Questionnaire-zika-virus-exposure-assessment.xml

Example instrument for assessing Zika virus exposure potential (id = "zika-virus-exposure-assessment")

<?xml version="1.0" encoding="UTF-8"?>

<Questionnaire xmlns="http://hl7.org/fhir">
  <id value="zika-virus-exposure-assessment"/> 
  <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative</b> </p> <p> <b> url</b> : <a> http://example.org/Questionnaire/zika-virus-exposure-assessment</a> </p> <p> <b> name</b> : ExampleZikaVirusExposureAssessment</p> <p> <b> title</b> : Example Zika Virus Exposure Assessment</p> <p> <b> status</b> : draft</p> <p> <b> subjectType</b> : Patient</p> <p> <b> date</b> : 2016-11-14</p> <p> <b> description</b> : Example questionnaire to assess Zika virus exposure potential.</p> <p> <b> effectivePeriod</b> : 2016-11-14 --&gt; (ongoing)</p> <blockquote> <p> <b> item</b> </p> <p> <b> linkId</b> : 1</p> <p> <b> code</b> : <span> CDE: Resident of or Frequent Traveler to Zika Area</span> </p> <p> <b> text</b> : Are you a resident of, or do you travel frequently to, an area with active Zika transmission?</p> <p> <b> type</b> : boolean</p> </blockquote> <blockquote> <p> <b> item</b> </p> <p> <b> linkId</b> : 2</p> <p> <b> code</b> : <span> CDE: Recent Travel to Zika Area</span> </p> <p> <b> text</b> : Have you recently traveled to an area with active Zika transmission?</p> <p> <b> type</b> : boolean</p> <h3> EnableWhens</h3> <table> <tr> <td> -</td> <td> <b> Question</b> </td> <td> <b> Operator</b> </td> <td> <b> Answer[x]</b> </td> </tr> <tr> <td> *</td> <td> 1</td> <td> =</td> <td> false</td> </tr> </table> </blockquote> <blockquote> <p> <b> item</b> </p> <p> <b> linkId</b> : 3</p> <p> <b> code</b> : <span> CDE: Time Since Returned From Travel</span> </p> <p> <b> text</b> : How long has it been since you returned?</p> <p> <b> type</b> : quantity</p> <h3> EnableWhens</h3> <table> <tr> <td> -</td> <td> <b> Question</b> </td> <td> <b> Operator</b> </td> <td> <b> Answer[x]</b> </td> </tr> <tr> <td> *</td> <td> 2</td> <td> =</td> <td> true</td> </tr> </table> </blockquote> <blockquote> <p> <b> item</b> </p> <p> <b> linkId</b> : 4</p> <p> <b> code</b> : <span> CDE: Recent Sexual Encounter with Traveler to Zika Area</span> </p> <p> <b> text</b> : Have you recently had condomless sex with a partner that has travelled in an area with
           active Zika transmission?</p> <p> <b> type</b> : boolean</p> <h3> EnableWhens</h3> <table> <tr> <td> -</td> <td> <b> Question</b> </td> <td> <b> Operator</b> </td> <td> <b> Answer[x]</b> </td> </tr> <tr> <td> *</td> <td> 2</td> <td> =</td> <td> false</td> </tr> </table> </blockquote> <blockquote> <p> <b> item</b> </p> <p> <b> linkId</b> : 5</p> <p> <b> code</b> : <span> CDE: Time Since Sexual Encounter</span> </p> <p> <b> text</b> : How long has it been since your last condomless sexual encounter?</p> <p> <b> type</b> : quantity</p> <h3> EnableWhens</h3> <table> <tr> <td> -</td> <td> <b> Question</b> </td> <td> <b> Operator</b> </td> <td> <b> Answer[x]</b> </td> </tr> <tr> <td> *</td> <td> 4</td> <td> =</td> <td> true</td> </tr> </table> </blockquote> <blockquote> <p> <b> item</b> </p> <p> <b> linkId</b> : 6</p> <p> <b> code</b> : <span> CDE: Planned Travel to Zika Area</span> </p> <p> <b> text</b> : Do you plan to travel to an area with active Zika transmission?</p> <p> <b> type</b> : boolean</p> <h3> EnableWhens</h3> <table> <tr> <td> -</td> <td> <b> Question</b> </td> <td> <b> Operator</b> </td> <td> <b> Answer[x]</b> </td> </tr> <tr> <td> *</td> <td> 4</td> <td> =</td> <td> false</td> </tr> </table> </blockquote> </div> </text> <url value="http://example.org/Questionnaire/zika-virus-exposure-assessment"/> 
  <name value="ExampleZikaVirusExposureAssessment"/> 
  <title value="Example Zika Virus Exposure Assessment"/> 
  <status value="draft"/> 
  <subjectType value="Patient"/> 
  <date value="2016-11-14"/> 
  <description value="Example questionnaire to assess Zika virus exposure potential."/> 
  <effectivePeriod> 
    <start value="2016-11-14"/> 
  </effectivePeriod> 

