| Source | cinc.fhir.ig#current:Care In The Community FHIR API (v4.0.1) |
| resourceType | Questionnaire |
| id | PregnancyAssessmentSurveyQuestionnaire |
| canonical | https://build.fhir.org/ig/tewhatuora/cinc-fhir-ig/Questionnaire/PregnancyAssessmentSurveyQuestionnaire |
| version | 0.2.8 |
| status | draft |
| publisher | Te Whatu Ora |
| name | PregnancyAssessmentSurveyQuestionnaire |
| title | Pregnancy Assessment Survey |
| date | 2023-09-04T01:21:52+00:00 |
| description | Te Whatu Ora pregnancy assessment survey. |
| jurisdictions | nz |
| Usages | (none) |
page 1: Pregnancy Context
page 1 question 1: Are you currently pregnant or postpartum? *
page 1 question 1.1: Gestation *
page 1 question 1.2: Expected Delivery Date (EDD) *
page 1 question 1.3: Postpartum *
page 1 question 2: Para *
How many live births of viable gestation has the patient had?
page 1 question 3: Gravida *
page 2: Midwife Information
page 2 question 1: Midwife Name *
page 2 question 2: Midwife Contact *
page 3: Findings
page 3 question 1: Ultrasound Findings
page 3 question 2: Blood Tests
page 4: Complications and Symptoms
page 4 question 1: Any current pregnancy complications?
page 4 question 1.1: Please explain your pregnancy complications *
page 4 question 2: Any previous pregnancy complications?
page 4 question 2.1: Please explain any complications from previous pregnancies *
page 4 question 3: Any signs of pre-eclampsia?
Headache, Epigastric pain, flashing lights.
page 4 question 3.1: Please explain any symptoms suggestive of pre-eclampsia? *
page 4 question 4: Any signs suggestive of a DVT? *
lateral swelling, redness or calf-tenderness
page 4 question 4.1: Please explain any symptoms suggestive of a DVT *
page 4 question 5: Any signs of Dysuria? *
page 4 question 5.1: Please explain any details of your Dysuria *
page 4 question 6: Vaginal Discharge? *
page 4 question 6.1: Please explain any details. *
page 5: Obstetrician Notes
page 5 question 1: Obstetrician Details and Discussion, including any potential clexane requirement?
page 6: Post 23 Week Information
page 6 question 1: Any baby movement felt? *
page 6 question 1.1: Any details surrounding the baby movement?
page 6 question 2: Any vaginal bleeding? *
page 6 question 2.1: Any details surrounding vaginal bleeding?
page 7: General Practice Information
page 7 question 1: GP Practice Name
page 7 question 2: Practice EDI
page 7 question 3: Send note to GP Inbox? *
Produced 08 Sep 2023