SDOH Clinical Care
3.0.0-ballot - STU 3 Ballot

SDOH Clinical Care - Downloaded Version 3.0.0-ballot See the Directory of published versions

## Questionnaire: SDOHCC Questionnaire PRAPARE

Official URL: http://hl7.org/fhir/us/sdoh-clinicalcare/Questionnaire/SDOHCC-QuestionnairePRAPARE | Version: 3.0.0-ballot
Standards status: Informative Draft as of 2021-04-01 | Computable Name: SDOHCCQuestionnairePRAPARE

- Tree view
- Sample Rendering
- Form Logic

Profile: Extractable Questionnaire - StructureMap

Structure

LinkID | Text | Cardinality | Type | Description & Constraints
--- | --- | --- | --- | ---
SDOHCCQuestionnairePRAPARE |  |  | Questionnaire | http://hl7.org/fhir/us/sdoh-clinicalcare/Questionnaire/SDOHCC-QuestionnairePRAPARE#3.0.0-ballot
/93025-5 | Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE] | 0..1 | group |
/93043-8 | Personal characteristics | 0..1 | group |
/93043-8/56051-6 | Hispanic or Latino | 0..1 | choice | Options: 3 options
/93043-8/32624-9 | Race | 0..* | choice | Options: 8 options
/93043-8/93035-4 | Has season or migrant farm work been your or your family's main source of income at any point in past 2 years? | 0..1 | choice | Options: 3 options
/93043-8/93034-7 | Have you been discharged from the armed forces of the United States? | 0..1 | choice | Options: 3 options
/93043-8/54899-0 | Preferred language | 0..1 | choice | Options: 3 options
/93042-0 | Family and home | 0..1 | group |
/93042-0/63512-8 | How many people are living or staying at this address? | 0..1 | integer |
/93042-0/71802-3 | Housing status | 0..1 | choice | Options: 3 options
/93042-0/71802-3-help | Describes patients living arrangement | 0..1 | display |
/93042-0/93033-9 | Are you worried about losing your housing? | 0..1 | choice | Options: 3 options
/93042-0/56799-0 | Address | 0..1 | string |
/93041-2 | Money and resources | 0..1 | group |
/93041-2/82589-3 | Highest level of educ | 0..1 | choice | Options: 4 options
/93041-2/67875-5 | Employment status current | 0..1 | choice | Options: 5 options
/93041-2/76437-3 | Primary insurance | 0..1 | choice | Options: 7 options
/93041-2/63586-2 | What was your best estimate of the total income of all family members from all sources, before taxes, in last year? | 0..1 | decimal |
/93041-2/93031-3 | In the past year, have you or any family members you live with been unable to get any of the following when it was really needed? | 0..* | choice | Options: 8 options
/93041-2/93030-5 | Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? | 0..* | choice | Options: 4 options
/93040-4 | Social and emotional health | 0..1 | group |
/93040-4/93029-7 | How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)? | 0..1 | choice | Options: 5 options
/93040-4/93038-8 | Stress is when someone feels tense, nervous, anxious or can't sleep at night because their mind is troubled. How stressed are you? | 0..1 | choice | Options: 6 options
/93039-6 | Optional additional questions | 0..1 | group |
/93039-6/93028-9 | In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility? | 0..1 | choice | Options: 3 options
/93039-6/93027-1 | Are you a refugee? | 0..1 | choice | Options: 3 options
/93039-6/93026-3 | Do you feel physically and emotionally safe where you currently live? | 0..1 | choice | Options: 4 options
/93039-6/76501-6 | Within the last year, have you been afraid of your partner or ex-partner? | 0..1 | choice | Options: 2 options
Documentation for this format

Options Sets

Answer options for /93043-8/56051-6

- http://loinc.org#LA33-6 ("Yes")
- http://loinc.org#LA32-8 ("No")
- http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93043-8/32624-9

