Health New Zealand Te Whatu Ora Shared Care FHIR API
1.4.8 - release New Zealand flag

Health New Zealand Te Whatu Ora Shared Care FHIR API - Local Development build (v1.4.8) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Questionnaire: Adult Health Questionnaire for EBUS

Official URL: https://build.fhir.org/ig/tewhatuora/cinc-fhir-ig/Questionnaire/RespiratoryAdultHealthQuestionnaire Version: 1.0.0
Active as of 2026-10-19 Computable Name: RespiratoryAdultHealthQuestionnaire
Other Identifiers: RespiratoryAdultHealthQuestionnaire (use: official)

Usage:Clinical Focus: M65 Respiratory Medicine

Questions about respiratory procedure health assessment

Respiratory procedure health assessment

Structure
LinkIDTextCardinalityTypeFlagsDescription & Constraintsdoco
RespiratoryAdultHealthQuestionnaireQuestions about respiratory procedure health assessmentQuestionnairehttps://build.fhir.org/ig/tewhatuora/cinc-fhir-ig/Questionnaire/RespiratoryAdultHealthQuestionnaire#1.0.0
RespiratoryAdultHealthQuestionnaire / meta-specialty-codeSpecialty Code0..1stringValue Set:
Initial Value: string = M65
RespiratoryAdultHealthQuestionnaire / meta-specialty-nameSpecialty Name0..1stringValue Set:
Initial Value: string = Respiratory Medicine
RespiratoryAdultHealthQuestionnaire / Section0PatientIDPatient ID0..1groupValue Set:
RespiratoryAdultHealthQuestionnaire / Section0PatientID / SurnameSurname0..1stringValue Set:
RespiratoryAdultHealthQuestionnaire / Section0PatientID / FirstNamesFirst Names0..1stringValue Set:
RespiratoryAdultHealthQuestionnaire / Section0PatientID / NHINHI0..1stringValue Set:
RespiratoryAdultHealthQuestionnaire / Section0PatientID / DateOfBirthDate of Birth0..1dateValue Set:
RespiratoryAdultHealthQuestionnaire / Section0PatientID / SexSex0..1stringValue Set:
RespiratoryAdultHealthQuestionnaire / Section1PatientDetailsSection 1 – Patient details0..1groupValue Set:
RespiratoryAdultHealthQuestionnaire / Section1PatientDetails / TodaysDateToday's date0..1dateValue Set:
RespiratoryAdultHealthQuestionnaire / Section1PatientDetails / HeightYour height (cm)0..1decimalValue Set:
RespiratoryAdultHealthQuestionnaire / Section1PatientDetails / WeightYour weight (kg)0..1decimalValue Set:
RespiratoryAdultHealthQuestionnaire / Section1PatientDetails / BMIBMI0..1decimalValue Set:
RespiratoryAdultHealthQuestionnaire / Section1PatientDetails / ProposedProcedureProposed surgery / procedure0..1stringValue Set:
Initial Value: string = Endobronchial Ultrasound (EBUS)
RespiratoryAdultHealthQuestionnaire / Section1PatientDetails / ContactDetailsGroupIf a phone call is required for further information relating to this questionnaire, please provide details on how we can contact you.0..1groupValue Set:
RespiratoryAdultHealthQuestionnaire / Section1PatientDetails / ContactDetailsGroup / ContactHomePhoneHome phone0..1stringValue Set:
RespiratoryAdultHealthQuestionnaire / Section1PatientDetails / ContactDetailsGroup / ContactWorkPhoneWork phone0..1stringValue Set:
RespiratoryAdultHealthQuestionnaire / Section1PatientDetails / ContactDetailsGroup / ContactMobilePhoneMobile phone0..1stringValue Set:
RespiratoryAdultHealthQuestionnaire / Section1PatientDetails / ContactDetailsGroup / ContactEmailEmail0..1stringValue Set:
RespiratoryAdultHealthQuestionnaire / Section1PatientDetails / HappyToLeaveMessageAre you happy for us to leave a message?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section1PatientDetails / MessageWithPersonWith a person?0..1choiceEnable When: HappyToLeaveMessage = Yes (yes)
Value Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section1PatientDetails / MessageWithPersonNameIf yes, please give person's name0..1stringEnable When:
Value Set:
RespiratoryAdultHealthQuestionnaire / Section1PatientDetails / MessageOnAnswerPhoneOn answer phone?0..1choiceEnable When: HappyToLeaveMessage = Yes (yes)
Value Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section1PatientDetails / BestTimeToCallWhen is the best time for you to receive telephone calls from staff?0..1stringValue Set:
RespiratoryAdultHealthQuestionnaire / Section2DHBUseOnlySection 2 – Capital and Coast DHB use only0..1groupValue Set:
RespiratoryAdultHealthQuestionnaire / Section2DHBUseOnly / AssessorNameName0..1stringValue Set:
RespiratoryAdultHealthQuestionnaire / Section2DHBUseOnly / AssessorPositionPosition0..1stringValue Set:
RespiratoryAdultHealthQuestionnaire / Section2DHBUseOnly / AssessmentDateDate0..1dateValue Set:
RespiratoryAdultHealthQuestionnaire / Section2DHBUseOnly / PreAnaesthesiaRequirementsPre-anaesthesia Requirements0..*choiceValue Set:
Options: 5 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditionsSection 3 – Medical conditions0..1groupValue Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / HighBloodPressure1. High blood pressure?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / HighBloodPressureBPAtClinicBP at clinic0..1stringEnable When: HighBloodPressure = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / HeartConditions2. Heart conditions (e.g. heart murmur, valve disease, chest pain or discomfort, angina, palpitations or irregular heart beat)?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / HeartConditionsCommentIf yes, or not certain, please comment0..1textEnable When: HeartConditions = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / HeartLungSurgery3. Heart/Lung surgery?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / HeartLungSurgeryCommentIf yes, or not certain, please comment0..1stringEnable When: HeartLungSurgery = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / ICDorPacemaker4. Implanted cardiac defibrillator (ICD) or Pacemaker?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / ICDorPacemakerLastCheckedWhen was it last checked?0..1stringEnable When: ICDorPacemaker = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / ShortnessOfBreathAtNight5. Shortness of breath at night?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / ShortnessOfBreathAtNightCommentIf yes, or not certain, please comment0..1stringEnable When: ShortnessOfBreathAtNight = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / BlackoutsOrFainting6. Blackouts or fainting?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / BlackoutsOrFaintingCircumstancesUnder what circumstances?0..1stringEnable When: BlackoutsOrFainting = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / SwollenAnkles7. Swollen ankles?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / SwollenAnklesCommentIf yes, or not certain, please comment0..1stringEnable When: SwollenAnkles = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / BreathingDifficulties8. Breathing difficulties (e.g. asthma, emphysema, C.O.R.D., bronchitis)?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / BreathingDifficultiesComment(Please bring peak flow recordings with you if available)0..1stringEnable When: BreathingDifficulties = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / SteroidsForBreathing9. Have you taken steroids for your breathing difficulty in the past 5 years?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / SteroidsForBreathingLastCourseWhen was the last course?0..1stringEnable When: SteroidsForBreathing = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / SleepApnoea10. Sleep apnoea (or have you been told you stop breathing while asleep)?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / SleepApnoeaCommentIf yes, or not certain, please comment0..1textEnable When: SleepApnoea = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / KidneyCondition11. Kidney (Renal) condition?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / KidneyConditionCommentIf yes, or not certain, please comment0..1stringEnable When: KidneyCondition = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / Diabetes12. Diabetes?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / DiabetesTypePlease tick which type0..1choiceEnable When: Diabetes = Yes (yes)
Value Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / DiabetesManagementDo you currently use (please tick):0..*choiceEnable When: Diabetes = Yes (yes)
Value Set:
Options: 3 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / Stroke13. Stroke (Cerebrovascular accident or CVA)?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / StrokeCommentIf yes, or not certain, please comment0..1textEnable When: Stroke = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / SuddenLossVisionSpeechMovement14. Sudden loss of vision, speech or movement?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / SuddenLossVisionSpeechMovementCommentIf yes, or not certain, please comment0..1stringEnable When: SuddenLossVisionSpeechMovement = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / BloodClotsOrBleedingDisorder15. Blood clots in lungs or legs or a bleeding disorder (PE, DVT, thrombosis)?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / BloodClotsOrBleedingDisorderCommentIf yes, or not certain, please comment0..1textEnable When: BloodClotsOrBleedingDisorder = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / HeartburnRefluxHiatusHernia16. Heartburn/reflux of acid/hiatus hernia?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / HeartburnRefluxHiatusHerniaCommentIf yes, or not certain, please comment0..1stringEnable When: HeartburnRefluxHiatusHernia = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / ThyroidProblems17. Thyroid problems?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / ThyroidProblemsCommentIf yes, or not certain, please comment0..1stringEnable When: ThyroidProblems = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / Dementia18. Dementia? (e.g. Alzheimer's, forgetfulness)0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / DementiaCommentIf yes, or not certain, please comment0..1textEnable When: Dementia = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / Epilepsy19. Epilepsy?