ICHOM FHIR Implementation Guide: Breast Cancer
1.0.0-ballot - ballot International flag

This page is part of the ICHOM FHIR Implementation Guide: Breast Cancer (v1.0.0-ballot: STU 1 Ballot 1) based on FHIR R4. . For a full list of available versions, see the Directory of published versions

Questionnaire: PatientReportedBaseline (Experimental)

Official URL: http://hl7.org/fhir/uv/ichom-breast-cancer/Questionnaire/PatientReportedBaseline Version: 1.0.0-ballot
Draft as of 2022-12-07 Computable Name: PatientReportedBaseline
Structure
LinkIdTextCardinalityTypeDescription & Constraintsdoco
.. PatientReportedBaselineQuestionnairehttp://hl7.org/fhir/uv/ichom-breast-cancer/Questionnaire/PatientReportedBaseline#1.0.0-ballot
... General-Information-ClinicalGeneral information1..1group
.... NA-ClinicalWhat is your medical record number?1..1string
.... LastName-ClinicalWhat is your last name?1..1string
... DemographicsDemographic factors1..1group
.... SexPlease indicate your sex at birth1..1choiceValue Set: AdministrativeGender
.... COUNTRYWhat is your country of residence?1..1choiceValue Set: Iso 3166 Part 1: 3 Letter Codes
.... EthnicityPlease indicate the ethnicity that you identify with1..1choiceValue Set: Ethnicity
.... RacePlease indicate the biological race that you identify with1..1choiceValue Set: Race
.... EducationLevelPlease indicate your highest level of schooling1..1choiceValue Set: Education level of patient ValueSet
.... RelationshipStatusPlease indicate your current relationship status1..1choiceValue Set: Relationship status of patient ValueSet
.... MENOPAUSEPlease indicate your current menopausal status1..1choiceEnable When: Sex = Female (AdministrativeGender#female)
Value Set: Menopausal status of patient ValueSet
... Baseline-Clinical-FactorsClinical factors1..1group
.... ComorbiditiesSACQHave you been told by a doctor that you have any of the following?1..*choiceValue Set: SACQ Patient's comorbidity history ValueSet
.... ComorbiditiesSACQ_HeartDiseaseFU1Do you receive treatment for heart disease (For example, angina, heart failure, or heart attack)?0..1booleanEnable When: ComorbiditiesSACQ = Heart disease (SNOMED CT#56265001)
.... ComorbiditiesSACQ_HeartDiseaseFU2Does your heart disease limit your activities?0..1booleanEnable When: ComorbiditiesSACQ = Heart disease (SNOMED CT#56265001)
.... ComorbiditiesSACQ_HighBloodPressureFU1Do you receive treatment for high blood pressure?0..1booleanEnable When: ComorbiditiesSACQ = High blood pressure (SNOMED CT#38341003)
.... ComorbiditiesSACQ_HighBloodPressureFU2Does your high blood pressure limit your activities?0..1booleanEnable When: ComorbiditiesSACQ = High blood pressure (SNOMED CT#38341003)
.... ComorbiditiesSACQ_LungDiseaseFU1Do you receive treatment for lung disease?0..1booleanEnable When: ComorbiditiesSACQ = Lung disorder (SNOMED CT#19829001)
.... ComorbiditiesSACQ_LungDiseaseFU2Does your lung disease limit your activities?0..1booleanEnable When: ComorbiditiesSACQ = Lung disorder (SNOMED CT#19829001)
.... ComorbiditiesSACQ_DiabetesFU1Do you receive treatment for diabetes?0..1booleanEnable When: ComorbiditiesSACQ = Diabetes mellitus (SNOMED CT#73211009)
.... ComorbiditiesSACQ_DiabetesFU2Does your diabetes limit your activities?0..1booleanEnable When: ComorbiditiesSACQ = Diabetes mellitus (SNOMED CT#73211009)
.... ComorbiditiesSACQ_StomachDiseaseFU1Do you receive treatment for an ulcer or stomach disease?0..1booleanEnable When: ComorbiditiesSACQ = Disorder of stomach (SNOMED CT#29384001)
.... ComorbiditiesSACQ_StomachDiseaseFU2Does your ulcer or stomach disease limit your activities?0..1booleanEnable When: ComorbiditiesSACQ = Disorder of stomach (SNOMED CT#29384001)
.... ComorbiditiesSACQ_KidneyDiseaseFU1Do you receive treatment for kidney disease?0..1booleanEnable When: ComorbiditiesSACQ = Kidney disease (SNOMED CT#90708001)
.... ComorbiditiesSACQ_KidneyDiseaseFU2Does your kidney disease limit your activities?0..1booleanEnable When: ComorbiditiesSACQ = Kidney disease (SNOMED CT#90708001)
.... ComorbiditiesSACQ_LiverDiseaseFU1Do you receive treatment for liver disease?0..1booleanEnable When: ComorbiditiesSACQ = Hepatopathy (SNOMED CT#235856003)
.... ComorbiditiesSACQ_LiverDiseaseFU2Does your liver disease limit your activities?0..1booleanEnable When: ComorbiditiesSACQ = Hepatopathy (SNOMED CT#235856003)
.... ComorbiditiesSACQ_BloodDiseaseFU1Do you receive treatment for anemia or other blood disease?0..1booleanEnable When: ComorbiditiesSACQ = Disorder of cellular component of blood (disorder) (SNOMED CT#414022008)
.... ComorbiditiesSACQ_BloodDiseaseFU2Does your anemia or other blood disease limit your activities?0..1booleanEnable When: ComorbiditiesSACQ = Disorder of cellular component of blood (disorder) (SNOMED CT#414022008)
.... ComorbiditiesSACQ_CancerFU1Do you receive treatment for cancer/another cancer?0..1booleanEnable When: ComorbiditiesSACQ = Malignant tumor (SNOMED CT#363346000)
.... ComorbiditiesSACQ_CancerFU2Does your cancer/other cancer limit your activities?0..1booleanEnable When: ComorbiditiesSACQ = Malignant tumor (SNOMED CT#363346000)
.... ComorbiditiesSACQ_DepressionFU1Do you receive treatment for depression?0..1booleanEnable When: ComorbiditiesSACQ = Depressive disorder (SNOMED CT#35489007)
.... ComorbiditiesSACQ_DepressionFU2Does your depression limit your activities?0..1booleanEnable When: ComorbiditiesSACQ = Depressive disorder (SNOMED CT#35489007)
.... ComorbiditiesSACQ_OsteoarthritisFU1Do you receive treatment for osteoarthritis/degenerative arthritis?0..1booleanEnable When: ComorbiditiesSACQ = Osteoarthritis (disorder) (SNOMED CT#396275006)