- http://loinc.org#LA6156-9 ("Asian")
- http://loinc.org#LA14045-1 ("Native Hawaiian")
- http://loinc.org#LA30187-1 ("Pacific Islander")
- http://loinc.org#LA14042-8 ("Black/African American")
- http://loinc.org#LA4457-3 ("White")
- http://loinc.org#LA4-4 ("American Indian/Alaskan Native")
- http://loinc.org#LA46-8 ("Other")
- http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93043-8/93035-4

- http://loinc.org#LA33-6 ("Yes")
- http://loinc.org#LA32-8 ("No")
- http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93043-8/93034-7

- http://loinc.org#LA33-6 ("Yes")
- http://loinc.org#LA32-8 ("No")
- http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93043-8/54899-0

- http://loinc.org#LA43-5 ("English")
- http://loinc.org#LA30188-9 ("Language other than English")
- http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93042-0/71802-3

- http://loinc.org#LA30189-7 ("I have housing")
- http://loinc.org#LA30190-5 ("I do not have housing (staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, or in a park)")
- http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93042-0/93033-9

- http://loinc.org#LA33-6 ("Yes")
- http://loinc.org#LA32-8 ("No")
- http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93041-2/82589-3

- http://loinc.org#LA30191-3 ("Less than high school degree")
- http://loinc.org#LA30192-1 ("High school diploma or GED")
- http://loinc.org#LA30193-9 ("More than high school")
- http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93041-2/67875-5

- http://loinc.org#LA17956-6 ("Unemployed")
- http://loinc.org#LA30138-4 ("Part-time or temporary work")
- http://loinc.org#LA30136-8 ("Full-time work")
- http://loinc.org#LA30137-6 ("Otherwise unemployed but not seeking work (ex: student, retired, disabled, unpaid primary care giver)")
- http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93041-2/76437-3

- http://loinc.org#LA30194-7 ("None/uninsured")
- http://loinc.org#LA17849-3 ("Medicaid")
- http://loinc.org#LA30195-4 ("CHIP Medicaid")
- http://loinc.org#LA15652-3 ("Medicare")
- http://loinc.org#LA30196-2 ("Other public insurance (not CHIP)")
- http://loinc.org#LA30197-0 ("Other public insurance (CHIP)")
- http://loinc.org#LA6350-8 ("Private insurance")

Answer options for /93041-2/93031-3

- http://loinc.org#LA30125-1 ("Food")
- http://loinc.org#LA30126-9 ("Clothing")
- http://loinc.org#LA30124-4 ("Utilities")
- http://loinc.org#LA30127-7 ("Child care")
- http://loinc.org#LA30128-5 ("Medicine or Any Health Care (Medical, Dental, Mental Health, Vision)")
- http://loinc.org#LA30129-3 ("Phone")
- http://loinc.org#LA46-8 ("Other")
- http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93041-2/93030-5

- http://loinc.org#LA30133-5 ("Yes, it has kept me from medical appointments or from getting my medications")
- http://loinc.org#LA30134-3 ("Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need")
- http://loinc.org#LA32-8 ("No")
- http://loinc.org#LA30257-2 ("Patient unable to respond")

Answer options for /93040-4/93029-7

- http://loinc.org#LA27722-0 ("Less than once a week")
- http://loinc.org#LA30130-1 ("1 or 2 times a week")
- http://loinc.org#LA30131-9 ("3 to 5 times a week")
- http://loinc.org#LA30132-7 ("5 or more times a week")
- http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93040-4/93038-8

- http://loinc.org#LA6568-5 ("Not at all")
- http://loinc.org#LA13863-8 ("A little bit")
- http://loinc.org#LA13909-9 ("Somewhat")
- http://loinc.org#LA13902-4 ("Quite a bit")
- http://loinc.org#LA13914-9 ("Very much")
- http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93039-6/93028-9

- http://loinc.org#LA33-6 ("Yes")
- http://loinc.org#LA32-8 ("No")
- http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93039-6/93027-1

- http://loinc.org#LA33-6 ("Yes")
- http://loinc.org#LA32-8 ("No")
- http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93039-6/93026-3

- http://loinc.org#LA33-6 ("Yes")
- http://loinc.org#LA32-8 ("No")
- http://loinc.org#LA14072-5 ("Unsure")
- http://loinc.org#LA30122-8 ("I choose not to answer this question")

Answer options for /93039-6/76501-6

- http://loinc.org#LA33-6 ("Yes")
- http://loinc.org#LA32-8 ("No")

Profile: Extractable Questionnaire - StructureMap

Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]

- linkId: /93025-5

Personal characteristics

- linkId: /93043-8

Hispanic or Latino

- linkId: /93043-8/56051-6
- Answers: 3 options

Race

- linkId: /93043-8/32624-9
- Answers: 8 options

Has season or migrant farm work been your or your family's main source of income at any point in past 2 years?