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / EpilepsySeizureFrequencyHow often do you have seizures?0..1stringEnable When: Epilepsy = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / EpilepsyLastSeizureWhen was your last seizure?0..1stringEnable When: Epilepsy = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / Arthritis20. Arthritis?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / ArthritisCommentIf yes, or not certain, please comment0..1stringEnable When: Arthritis = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / JointReplacementOrMetalware21. Joint replacement or orthopaedic metalware?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / JointReplacementOrMetalwareTypeWhat type?0..1stringEnable When: JointReplacementOrMetalware = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / MuscleOrNeurologicalDisease22. Muscle or Neurological disease (e.g. MS, Parkinson's, Muscular dystrophy)?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / MuscleOrNeurologicalDiseaseCommentIf yes, or not certain, please comment0..1textEnable When: MuscleOrNeurologicalDisease = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / JawOrNeckProblems23. Jaw or neck problems?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / JawOrNeckProblemsCommentIf yes, or not certain, please comment0..1stringEnable When: JawOrNeckProblems = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / HepatitisOrLiverCondition24. Hepatitis A, B, C, jaundice or liver condition?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / HepatitisOrLiverConditionCommentIf yes, or not certain, please comment0..1stringEnable When: HepatitisOrLiverCondition = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / TransmittableDisease25. Transmittable disease (such as MRSA, 'golden staph', boils, skin or other infection, septicaemia, HIV, VRSA)?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / TransmittableDiseaseCommentIf yes, or not certain, please comment0..1textEnable When: TransmittableDisease = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / Tuberculosis26. Tuberculosis (TB)?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / TuberculosisTreatmentHave you had or are you on treatment for this?0..1stringEnable When: Tuberculosis = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / FamilyConditions27. Are there any conditions that run in your family? (e.g. malignant hyperthermia, thalassaemia, muscular dystrophy)?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / FamilyConditionsCommentIf yes, or not certain, please comment0..1textEnable When: FamilyConditions = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / Anaemia28. Anaemia?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / AnaemiaCommentIf yes, or not certain, please comment0..1stringEnable When: Anaemia = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / PreviousBloodTransfusion29. Previous blood transfusion?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / PreviousBloodTransfusionCommentWhen was the last?0..1stringEnable When: PreviousBloodTransfusion = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / BloodTransfusionRefusal30. Do you have any reasons which might stop you from accepting a blood transfusion?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / BloodTransfusionRefusalCommentWhat was the reason?0..1textEnable When: BloodTransfusionRefusal = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / Phobias31. Phobias (e.g. claustrophobia, anxiety attacks)?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / PhobiasCommentIf yes, or not certain, please comment0..1textEnable When: Phobias = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / TravelledOverseas32. Travelled overseas in the last 6 months?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / TravelledOverseasHospitalisedWere you hospitalised?0..1stringEnable When: TravelledOverseas = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / VisualOrHearingImpairment33. A visual or hearing impairment?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / VisualOrHearingImpairmentCommentIf yes, or not certain, please comment0..1stringEnable When: VisualOrHearingImpairment = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / CurrentPainProblems34. Do you have any current pain problems?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / CurrentPainProblemsLocationWhat is the location of the pain?0..1stringEnable When: CurrentPainProblems = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section3MedicalConditions / OtherRelevantMedicalCondition35. Is there any other relevant medical condition that you need to tell us about?0..1textValue Set:
RespiratoryAdultHealthQuestionnaire / Section4HealthProfessionalsSection 4 – Health professionals0..1groupValue Set:
RespiratoryAdultHealthQuestionnaire / Section4HealthProfessionals / HealthProfessionalsGroupList the name(s) of the hospital/clinic/doctors/surgeons/nurses you see.0..*groupValue Set:
RespiratoryAdultHealthQuestionnaire / Section4HealthProfessionals / HealthProfessionalsGroup / HealthProfessionalNameDoctor's name0..1stringValue Set:
RespiratoryAdultHealthQuestionnaire / Section4HealthProfessionals / HealthProfessionalsGroup / HealthProfessionalReasonReason you see this doctor0..1stringValue Set:
RespiratoryAdultHealthQuestionnaire / Section4HealthProfessionals / HealthProfessionalsGroup / HealthProfessionalLastVisitDate of last visit0..1dateValue Set:
RespiratoryAdultHealthQuestionnaire / Section5FitnessAndLifestyleSection 5 – Fitness and lifestyle0..1groupValue Set:
RespiratoryAdultHealthQuestionnaire / Section5FitnessAndLifestyle / StairsWithoutStoppingNow1. What can you do without stopping or getting breathless?0..1choiceValue Set:
Options: 4 options
RespiratoryAdultHealthQuestionnaire / Section5FitnessAndLifestyle / ManageAroundHouse2. Can you manage around the house?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section5FitnessAndLifestyle / ChangedInLast6Months3. Has this changed in the last 6 months?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section5FitnessAndLifestyle / StairsWithoutStopping6MonthsAgoIf yes, what could you do without stopping or getting breathless 6 months ago?0..1choiceEnable When: ChangedInLast6Months = Yes (yes)
Value Set:
Options: 4 options
RespiratoryAdultHealthQuestionnaire / Section5FitnessAndLifestyle / WhatStopsWalking4. What stops or restricts you from walking now? (e.g. getting breathless, pain in joints, pain in calf muscles)0..1textValue Set:
RespiratoryAdultHealthQuestionnaire / Section5FitnessAndLifestyle / DoYouSmoke5. Do you smoke?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section5FitnessAndLifestyle / SmokeHowManyPerDayHow many per day?0..1integerEnable When: DoYouSmoke = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section5FitnessAndLifestyle / EverSmoked6. Have you ever smoked?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section5FitnessAndLifestyle / WhenDidYouStopSmokingIf so, when did you stop?0..1stringEnable When: EverSmoked = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section5FitnessAndLifestyle / DrinkAlcoholRegularly7. Do you drink alcohol regularly?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section5FitnessAndLifestyle / AlcoholHowMuchPerWeekHow much per week?0..1stringEnable When: DrinkAlcoholRegularly = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section5FitnessAndLifestyle / PregnantOrMayBePregnant8. Are you or do you think you may be pregnant?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section5FitnessAndLifestyle / PregnancyWeeksIf yes – how many weeks?0..1integerEnable When: PregnantOrMayBePregnant = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section6AllergiesSection 6 – Allergies0..1groupValue Set:
RespiratoryAdultHealthQuestionnaire / Section6Allergies / AllergiesOrReactions1. Allergies or reactions to medicines (sticking plasters, food, paint, latex / rubber products or x-ray dye)?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section6Allergies / AllergiesDescriptionPlease describe what happens to you:0..1textEnable When: AllergiesOrReactions = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section7MedicationsSection 7 – Medications0..1groupValue Set:
RespiratoryAdultHealthQuestionnaire / Section7Medications / MedicationsGroupMedication / Therapy0..*groupValue Set:
RespiratoryAdultHealthQuestionnaire / Section7Medications / MedicationsGroup / MedicationNameName of Medication/Therapy0..1stringValue Set:
RespiratoryAdultHealthQuestionnaire / Section7Medications / MedicationsGroup / MedicationHowMuchHow much?0..1stringValue Set:
RespiratoryAdultHealthQuestionnaire / Section7Medications / MedicationsGroup / MedicationHowOftenHow often each day? (Breakfast, lunch, tea)0..1stringValue Set:
RespiratoryAdultHealthQuestionnaire / Section8PreviousSurgeryAnaesthesiaSection 8 – Previous surgery / anaesthesia0..1groupValue Set:
RespiratoryAdultHealthQuestionnaire / Section8PreviousSurgeryAnaesthesia / PreviousSurgeryOrAdmission1. Have you ever had surgery or been admitted to hospital before? (Including day surgery)0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section8PreviousSurgeryAnaesthesia / PreviousSurgeryGroupIf yes, when, what for and what hospital was that in?0..*groupEnable When: PreviousSurgeryOrAdmission = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section8PreviousSurgeryAnaesthesia / PreviousSurgeryGroup / PreviousSurgeryOperationIllnessOperation / Illness0..1stringValue Set:
