MentalHealthAssessmentSurveyQuestionnaire
type: Questionnaire
node role: treeRoot
id:
  v: MentalHealthAssessmentSurveyQuestionnaire
text:
  status:
    v: extensions
  div: Generated Narrative: Questionnaire MentalHealthAssessmentSurveyQuestionnaire Structure LinkID Text Cardinality Type Description & Constraints<img src="[binary]" alt="doco" style="background-color: inherit"/> MentalHealthAssessmentSurveyQuestionnaire Te Whatu Ora Mental Health Assessment Survey Questionnaire https://build.fhir.org/ig/tewhatuora/cinc-fhir-ig/Questionnaire/MentalHealthAssessmentSurveyQuestionnaire#0.4.5 #xD; p01 page 1. History and Examination 0..1 group #xD; p01-q01-IssueDescription page 1 question 1. Description of presenting issue 1..1 text #xD; p01-q02-Mood page 1 question 2. Assessment of Mood 1..1 text #xD; p01-q03-SleepHygine page 1 question 3. Assessment of sleep hygiene 1..1 text #xD; p01-q04-SupportStructure page 1 question 4. Assessment of whanau and support structures 1..1 text #xD; p01-q05-Trauma page 1 question 5. Is there a history of previous trauma and stressors? 1..1 boolean #xD; p01-q05-1-Trauma.Description page 1 question 5.1. Please provide information surrounding this history. 1..1 text Enable When: p01-q05-Trauma = #xD; p01-q06-SuicideAttemptHistory page 1 question 6. Have there been any previous suicide attempts? 1..1 boolean #xD; p01-q06-1-SuicideAttemptHistory.Description page 1 question 6.1. Please provide details surrounding these attempts 1..1 text Enable When: p01-q06-SuicideAttemptHistory = #xD; p01-q07-CigaretteSmoker page 1 question 7. Is the patient smoking cigarettes? 1..1 boolean #xD; p01-q01-1-CigaretteSmoker.HowMany page 1 question 7.1. How many cigarettes per day? 1..1 choice Enable When: p01-q07-CigaretteSmoker = Options: 2 options #xD; p01-q08-CurrentDrinker page 1 question 8. Does the patient consume alcohol? 1..1 boolean #xD; p01-q08-1-CurrentDrinker.HowMany page 1 question 8.1. How many drinks per week? 1..1 choice Enable When: p01-q08-CurrentDrinker = Options: 3 options #xD; p01-q09-RecreationalDrugs page 1 question 9. Does the patient use recreational drugs? 1..1 boolean #xD; p01-q10-PsychiatricMedication p…
url:
  v: https://build.fhir.org/ig/tewhatuora/cinc-fhir-ig/Questionnaire/MentalHealthAssessmentSurveyQuestionnaire
identifier:
  use:
    v: official
  value:
    v: MentalHealthAssessmentSurveyQuestionnaire
  period:
    start:
      v: 2023-08-16
identifier:
  use:
    v: temp
  value:
    v: Questionnaire-MentalHealthAssessmentSurveyQuestionnaire
  period:
    start:
      v: 2023-03-07
    end:
      v: 2023-07-26
version:
  v: 0.4.5
name:
  v: MentalHealthAssessmentSurveyQuestionnaire
title:
  v: Mental Health Assessment Survey
status:
  v: draft
date:
  v: 2026-03-03T21:51:04+00:00
publisher:
  v: Te Whatu Ora
contact:
  name:
    v: Te Whatu Ora
  telecom:
    system:
      v: url
    value:
      v: https://www.tewhatuora.govt.nz/
contact:
  name:
    v: Te Whatu Ora Integration Team
  telecom:
    system:
      v: email
    use:
      v: work
description:
  v: Te Whatu Ora Mental Health Assessment Survey
jurisdiction:
  coding:
    system:
      v: urn:iso:std:iso:3166
    code:
      v: NZ
    display:
      v: New Zealand
item:
  link id:
    v: p01
  prefix:
    v: page 1
  text:
    v: History and Examination
  type:
    v: group
  item:
    link id:
      v: p01-q01-IssueDescription
    prefix:
      v: page 1 question 1
    text:
      v: Description of presenting issue
    type:
      v: text
    required:
      v: true
  item:
    link id:
      v: p01-q02-Mood
    code: http://snomed.info/id/106131003
      system:
        v: http://snomed.info/sct
      code:
        v: 106131003
      display:
        v: Mood finding
    prefix:
      v: page 1 question 2
    text:
      v: Assessment of Mood
    type:
      v: text
    required:
      v: true
  item:
    link id:
      v: p01-q03-SleepHygine
    code: http://snomed.info/id/106168000
      system:
        v: http://snomed.info/sct
      code:
        v: 106168000
      display:
        v: Finding related to sleep
    prefix:
      v: page 1 question 3
    text:
      v: Assessment of sleep hygiene
    type:
      v: text
    required:
      v: true
  item:
    link id:
      v: p01-q04-SupportStructure
    prefix:
      v: page 1 question 4
    text:
      v: Assessment of whanau and support structures
    type:
      v: text
    required:
      v: true
  item:
    link id:
      v: p01-q05-Trauma
    prefix:
      v: page 1 question 5
    text:
      v: Is there a history of previous trauma and stressors?
    type:
      v: boolean
    required:
      v: true
    repeats:
      v: false
  item:
    link id:
      v: p01-q05-1-Trauma.Description
    prefix:
      v: page 1 question 5.1
    text:
      v: Please provide information surrounding this history.
    type:
      v: text
    enable when:
      question:
        v: p01-q05-Trauma
      operator:
        v: =
      answer: boolean
        v: true
    enable behavior:
      v: all
    required:
      v: true
    repeats:
      v: false
  item:
    link id:
      v: p01-q06-SuicideAttemptHistory
    code: http://snomed.info/id/23233009
      system:
        v: http://snomed.info/sct
      code:
        v: 23233009
      display:
        v: Previous known suicide attempt
    prefix:
      v: page 1 question 6
    text:
      v: Have there been any previous suicide attempts?
    type:
      v: boolean
    required:
      v: true
    repeats:
      v: false
  item:
    link id:
      v: p01-q06-1-SuicideAttemptHistory.Description
    prefix:
      v: page 1 question 6.1
    text:
      v: Please provide details surrounding these attempts
    type:
      v: text
    enable when:
      question:
        v: p01-q06-SuicideAttemptHistory
      operator:
        v: =
      answer: boolean
        v: true