.... ComorbiditiesSACQ_OsteoarthritisFU2Does your osteoarthritis/degenerative arthritis limit your activities?0..1booleanEnable When: ComorbiditiesSACQ = Osteoarthritis (disorder) (SNOMED CT#396275006)
.... ComorbiditiesSACQ_BackPainFU1Do you receive treatment for back pain?0..1booleanEnable When: ComorbiditiesSACQ = Backache (SNOMED CT#161891005)
.... ComorbiditiesSACQ_BackPainFU2Does your back pain limit your activities?0..1booleanEnable When: ComorbiditiesSACQ = Backache (SNOMED CT#161891005)
.... ComorbiditiesSACQ_RheumatoidArthritisFU1Do you receive treatment for rheumatoid arthritis?0..1booleanEnable When: ComorbiditiesSACQ = Rheumatoid arthritis (SNOMED CT#69896004)
.... ComorbiditiesSACQ_RheumatoidArthritisFU2Does your rheumatoid arthritis limit your activities?0..1booleanEnable When: ComorbiditiesSACQ = Rheumatoid arthritis (SNOMED CT#69896004)
.... ComorbiditiesSACQ_OtherWhat other medical problems are you experiencing?0..1textEnable When: ComorbiditiesSACQ = other (NullFlavor#OTH)
... Treatment-VariablesTreatment Variables1..1group
.... PatientEducationDid you feel you received sufficient information about your treatment options?1..1choiceValue Set: Patient Treatment Education ValueSet
... Degree-of-Health-EORTC-QLQDegree of Health - EORTC-QLQ0..1group
.... EORTCQLQ-Question01-05We are interested in some things about you and your health. Please answer all of the questions yourself by selecting the answer that best applies to you. There are no 'right' or 'wrong' answers. The information that you provide will remain strictly confidential.0..1group
..... EORTCQLQC30_Q01Do you have any trouble doing strenuous activities, like carrying a heavy shopping bag or a suitcase?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q02Do you have any trouble taking a long walk?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q03Do you have any trouble taking a short walk outside of the house?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q04Do you need to stay in bed or a chair during the day?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q05Do you need help with eating, dressing, washing yourself or using the toilet?1..1choiceValue Set: Agreement response ValueSet
.... EORTCQLQ-Question06-28During the past week:0..1group
..... EORTCQLQC30_Q06Were you limited in doing either your work or other daily activities?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q07Were you limited in pursuing your hobbies or other leisure time activities?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q08Were you short of breath?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q09Have you had pain?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q10Did you need to rest?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q11Have you had trouble sleeping?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q12Have you felt weak?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q13Have you lacked appetite?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q14Have you felt nauseated?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q15Have you vomited?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q16Have you been constipated?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q17Have you had diarrhea?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q18Were you tired?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q19Did pain interfere with your daily activities?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q20Have you had difficulty in concentrating on things, like reading a newspaper or watching television?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q21Did you feel tense?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q22Did you worry?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q23Did you feel irritable?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q24Did you feel depressed?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q25Have you had difficulty remembering things?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q26Has your physical condition or medical treatment interfered with your family life?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q27Has your physical condition or medical treatment interfered with your social activities?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQC30_Q28Has your physical condition or medical treatment caused you financial difficulties?1..1choiceValue Set: Agreement response ValueSet
.... EORTCQLQ-Question29-30For the following questions please select the number between 1 and 7 that best applies to you, with 1 = Very poor and 7 = Excellent.0..1group
..... EORTCQLQC30_Q29How would you rate your overall health during the past week?1..1choiceOptions: 7 options
..... EORTCQLQC30_Q30How would you rate your overall quality of life during the past week?1..1choiceOptions: 7 options
.... EORTCQLQ-Question31-43Patients sometimes report that they have the following symptoms or problems. Please indicate the extent to which you have experienced these symptoms or problems during the past week. Please answer by selecting the answer that best applies to you. During the past week:0..1group
..... EORTCQLQBR23_Q31Have you had dry mouth?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR23_Q32Have food and drink tasted different than usual?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR23_Q33Have your eyes been painful, irritated or watery?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR23_Q34Have you lost any hair?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR23_Q35Have you been upset by the loss of your hair?0..1choiceEnable When: EORTCQLQBR23_Q34 != Not at all (Agreement response CodeSystem#no)