RespiratoryAdultHealthQuestionnaire / Section8PreviousSurgeryAnaesthesia / PreviousSurgeryGroup / PreviousSurgeryYearYear0..1stringValue Set:
RespiratoryAdultHealthQuestionnaire / Section8PreviousSurgeryAnaesthesia / PreviousSurgeryGroup / PreviousSurgeryHospitalHospital0..1stringValue Set:
RespiratoryAdultHealthQuestionnaire / Section9AnaesthesiaRelatedIssuesSection 9 – Anaesthesia related issues0..1groupValue Set:
RespiratoryAdultHealthQuestionnaire / Section9AnaesthesiaRelatedIssues / ProblemsUnderAnaesthetic1. Have you had any problems while under an anaesthetic?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section9AnaesthesiaRelatedIssues / ProblemsUnderAnaestheticComment(e.g. slow to wake, nausea and vomiting, post surgery confusion, agitation)0..1stringEnable When: ProblemsUnderAnaesthetic = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section9AnaesthesiaRelatedIssues / RelativeProblemsUnderAnaesthetic2. Has any blood relative had problems while under an anaesthetic?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section9AnaesthesiaRelatedIssues / RelativeProblemsUnderAnaestheticCommentIf yes, or not certain, please comment0..1stringEnable When: RelativeProblemsUnderAnaesthetic = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section9AnaesthesiaRelatedIssues / AttendedPreAnaesthesiaAssessment3. Have you attended a pre-anaesthesia assessment before?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section9AnaesthesiaRelatedIssues / AttendedPreAnaesthesiaAssessmentLastTimeWhen was the last time?0..1stringEnable When: AttendedPreAnaesthesiaAssessment = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section10DischargePlanningSection 10 – Discharge planning0..1groupValue Set:
RespiratoryAdultHealthQuestionnaire / Section10DischargePlanning / RequirePhysicalSupportOrAids1. Do you require any physical support or aids?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section10DischargePlanning / RequirePhysicalSupportOrAidsDetailsIf so what?0..1stringEnable When: RequirePhysicalSupportOrAids = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section10DischargePlanning / LiveAlone2. Do you live alone?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section10DischargePlanning / LiveAloneCommentIf yes, or not certain, please comment0..1stringEnable When: LiveAlone = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section10DischargePlanning / ProblemsWithDailyActivities3. Do you have any problems with daily activities?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section10DischargePlanning / ProblemsWithDailyActivitiesComment(e.g. showering, bathing, dressing)0..1stringEnable When: ProblemsWithDailyActivities = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section10DischargePlanning / WhoWillTakeYouHome4. Who will be taking you home?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section10DischargePlanning / WhoWillTakeYouHomeCommentIf yes, or not certain, please comment0..1stringEnable When: WhoWillTakeYouHome = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section10DischargePlanning / SomeoneToStayOvernight5. Do you have someone to stay overnight with you when you get home?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section10DischargePlanning / SomeoneToStayOvernightCommentIf yes, or not certain, please comment0..1textEnable When: SomeoneToStayOvernight = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section10DischargePlanning / UsingCommunitySupportServices6. Are you currently using any community support services?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section10DischargePlanning / CommunitySupportServicesListIf so please list:0..1stringEnable When: UsingCommunitySupportServices = Yes (yes)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section10DischargePlanning / SpeakUnderstandEnglish7. Do you speak and understand English?0..1choiceValue Set:
Options: 2 options
RespiratoryAdultHealthQuestionnaire / Section10DischargePlanning / FirstLanguageIf not, what is your first language?0..1stringEnable When: SpeakUnderstandEnglish = No (no)
Value Set:
RespiratoryAdultHealthQuestionnaire / Section10DischargePlanning / AnythingToDiscuss8. Is there anything in particular you would like to discuss?0..1textValue Set:
RespiratoryAdultHealthQuestionnaire / Section11PatientDeclarationSection 11 – Patient declaration0..1groupValue Set:
RespiratoryAdultHealthQuestionnaire / Section11PatientDeclaration / DeclarationStatementThe above health information is a true and accurate account of my health status.0..1displayValue Set:
RespiratoryAdultHealthQuestionnaire / Section11PatientDeclaration / PatientSignaturePatient's signature0..1stringValue Set:
RespiratoryAdultHealthQuestionnaire / Section11PatientDeclaration / DeclarationDateDate0..1dateValue Set:

doco Documentation for this format

Options Sets

Answer options for HappyToLeaveMessage

  • null#yes ("Yes")
  • null#no ("No")

Answer options for MessageWithPerson

  • null#yes ("Yes")
  • null#no ("No")

Answer options for MessageOnAnswerPhone

  • null#yes ("Yes")
  • null#no ("No")

Answer options for PreAnaesthesiaRequirements

  • null#nurse-telephone-call ("Nurse telephone call")
  • null#routine ("Routine")
  • null#complex ("Complex")
  • null#high-risk ("High risk")
  • null#paediatric-specialist ("Paediatric specialist")

Answer options for HighBloodPressure

  • null#yes ("Yes")
  • null#no ("No")

Answer options for HeartConditions

  • null#yes ("Yes")
  • null#no ("No")

Answer options for HeartLungSurgery

  • null#yes ("Yes")
  • null#no ("No")

Answer options for ICDorPacemaker

  • null#yes ("Yes")
  • null#no ("No")

Answer options for ShortnessOfBreathAtNight

  • null#yes ("Yes")
  • null#no ("No")

Answer options for BlackoutsOrFainting

  • null#yes ("Yes")
  • null#no ("No")

Answer options for SwollenAnkles

  • null#yes ("Yes")
  • null#no ("No")

Answer options for BreathingDifficulties

  • null#yes ("Yes")
  • null#no ("No")

Answer options for SteroidsForBreathing

  • null#yes ("Yes")
  • null#no ("No")

Answer options for SleepApnoea

  • null#yes ("Yes")
  • null#no ("No")

Answer options for KidneyCondition

  • null#yes ("Yes")
  • null#no ("No")

Answer options for Diabetes

  • null#yes ("Yes")
  • null#no ("No")

Answer options for DiabetesType

  • null#type-1 ("Type 1")
  • null#type-2 ("Type 2")

Answer options for DiabetesManagement

  • null#insulin ("Insulin")
  • null#tablets ("Tablets")
  • null#diet-control ("Diet control")

Answer options for Stroke

  • null#yes ("Yes")
  • null#no ("No")

Answer options for SuddenLossVisionSpeechMovement

  • null#yes ("Yes")
  • null#no ("No")

Answer options for BloodClotsOrBleedingDisorder

  • null#yes ("Yes")
  • null#no ("No")

Answer options for HeartburnRefluxHiatusHernia

  • null#yes ("Yes")
  • null#no ("No")