v: all

v: true

v: false

link id:
  v: p01-q07-CigaretteSmoker
code: http://snomed.info/id/65568007
  system:
    v: http://snomed.info/sct
  code:
    v: 65568007
  display:
    v: Cigarette smoker
prefix:
  v: page 1 question 7
text:
  v: Is the patient smoking cigarettes?
type:
  v: boolean
required:
  v: true
repeats:
  v: false

link id:
  v: p01-q01-1-CigaretteSmoker.HowMany
prefix:
  v: page 1 question 7.1
text:
  v: How many cigarettes per day?
type:
  v: choice
enable when:
  question:
    v: p01-q07-CigaretteSmoker
  operator:
    v: =
  answer: boolean
    v: true
enable behavior:
  v: all
required:
  v: true
repeats:
  v: false
answer option:
  value: Coding
    code:
      v: Less than 10
    display:
      v: Less than 10
answer option:
  value: Coding
    code:
      v: 10 or more
    display:
      v: 10 or more

link id:
  v: p01-q08-CurrentDrinker
code: http://snomed.info/id/219006
  system:
    v: http://snomed.info/sct
  code:
    v: 219006
  display:
    v: Current drinker
prefix:
  v: page 1 question 8
text:
  v: Does the patient consume alcohol?
type:
  v: boolean
required:
  v: true
repeats:
  v: false

link id:
  v: p01-q08-1-CurrentDrinker.HowMany
prefix:
  v: page 1 question 8.1
text:
  v: How many drinks per week?
type:
  v: choice
enable when:
  question:
    v: p01-q08-CurrentDrinker
  operator:
    v: =
  answer: boolean
    v: true
enable behavior:
  v: all
required:
  v: true
repeats:
  v: false
answer option:
  value: Coding
    code:
      v: Less than 10
    display:
      v: Less than 10
answer option:
  value: Coding
    code:
      v: 10 to 16
    display:
      v: 10 to 16
answer option:
  value: Coding
    code:
      v: More than 16
    display:
      v: More than 16