- linkId: /93043-8/93035-4
- Answers: 3 options

Have you been discharged from the armed forces of the United States?

- linkId: /93043-8/93034-7
- Answers: 3 options

Preferred language

- linkId: /93043-8/54899-0
- Answers: 3 options

Family and home

- linkId: /93042-0

How many people are living or staying at this address?

- linkId: /93042-0/63512-8

Housing status

- linkId: /93042-0/71802-3
- Answers: 3 options

Describes patients living arrangement

- linkId: /93042-0/71802-3-help

Are you worried about losing your housing?

- linkId: /93042-0/93033-9
- Answers: 3 options

Address

- linkId: /93042-0/56799-0

Money and resources

- linkId: /93041-2

Highest level of educ

- linkId: /93041-2/82589-3
- Answers: 4 options

Employment status current

- linkId: /93041-2/67875-5
- Answers: 5 options

Primary insurance

- linkId: /93041-2/76437-3
- Answers: 7 options

What was your best estimate of the total income of all family members from all sources, before taxes, in last year?

- linkId: /93041-2/63586-2

In the past year, have you or any family members you live with been unable to get any of the following when it was really needed?

- linkId: /93041-2/93031-3
- Answers: 8 options

Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?

- linkId: /93041-2/93030-5
- Answers: 4 options

Social and emotional health

- linkId: /93040-4

How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)?

- linkId: /93040-4/93029-7
- Answers: 5 options

Stress is when someone feels tense, nervous, anxious or can't sleep at night because their mind is troubled. How stressed are you?

- linkId: /93040-4/93038-8
- Answers: 6 options

Optional additional questions

- linkId: /93039-6

In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility?

- linkId: /93039-6/93028-9
- Answers: 3 options

Are you a refugee?

- linkId: /93039-6/93027-1
- Answers: 3 options

Do you feel physically and emotionally safe where you currently live?

- linkId: /93039-6/93026-3
- Answers: 4 options

Within the last year, have you been afraid of your partner or ex-partner?

- linkId: /93039-6/76501-6
- Answers: 2 options

Profile: Extractable Questionnaire - StructureMap

LinkID | Description & Constraints
--- | ---
/93025-5 |
/93043-8 |
/93043-8/56051-6 | Options: 3 options
/93043-8/32624-9 | Options: 8 options
/93043-8/93035-4 | Options: 3 options
/93043-8/93034-7 | Options: 3 options
/93043-8/54899-0 | Options: 3 options
/93042-0 |
/93042-0/63512-8 |
/93042-0/71802-3 | Options: 3 options
/93042-0/71802-3-help |
/93042-0/93033-9 | Options: 3 options
/93042-0/56799-0 |
/93041-2 |
/93041-2/82589-3 | Options: 4 options
/93041-2/67875-5 | Options: 5 options
/93041-2/76437-3 | Options: 7 options
/93041-2/63586-2 |
/93041-2/93031-3 | Options: 8 options
/93041-2/93030-5 | Options: 4 options
/93040-4 |
/93040-4/93029-7 | Options: 5 options
/93040-4/93038-8 | Options: 6 options
/93039-6 |
/93039-6/93028-9 | Options: 3 options
/93039-6/93027-1 | Options: 3 options
/93039-6/93026-3 | Options: 4 options
/93039-6/76501-6 | Options: 2 options
Documentation for this format

### Test this Questionnaire

Profile: Extractable Questionnaire - StructureMap

Try this questionnaire out:

### Responses for this Questionnaire

- (no description)
- (no description)