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| { | |
| "lformsVersion": "34.0.0", | |
| "PATH_DELIMITER": "/", | |
| "code": "phr", | |
| "codeList": [ | |
| { | |
| "code": "phr", | |
| "display": "Health Record" | |
| } | |
| ], | |
| "identifier": null, | |
| "name": " \u300c \u2726 \u2726 \u2726 DARNAHI \u270e \u2726 \u2726 \u2726 \u2726 \u300d ", | |
| "template": "table", | |
| "items": [ | |
| { | |
| "header": true, | |
| "dataType": "SECTION", | |
| "question": "ABOUT ME", | |
| "codeList": [ | |
| { | |
| "system": "custom", | |
| "code": "birthdate", | |
| "display": "BIRTHDATE" | |
| } | |
| ], | |
| "questionCode": "birthdate", | |
| "questionCodeSystem": "custom", | |
| "linkId": "679676784038", | |
| "questionCardinality": { | |
| "max": "1", | |
| "min": "1" | |
| }, | |
| "items": [ | |
| { | |
| "dataType": "DT", | |
| "question": "DATE OF BIRTH", | |
| "questionCode": "593486088490", | |
| "questionCodeSystem": "LinkId", | |
| "linkId": "593486088490", | |
| "questionCardinality": { | |
| "max": "1", | |
| "min": "1" | |
| }, | |
| "codeList": [], | |
| "answerCardinality": { | |
| "min": "0", | |
| "max": "1" | |
| }, | |
| "value": "1900-01-01" | |
| }, | |
| { | |
| "dataType": "CWE", | |
| "question": "BIOLOGICAL SEX", | |
| "questionCode": "571347576477", | |
| "questionCodeSystem": "LinkId", | |
| "linkId": "571347576477", | |
| "answerCardinality": { | |
| "max": "1", | |
| "min": "0" | |
| }, | |
| "displayControl": { | |
| "answerLayout": { | |
| "type": "RADIO_CHECKBOX" | |
| } | |
| }, | |
| "answers": [ | |
| { | |
| "text": "M" | |
| }, | |
| { | |
| "text": "F" | |
| } | |
| ], | |
| "codeList": [], | |
| "questionCardinality": { | |
| "min": "1", | |
| "max": "1" | |
| }, | |
| "value": { | |
| "text": "F" | |
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| } | |
| ], | |
| "displayControl": { | |
| "questionLayout": "vertical" | |
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| "answerCardinality": { | |
| "min": "0", | |
| "max": "1" | |
| } | |
| }, | |
| { | |
| "dataType": "ST", | |
| "question": "ALLERGIES", | |
| "questionCode": "4547915263358", | |
| "questionCodeSystem": "LinkId", | |
| "linkId": "4547915263358", | |
| "questionCardinality": { | |
| "max": "1", | |
| "min": "1" | |
| }, | |
| "items": [ | |
| { | |
| "header": true, | |
| "dataType": "SECTION", | |
| "question": "Allergies and Other Dangerous Reactions", | |
| "codeList": [ | |
| { | |
| "system": "Custom", | |
| "code": "allergies", | |
| "display": "Allergies and Other Dangerous Reactions" | |
| } | |
| ], | |
| "questionCode": "allergies", | |
| "questionCodeSystem": "Custom", | |
| "linkId": "/allergies", | |
| "questionCardinality": { | |
| "max": "*", | |
| "min": "1" | |
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| "displayControl": { | |
| "questionLayout": "horizontal" | |
| }, | |
| "items": [ | |
| { | |
| "dataType": "CWE", | |
| "question": "Name", | |
| "codeList": [ | |
| { | |
| "system": "Custom", | |
| "code": "allergy_name", | |
| "display": "Name" | |
| } | |
| ], | |
| "questionCode": "allergy_name", | |
| "questionCodeSystem": "Custom", | |
| "linkId": "/allergies/allergy_name", | |
| "answerCardinality": { | |
| "max": "1", | |
| "min": "0" | |
| }, | |
| "displayControl": { | |
| "answerLayout": { | |
| "type": "COMBO_BOX" | |
| } | |
| }, | |
| "answers": [ | |
| { | |
| "code": "food", | |
| "text": "Food allergies" | |
| }, | |
| { | |
| "code": "FOOD-2", | |
| "text": "Chocolate" | |
| }, | |