Answer options for ThyroidProblems

  • null#yes ("Yes")
  • null#no ("No")

Answer options for Dementia

  • null#yes ("Yes")
  • null#no ("No")

Answer options for Epilepsy

  • null#yes ("Yes")
  • null#no ("No")

Answer options for Arthritis

  • null#yes ("Yes")
  • null#no ("No")

Answer options for JointReplacementOrMetalware

  • null#yes ("Yes")
  • null#no ("No")

Answer options for MuscleOrNeurologicalDisease

  • null#yes ("Yes")
  • null#no ("No")

Answer options for JawOrNeckProblems

  • null#yes ("Yes")
  • null#no ("No")

Answer options for HepatitisOrLiverCondition

  • null#yes ("Yes")
  • null#no ("No")

Answer options for TransmittableDisease

  • null#yes ("Yes")
  • null#no ("No")

Answer options for Tuberculosis

  • null#yes ("Yes")
  • null#no ("No")

Answer options for FamilyConditions

  • null#yes ("Yes")
  • null#no ("No")

Answer options for Anaemia

  • null#yes ("Yes")
  • null#no ("No")

Answer options for PreviousBloodTransfusion

  • null#yes ("Yes")
  • null#no ("No")

Answer options for BloodTransfusionRefusal

  • null#yes ("Yes")
  • null#no ("No")

Answer options for Phobias

  • null#yes ("Yes")
  • null#no ("No")

Answer options for TravelledOverseas

  • null#yes ("Yes")
  • null#no ("No")

Answer options for VisualOrHearingImpairment

  • null#yes ("Yes")
  • null#no ("No")

Answer options for CurrentPainProblems

  • null#yes ("Yes")
  • null#no ("No")

Answer options for StairsWithoutStoppingNow

  • null#10-stairs ("10 stairs")
  • null#20-stairs ("20 stairs")
  • null#30-stairs ("30 stairs")
  • null#40-stairs ("40 stairs")

Answer options for ManageAroundHouse

  • null#yes ("Yes")
  • null#no ("No")

Answer options for ChangedInLast6Months

  • null#yes ("Yes")
  • null#no ("No")

Answer options for StairsWithoutStopping6MonthsAgo

  • null#10-stairs ("10 stairs")
  • null#20-stairs ("20 stairs")
  • null#30-stairs ("30 stairs")
  • null#40-stairs ("40 stairs")

Answer options for DoYouSmoke

  • null#yes ("Yes")
  • null#no ("No")

Answer options for EverSmoked

  • null#yes ("Yes")
  • null#no ("No")

Answer options for DrinkAlcoholRegularly

  • null#yes ("Yes")
  • null#no ("No")

Answer options for PregnantOrMayBePregnant

  • null#yes ("Yes")
  • null#no ("No")

Answer options for AllergiesOrReactions

  • null#yes ("Yes")
  • null#no ("No")

Answer options for PreviousSurgeryOrAdmission

  • null#yes ("Yes")
  • null#no ("No")

Answer options for ProblemsUnderAnaesthetic

  • null#yes ("Yes")
  • null#no ("No")

Answer options for RelativeProblemsUnderAnaesthetic

  • null#yes ("Yes")
  • null#no ("No")

Answer options for AttendedPreAnaesthesiaAssessment

  • null#yes ("Yes")
  • null#no ("No")

Answer options for RequirePhysicalSupportOrAids

  • null#yes ("Yes")
  • null#no ("No")

Answer options for LiveAlone

  • null#yes ("Yes")
  • null#no ("No")

Answer options for ProblemsWithDailyActivities

  • null#yes ("Yes")
  • null#no ("No")

Answer options for WhoWillTakeYouHome

  • null#yes ("Yes")
  • null#no ("No")

Answer options for SomeoneToStayOvernight

  • null#yes ("Yes")
  • null#no ("No")

Answer options for UsingCommunitySupportServices

  • null#yes ("Yes")
  • null#no ("No")

Answer options for SpeakUnderstandEnglish

  • null#yes ("Yes")
  • null#no ("No")