  <item> 
  <extension url="http://example.org/additional-information">
    <valueAttachment> 
      <url value="http://www.cdc.gov/zika/geo/index.html"/> 
      <title value="Areas with active Zika virus transmission/exposure risk"/> 
    </valueAttachment> 
  </extension> 
    <linkId value="1"/> 
    <code> 
      <system value="http://example.org/questionnaires"/> 
      <code value="CDE: Resident of or Frequent Traveler to Zika Area"/> 
    </code> 
    <text value="Are you a resident of, or do you travel frequently to, an area with active Zika transmission?"/> 
    <type value="boolean"/> 
  </item> 

  <item> 
  <extension url="http://example.org/additional-information">
    <valueAttachment> 
      <url value="http://www.cdc.gov/zika/geo/index.html"/> 
      <title value="Areas with active Zika virus transmission/exposure risk"/> 
    </valueAttachment> 
  </extension> 
    <linkId value="2"/> 
    <code> 
    <system value="http://example.org/questionnaires"/> 
    <code value="CDE: Recent Travel to Zika Area"/> 
    </code> 
  <text value="Have you recently traveled to an area with active Zika transmission?"/> 
  <type value="boolean"/> 
  <enableWhen> 
    <question value="1"/> 
    <operator value="="/> 
    <answerBoolean value="false"/> 
  </enableWhen> 
  </item> 
  <item> 
    <linkId value="3"/> 
    <code> 
    <system value="http://example.org/questionnaires"/> 
    <code value="CDE: Time Since Returned From Travel"/> 
    </code> 
  <text value="How long has it been since you returned?"/> 
  <type value="quantity"/> 
  <enableWhen> 
    <question value="2"/> 
    <operator value="="/> 
    <answerBoolean value="true"/> 
  </enableWhen> 
  </item> 
  <item> 
  <extension url="http://example.org/additional-information">
    <valueAttachment> 
      <url value="http://www.cdc.gov/zika/geo/index.html"/> 
      <title value="Areas with active Zika virus transmission/exposure risk"/> 
    </valueAttachment> 
  </extension> 
    <linkId value="4"/> 
    <code> 
    <system value="http://example.org/questionnaires"/> 
    <code value="CDE: Recent Sexual Encounter with Traveler to Zika Area"/> 
    </code> 
  <text value="Have you recently had condomless sex with a partner that has travelled in an area with
     active Zika transmission?"/> 
  <type value="boolean"/> 
  <enableWhen> 
    <question value="2"/> 
    <operator value="="/> 
    <answerBoolean value="false"/> 
  </enableWhen> 
  </item> 
  <item> 
    <linkId value="5"/> 
    <code> 
    <system value="http://example.org/questionnaires"/> 
    <code value="CDE: Time Since Sexual Encounter"/> 
    </code> 
  <text value="How long has it been since your last condomless sexual encounter?"/> 
  <type value="quantity"/> 
  <enableWhen> 
    <question value="4"/> 
    <operator value="="/> 
    <answerBoolean value="true"/> 
  </enableWhen> 
  </item> 
  <item> 
  <extension url="http://example.org/additional-information">
    <valueAttachment> 
      <url value="http://www.cdc.gov/zika/geo/index.html"/> 
      <title value="Areas with active Zika virus transmission/exposure risk"/> 
    </valueAttachment> 
  </extension> 
    <linkId value="6"/> 
    <code> 
      <system value="http://example.org/questionnaires"/> 
      <code value="CDE: Planned Travel to Zika Area"/> 
    </code> 
    <text value="Do you plan to travel to an area with active Zika transmission?"/> 
  <type value="boolean"/> 
  <enableWhen> 
    <question value="4"/> 
    <operator value="="/> 
    <answerBoolean value="false"/> 
  </enableWhen> 
  </item> 
</Questionnaire>