Argonaut Questionnaire Implementation Guide (Release 1.0.0 )

This page is part of the Argonaut Questionnaire Implementation Guide (v1.0.0: Release) based on FHIR R3. This is the current published version in it's permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

XML Format: Questionnaire-questionnaire-example-housing

Download Raw xml


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    <div xmlns="http://www.w3.org/1999/xhtml"><h3>Housing Questions</h3><img src="data:image/gif;base64,R0lGODlhLwRYAncAACH5BAEAAAAALAAAAAAvBFgCh/8A/wq99R299RvK+CgkJSgkLigkOCgkTCgk
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"alt="Housing Questions"/><p>Billioux, Alexander, MD, Dphil; Verlander, Katherine, MPH; Anthony, Susan, DrPH; Alley, Dawn, PhD; National Academy of Sciences, “Standardized Screening for Health-Related Social Needs in Clinical Settings - The Accountable Health Communities Screening Tool,“ https://nam.edu/wp-content/uploads/2017/05/Standardized-Screening-for-Health-Related-Social-Needs-in-Clinical-Settings.pdf  
</p></div>
  </text>
  <url
       value="http://fhir.org/guides/argonaut/questionnaire/Questionnaire/questionnaire-example-housing"/>
  <identifier>
    <system value="http://acme.org/q-identifiers"/>
    <value value="business-identifier4"/>
  </identifier>
  <version value="0.0.0"/>
  <title value="Housing Questions"/>
  <status value="draft"/>
  <date value="2018-07-26"/>
  <publisher value="Argonaut Project"/>
  <useContext>
    <code>
      <system value="http://hl7.org/fhir/usage-context-type"/>
      <code value="task"/>
      <display value="Workflow Task"/>
    </code>
    <valueCodeableConcept>
      <coding>
        <system value="http://acme.org"/>
        <code value="example"/>
        <display value="Example of Use"/>
      </coding>
    </valueCodeableConcept>
  </useContext>
  <jurisdiction>
    <coding>
      <system value="urn:iso:std:iso:3166"/>
      <code value="US"/>
      <display value="United States of America"/>
    </coding>
  </jurisdiction>
  <contact>
    <telecom>
      <system value="url"/>
      <value value="http://argonautwiki.hl7.org"/>
    </telecom>
  </contact>
  <copyright
             value="Billioux, Alexander, MD, Dphil; Verlander, Katherine, MPH; Anthony, Susan, DrPH; Alley, Dawn, PhD; National Academy of Sciences, “Standardized Screening for Health-Related Social Needs in Clinical Settings - The Accountable Health Communities Screening Tool,“ https://nam.edu/wp-content/uploads/2017/05/Standardized-Screening-for-Health-Related-Social-Needs-in-Clinical-Settings.pdf  
"/>
  <code>
    <system value="http://acme.org/codes"/>
    <code value="housing"/>
    <display value="Housing Questions"/>
  </code>
  <subjectType value="Patient"/>
  <item>
    <linkId value="g1"/>
    <type value="group"/>
    <item>
      <extension
                 url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
        <valueInteger value="0"/>
      </extension>
      <linkId value="g1.d"/>
      <text
            value="Accountable Health Communities Core Health-Related Social Needs Screening Questions 
Underlined answer options indicate positive responses for the associated health-related social need. 
A value greater than 10 when the numerical values for answers to questions 7-10 are summed indicates a positive screen for interpersonal safety."/>
      <type value="display"/>
    </item>
    <item>
      <extension
                 url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
        <valueInteger value="1"/>
      </extension>
      <linkId value="g1.1"/>
      <prefix value="1"/>
      <text value="What is your housing situation today?"/>
      <type value="choice"/>
      <required value="true"/>
      <repeats value="false"/>
      <option>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="0"/>
        </extension>
        <valueString
                     value="I do not have housing (I am staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)"/>
      </option>
      <option>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="1"/>
        </extension>
        <valueString
                     value="I have housing today, but I am worried about losing housing in the future"/>
      </option>
      <option>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="2"/>
        </extension>
        <valueString value="I have housing"/>
      </option>
    </item>
    <item>
      <extension
                 url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
        <valueInteger value="2"/>
      </extension>
      <linkId value="g1.2"/>
      <prefix value="2"/>
      <text
            value="Think about the place you live. Do you have problems with any of the following? (check all that apply)"/>
      <type value="choice"/>
      <required value="true"/>
      <repeats value="true"/>
      <option>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="0"/>
        </extension>
        <valueString value="Bug infestation"/>
      </option>
      <option>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="1"/>
        </extension>
        <valueString value="Mold"/>
      </option>
      <option>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="2"/>
        </extension>
        <valueString value="Lead paint or pipes"/>
      </option>
      <option>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="3"/>
        </extension>
        <valueString value="Inadequate heat"/>
      </option>
      <option>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="4"/>
        </extension>
        <valueString value="Oven or stove not working"/>
      </option>
      <option>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="5"/>
        </extension>
        <valueString value="No or not working smoke detectors"/>
      </option>
      <option>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="6"/>
        </extension>
        <valueString value="Water leaks"/>
      </option>
      <option>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="7"/>
        </extension>
        <modifierExtension
                           url="http://hl7.org/fhir/StructureDefinition/questionnaire-optionExclusive">
          <valueBoolean value="true"/>
        </modifierExtension>
        <valueString value="None of the above"/>
      </option>
    </item>
  </item>
</Questionnaire>