ] }, { "linkId": "additionalinfo_preferredlanguage_translatorrequired", "text": "Translator required", "answer": [ { "valueString": "Translator Required" } ] }, { "linkId": "additionalinfo_bestmethodofcontact", "text": "Best method of contact:", "answer": [ { "valueCoding": { "system": "http://hl7.org/fhir/contact-point-system", "code": "phone", "display": "Phone" } } ] }, { "linkId": "additionalinfo_bestmethodofcontact_voicemails", "text": "Voicemails acceptable", "answer": [ { "valueString": "Voicemails acceptable" } ] }, { "linkId": "additionalinfo_alternatecontact_select", "text": "Alternate contact", "answer": [ { "valueString": "Alternate contact" } ] }, { "linkId": "additionalinfo_alternatecontact_name", "text": "Name:", "answer": [ { "valueString": "Imran Patel" } ] }, { "linkId": "additionalinfo_alternatecontact_phone", "text": "Alternate contact phone #:", "answer": [ { "valueString": "416-555-0144" } ] }, { "linkId": "additionalinfo_alternatecontact_relationship", "text": "Relationship:", "answer": [ { "valueString": "Spouse" } ] }, { "linkId": "additionalinfo_alternatecontact_bookingcontact", "text": "Is Alternate contact the appointment booking contact?:", "answer": [ { "valueString": "Yes" } ] }, { "linkId": "additionalinfo_accessibilityconcernsordisability_selectt", "text": "Accessibility concerns or disability", "answer": [ { "valueString": "Accessibility concerns or disability" } ] }, { "linkId": "additionalinfo_accessibilityconcernsordisability", "text": "Accessibility concerns Options", "answer": [ { "valueCoding": { "system": "http://snomed.info/sct", "code": "105503008", "display": "Dependence on wheelchair" } } ] }, { "linkId": "additionalinfo_specialconsiderations_select", "text": "Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)", "answer": [ { "valueString": "Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)" } ] }, { "linkId": "additionalinfo_specialconsiderations", "text": "Details of special considerations:", "answer": [ { "valueString": "Patient has significant anxiety in medical settings. Please explain steps in advance; prefers a quiet waiting area when possible." } ] }, { "linkId": "additionalinfo_sendcopiestoadditionalproviders", "text": "Send copies of reports to additional providers", "answer": [ { "valueString": "Send copies of reports to additional providers" } ] }, { "linkId": "additionalinfo_sendcopiestoadditionalproviders_names", "text": "Name(s):", "answer": [ { "valueString": "Dr. Farah Alvi (Endocrinology)" } ] }, { "linkId": "additionalinfo_sendcopiestoadditionalproviders_contactinfo", "text": "Contact information:", "answer": [ { "valueString": "Fax 416-555-0187" } ] } ] }, { "linkId": "274716928898", "text": "Referral Details", "item": [ { "linkId": "836886186557", "text": "Triage Considerations", "item": [ { "linkId": "referral_requestedpriority", "text": "Requested Priority:", "answer": [ { "valueCoding": { "system": "http://hl7.org/fhir/request-priority", "code": "urgent", "display": "Urgent" } } ] }, { "linkId": "referral_requestedpriority_urgentreason", "text": "Reason for urgent triage:", "answer": [ { "valueString": "Progressive exertional chest tightness with reduced exercise tolerance over the past 3 weeks." } ] } ] }, { "linkId": "200848944281", "text": "Name of the suspected diagnosis/problem triggering referral:", "answer": [ { "valueString": "New exertional chest tightness; rule out stable angina / ischemic heart disease." } ] }, { "linkId": "602158378622", "text": "Brief Description of Referral, History, Management, and Investigations", "answer": [ { "valueString": "38F with 3-month history of exertional substernal chest tightness when climbing stairs, relieved by rest in 3–5 minutes. No syncope. Occasional palpitations. Risk factors: type 2 diabetes (A1c 7.6%), hypertension, dyslipidemia, strong family history (father MI at 52). Vitals today: BP 146/92, HR 82. Physical exam unremarkable. Baseline ECG in clinic: normal sinus rhythm, no acute ischemic changes. Started ASA 81 mg daily and optimized statin (rosuvastatin 20 mg)." } ] } ] }, { "linkId": "preferredconsultlocation_header", "text": "Preferred Consultant or Location All patients will be triaged to the shortest wait time unless a preferred consultant or location is entered.", "item": [ { "linkId": "preferredconsultlocation_selector", "text": "Preferred consultant or location", "answer": [ { "valueString": "Preferred consultant or location" } ] }, { "linkId": "preferredconsultlocation_specify", "text": "Please specify either a preferred consultant or location", "item": [ { "linkId": "preferredconsultlocation_consultant", "text": "Consultant:", "answer": [ { "valueString": "Dr. Samantha Chen" } ] }, { "linkId": "preferredconsultlocation_location", "text": "Location:", "answer": [ { "valueString": "Toronto General Hospital – Cardiology Clinic" } ] } ] }, { "linkId": "preferredconsultlocation_willingtotravel", "text": "Patient willing to travel for shorter wait time", "answer": [ { "valueString": "Patient willing to travel for shorter wait time" } ] }, { "linkId": "preferredconsultlocation_otherconsiderations", "text": "Other considerations:", "answer": [ { "valueString": "Prefers weekday mornings; relies on translator services." } ] } ] }, { "linkId": "referrer_header", "text": "Referrer's Information", "item": [ { "linkId": "referrer_sitename", "text": "Site Name:", "answer": [ { "valueString": "Parkdale Family Health Team" } ] }, { "linkId": "referrer_address_line1", "text": "Address (Line 1):", "answer": [ { "valueString": "123 Brock Ave" } ] }, { "linkId": "referrer_address_line2", "text": "Address (Line 2):", "answer": [ { "valueString": "Suite 401" } ] }, { "linkId": "referrer_address_city", "text": "City:", "answer": [ { "valueString": "Toronto" } ] }, { "linkId": "referrer_address_province", "text": "Province:", "answer": [ { "valueString": "ON" } ] }, { "linkId": "referrer_address_postalcode", "text": "Postal Code:", "answer": [ { "valueString": "M6K 2L5" } ] }, { "linkId": "referrer_phone", "text": "Phone #:", "answer": [ { "valueString": "416-555-0101" } ] }, { "linkId": "referrer_fax", "text": "Fax #:", "answer": [ { "valueString": "416-555-0102" } ] }, { "linkId": "referrer_professionalid", "text": "Professional ID:", "answer": [ { "valueInteger": 7654321 } ] }, { "linkId": "referrer_signature", "text": "Signed:", "answer": [ { "valueString": "Dr. Nadia Rahman, MD CCFP" } ] }, { "linkId": "referrer_role", "text": "Role:", "answer": [ { "valueCoding": { "system": "http://snomed.info/sct", "code": "449161006", "display": "Physician assistant" } } ] } ] } ] }