Value Set: Agreement response ValueSet
..... EORTCQLQBR23_Q36Have you felt ill or unwell?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR23_Q37Have you had hot flushes?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR23_Q38Have you had headaches?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR23_Q39Have you felt physically less attractive as a result of your disease or treatment?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR23_Q40Have you felt less feminine as a result of your disease or treatment?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR23_Q41Have you had problems looking at yourself naked?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR23_Q42Have you been dissatisfied with your body?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR23_Q43Have you worried about your health in the future?1..1choiceValue Set: Agreement response ValueSet
.... EORTCQLQ-Question44-46During the past four weeks:0..1group
..... EORTCQLQBR23_Q44Have you been sexually active? (with or without intercourse)1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR23_Q45To what extent were you sexually active? (with or without intercourse)1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR23_Q46Has sex been enjoyable for you?0..1choiceEnable When: EORTCQLQBR23_Q45 != Not at all (Agreement response CodeSystem#no)
Value Set: Agreement response ValueSet
.... EORTCQLQ-Question47-69During the past week:0..1group
..... EORTCQLQBR23_Q48Have you had a swollen arm or hand?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR23_Q49Have you had problems raising your arm or moving it sideways?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR23_Q50Have you had any pain in the area of your affected breast?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR23_Q51Has the area of your affected breast been swollen?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR23_Q52Has the area of your affected breast been oversensitive?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR23_Q53Have you had skin problems on or in the area of your affected breast (e.g., itchy, dry, flaky)?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR45_Q54Have you sweated excessively?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR45_Q55Have you had mood swings?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR45_Q56Have you been dizzy?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR45_Q57Have you had soreness in your mouth?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR45_Q58Have you had any reddening in your mouth?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR45_Q59Have you had pain in your hands or feet?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR45_Q60Have you had any redenning on your hands or feet?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR45_Q61Have you had tingling in your fingers or toes?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR45_Q62Have you had numbness in your fingers or toes?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR45_Q63Have you had problems with your joints?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR45_Q64Have you had stiffness in your joints?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR45_Q65Have you had pain in your joints?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR45_Q66Have you had aches or pains in your bones?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR45_Q67Have you had aches or pains in your muscles?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR45_Q68Have you gained weight?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR45_Q69Has weight gain been a problem for you?1..1choiceValue Set: Agreement response ValueSet
.... EORTCQLQ-Question70-71During the past four weeks:0..1group
..... EORTCQLQBR45_Q70Have you had a dry vagina?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR45_Q71Have you had discomfort in your vagina?1..1choiceValue Set: Agreement response ValueSet
.... EORTCQLQ-Question72-73Please answer the following two questions only if you have been sexually active:0..1group
..... EORTCQLQBR45_Q72Have you had pain in your vagina during sexual activity?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR45_Q73Have you experienced a dry vagina during sexual activity?1..1choiceValue Set: Agreement response ValueSet
.... EORTCQLQ-Question74-75During the past week:0..1group
..... EORTCQLQBR45_Q74Have you been satisfied with the cosmetic result of the surgery?1..1choiceValue Set: Agreement response ValueSet
..... EORTCQLQBR45_Q75Have you been satisfied with the appearance of the skin of your affected breast (thoracic area)?1..1choiceValue Set: Agreement response ValueSet
... Degree-of-Health-BreastQDegree of Health - BreastQ:0..1group
.... IntroBreastQWith your breasts in mind, or if you have had a mastectomy, with your breast area in mind, in the past 2 weeks, how satisfied or dissatisfied have you been with:0..1group
..... BREASTQMAST_Q01How you look in the mirror clothed?1..1choiceValue Set: Satisfaction response ValueSet
..... BREASTQMAST_Q02How comfortable your bras fit?1..1choiceValue Set: Satisfaction response ValueSet
..... BREASTQMAST_Q03Being able to wear clothing that is more fitted?1..1choiceValue Set: Satisfaction response ValueSet
..... BREASTQMAST_Q04How you look in the mirror unclothed?1..1choiceValue Set: Satisfaction response ValueSet

doco Documentation for this format

Option Sets

Answer options for EORTCQLQC30_Q29

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Answer options for EORTCQLQC30_Q30

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