| { | |
| "code": "FOOD-22", | |
| "text": "Crab" | |
| }, | |
| { | |
| "code": "FOOD-4", | |
| "text": "Egg" | |
| }, | |
| { | |
| "code": "FOOD-5", | |
| "text": "Fish" | |
| }, | |
| { | |
| "code": "FOOD-7", | |
| "text": "Gluten" | |
| }, | |
| { | |
| "code": "FOOD-19", | |
| "text": "Milk" | |
| }, | |
| { | |
| "code": "FOOD-16", | |
| "text": "Monosodium Glutamate (MSG)" | |
| }, | |
| { | |
| "code": "FOOD-9", | |
| "text": "Peanut" | |
| }, | |
| { | |
| "code": "FOOD-10", | |
| "text": "Pork" | |
| }, | |
| { | |
| "code": "FOOD-18", | |
| "text": "Sesame" | |
| }, | |
| { | |
| "code": "FOOD-12", | |
| "text": "Shellfish" | |
| }, | |
| { | |
| "code": "FOOD-21", | |
| "text": "Shrimp" | |
| }, | |
| { | |
| "code": "FOOD-13", | |
| "text": "Soy" | |
| }, | |
| { | |
| "code": "FOOD-14", | |
| "text": "Tomatoes" | |
| }, | |
| { | |
| "code": "FOOD-17", | |
| "text": "Tree Nuts" | |
| }, | |
| { | |
| "code": "FOOD-20", | |
| "text": "Wheat" | |
| }, | |
| { | |
| "code": "FOOD-23", | |
| "text": "Cochineal extract (Carmine) red dye" | |
| }, | |
| { | |
| "code": "FOOD-24", | |
| "text": "FD&C Blue No. 1 dye" | |
| }, | |
| { | |
| "code": "FOOD-25", | |
| "text": "FD&C Yellow No. 2 dye" | |
| }, | |
| { | |
| "code": "environmental", | |
| "text": "Environmental allergies" | |
| }, | |
| { | |
| "code": "OTHR-18", | |
| "text": "Cat" | |
| }, | |
| { | |
| "code": "OTHR-4", | |
| "text": "Cockroach" | |
| }, | |
| { | |
| "code": "OTHR-5", | |
| "text": "Cold Weather" | |
| }, | |
| { | |
| "code": "OTHR-17", | |
| "text": "Dog" | |
| }, | |
| { | |
| "code": "OTHR-6", | |
| "text": "Dust Mites" | |
| }, | |
| { | |
| "code": "OTHR-7", | |
| "text": "Hay Fever" | |
| }, | |
| { | |
| "code": "OTHR-1", | |
| "text": "Iodinated x-ray contrast" | |
| }, | |
| { | |
| "code": "OTHR-2", | |
| "text": "Latex" | |
| }, | |
| { | |
| "code": "OTHR-8", | |
| "text": "Mold" | |
| }, | |
| { | |
| "code": "OTHR-9", | |
| "text": "Nickel" | |
| }, | |
| { | |
| "code": "OTHR-10", | |
| "text": "Pet Dander" | |
| }, | |
| { | |
| "code": "OTHR-19", | |
| "text": "Pollen" | |
| }, | |
| { | |
| "code": "OTHR-11", | |
| "text": "Ragweed" | |
| }, | |
| { | |
| "code": "OTHR-12", | |
| "text": "Semen" | |
| }, | |
| { | |
| "code": "OTHR-13", | |
| "text": "Sun" | |
| }, | |
| { | |
| "code": "OTHR-3", | |
| "text": "Wasp, hornet, bee sting" | |
| }, | |
| { | |
| "code": "medClass", | |
| "text": "Medication class allergies" | |
| }, | |
| { | |
| "code": "DRUG-CLASS-1", | |
| "text": "ACE Inhibitors" | |
| }, | |
| { | |
| "code": "DRUG-CLASS-2", | |
| "text": "Aminoglycosides" | |
| }, | |
| { | |
| "code": "DRUG-CLASS-3", | |
| "text": "Antihistamines" | |
| }, | |
| { | |
| "code": "DRUG-CLASS-4", | |
| "text": "Benzodiazepines" | |
| }, | |
| { | |
| "code": "DRUG-CLASS-5", | |
| "text": "Beta Blockers" | |
| }, | |
| { | |
| "code": "DRUG-CLASS-6", | |
| "text": "Calcium Channel Blockers" | |
| }, | |
| { | |
| "code": "DRUG-CLASS-7", | |
| "text": "Cephalosporins" | |
| }, | |
| { | |
| "code": "DRUG-CLASS-8", | |
| "text": "Diuretics" | |
| }, | |
| { | |
| "code": "DRUG-CLASS-9", | |
| "text": "H2 Blockers" | |
| }, | |
| { | |
| "code": "DRUG-CLASS-10", | |
| "text": "Insulins" | |
| }, | |
| { | |
| "code": "DRUG-CLASS-11", | |
| "text": "Iodine Containing Medications" | |
| }, | |
| { | |
| "code": "DRUG-CLASS-12", | |
| "text": "Local Anesthetics" | |
| }, | |
| { | |
| "code": "DRUG-CLASS-13", | |
| "text": "Macrolides (like Erythromycin)" | |