link id:
  v: p01-q09-RecreationalDrugs
code: http://snomed.info/id/424848002
  system:
    v: http://snomed.info/sct
  code:
    v: 424848002
  display:
    v: Recreational drug user
prefix:
  v: page 1 question 9
text:
  v: Does the patient use recreational drugs?
type:
  v: boolean
required:
  v: true
repeats:
  v: false

link id:
  v: p01-q10-PsychiatricMedication
prefix:
  v: page 1 question 10
text:
  v: Psychiatric Medication?
type:
  v: text

link id:
  v: p02
prefix:
  v: page 2
text:
  v: Risk Assessment
type:
  v: group
item:
  link id:
    v: p02-q01-SuicidalIntent
  code: http://snomed.info/id/304594002
    system:
      v: http://snomed.info/sct
    code:
      v: 304594002
    display:
      v: Suicidal intent
  prefix:
    v: page 2 question 1
  text:
    v: Suicidal Intent?
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: p02-q02-HarmfulThoughts
  code: http://snomed.info/id/285261008
    system:
      v: http://snomed.info/sct
    code:
      v: 285261008
    display:
      v: Dangerous and harmful thoughts
  prefix:
    v: page 2 question 2
  text:
    v: Threat to others?
  type:
    v: boolean
  required:
    v: true
  repeats:
    v: false

link id:
  v: p03
prefix:
  v: page 3
text:
  v: Current and past psychiatric diagnosis
type:
  v: group
item:
  link id:
    v: p03-g01-AddDiagnosis
  prefix:
    v: page 3 group 1
  text:
    v: Add Diagnosis
  type:
    v: group
  required:
    v: false
  repeats:
    v: true
  item:
    link id:
      v: p03-g01-q01-AddDiagnosis.Diagnosis
    code: http://snomed.info/id/404684003
      system:
        v: http://snomed.info/sct
      code:
        v: 404684003
      display:
        v: Clinical finding
    prefix:
      v: page 3 group 1 question 1
    text:
      v: Diagnosis
    type:
      v: text
    required:
      v: true
    repeats:
      v: false
  item:
    link id:
      v: p03-g01-q02-AddDiagnosis.Year
    prefix:
      v: page 3 group 1 question 2
    text:
      v: Year of Diagnosis
    type:
      v: date
    required:
      v: true
    repeats:
      v: false
  item:
    link id:
      v: p03-g01-q03-AddDiagnosis.Place
    prefix:
      v: page 3 group 1 question 3
    text:
      v: Place of Diagnosis
    type:
      v: string
    required:
      v: true
    repeats:
      v: false
  item:
    link id:
      v: p03-g01-q04-AddDiagnosis.Hospitalisation
    prefix:
      v: page 3 group 1 question 4
    text:
      v: Hospitalisation?
    type:
      v: boolean
    required:
      v: true
    repeats:
      v: false
  item:
    link id:
      v: p03-g01-q05-AddDiagnosis.Active
    prefix:
      v: page 3 group 1 question 5
    text:
      v: Active?
    type:
      v: boolean
    required:
      v: true

link id:
  v: p04
prefix:
  v: page 4
text:
  v: General Practice Information
type:
  v: group
item:
  link id:
    v: p04-q01-SendNote
  prefix:
    v: page 4 question 1
  text:
    v: Send note to GP Inbox?
  type:
    v: boolean
  required:
    v: true
  repeats:
    v: false
  initial:
    value: boolean
      v: false
item:
  link id:
    v: p04-q02-PracticeName
  prefix:
    v: page 4 question 2
  text:
    v: GP Practice Name
  type:
    v: string
  required:
    v: false
  repeats:
    v: false
item:
  link id:
    v: p04-q03-PracticeEDI
  prefix:
    v: page 4 question 3
  text:
    v: Practice EDI
  type:
    v: string
  required:
    v: false
  repeats:
    v: false