| }, | |
| { | |
| "code": "DRUG-CLASS-14", | |
| "text": "Muscle Relaxants, Skeletal" | |
| }, | |
| { | |
| "code": "DRUG-CLASS-15", | |
| "text": "Narcotic Analgesics" | |
| }, | |
| { | |
| "code": "DRUG-CLASS-16", | |
| "text": "Nonsteroidal Anti Inflam. Agents (NSAID)" | |
| }, | |
| { | |
| "code": "DRUG-CLASS-24", | |
| "text": "Penicillin and Derivatives" | |
| }, | |
| { | |
| "code": "DRUG-CLASS-17", | |
| "text": "Phenothiazines" | |
| }, | |
| { | |
| "code": "DRUG-CLASS-18", | |
| "text": "Proton Pump Inhibitors" | |
| }, | |
| { | |
| "code": "DRUG-CLASS-19", | |
| "text": "Quinolone Antibiotics" | |
| }, | |
| { | |
| "code": "DRUG-CLASS-20", | |
| "text": "Serotonin Re-Uptake Inhibitors" | |
| }, | |
| { | |
| "code": "DRUG-CLASS-21", | |
| "text": "Statins" | |
| }, | |
| { | |
| "code": "DRUG-CLASS-22", | |
| "text": "Sulfa Drugs" | |
| }, | |
| { | |
| "code": "DRUG-CLASS-23", | |
| "text": "Tetracycline" | |
| }, | |
| { | |
| "code": "medication", | |
| "text": "Medication allergies" | |
| }, | |
| { | |
| "code": "MED-57", | |
| "text": "ALEVE (Naproxen)" | |
| }, | |
| { | |
| "code": "MED-2", | |
| "text": "AMBIEN (Zolpedem)" | |
| }, | |
| { | |
| "code": "MED-97", | |
| "text": "Amoxicillin" | |
| }, | |
| { | |
| "code": "MED-6", | |
| "text": "Aspirin (ASA)" | |
| }, | |
| { | |
| "code": "MED-7", | |
| "text": "ATIVAN (Lorazapam)" | |
| }, | |
| { | |
| "code": "MED-8", | |
| "text": "ATROVENT (Ipartropium)" | |
| }, | |
| { | |
| "code": "MED-55", | |
| "text": "AVINZA (Morphine)" | |
| }, | |
| { | |
| "code": "MED-9", | |
| "text": "Bacitracin" | |
| }, | |
| { | |
| "code": "MED-10", | |
| "text": "BACTRIM (Sulfamethoxazol/trimethaprim)" | |
| }, | |
| { | |
| "code": "MED-11", | |
| "text": "BENADRYL (Diphenhydramine )" | |
| }, | |
| { | |
| "code": "MED-13", | |
| "text": "BUMEX (Bumetanide)" | |
| }, | |
| { | |
| "code": "MED-16", | |
| "text": "CARDIZEM (Diltizzam)" | |
| }, | |
| { | |
| "code": "MED-99", | |
| "text": "CEFZIL (Cefprozil)" | |
| }, | |
| { | |
| "code": "MED-18", | |
| "text": "CIPROFLOXACIN (Cipro)" | |
| }, | |
| { | |
| "code": "MED-19", | |
| "text": "Codeine" | |
| }, | |
| { | |
| "code": "MED-20", | |
| "text": "COLACE (Docusate Sodium)" | |
| }, | |
| { | |
| "code": "MED-21", | |
| "text": "COMPAZINE (Prochlorperazine Maleate)" | |
| }, | |
| { | |
| "code": "MED-22", | |
| "text": "COUMADIN (Warfarin)" | |
| }, | |
| { | |
| "code": "MED-23", | |
| "text": "DALMANE (Flurazepam)" | |
| }, | |
| { | |
| "code": "MED-52", | |
| "text": "DEMEROL (Meperidine)" | |
| }, | |
| { | |
| "code": "MED-88", | |
| "text": "DEPAKOTE ER (Valproic Acid)" | |
| }, | |
| { | |
| "code": "MED-26", | |
| "text": "DILANTIN (Phenytoin)" | |
| }, | |
| { | |
| "code": "MED-28", | |
| "text": "DULCOLAX (Bisacodyl)" | |
| }, | |
| { | |
| "code": "MED-29", | |
| "text": "E-MYCIN (Erythromycin)" | |
| }, | |
| { | |
| "code": "MED-30", | |
| "text": "GASTROGRAFIN(Diatrizoate Meglumine)" | |
| }, | |
| { | |
| "code": "MED-31", | |
| "text": "GLUCOPHAGE (Metformin)" | |
| }, | |
| { | |
| "code": "MED-32", | |
| "text": "HALCION (Triazolam)" | |
| }, | |
| { | |
| "code": "MED-33", | |
| "text": "HALDOL (Haloperidol)" | |
| }, | |
| { | |
| "code": "MED-35", | |
| "text": "HUMALIN (human insulin)" | |
| }, | |
| { | |
| "code": "MED-37", | |
| "text": "IMDUR (Isosorbide)" | |
| }, | |
| { | |
| "code": "MED-64", | |
| "text": "ISONIAZID (Isoniazide)" | |
| }, | |
| { | |
| "code": "MED-41", | |
| "text": "KAYEVELATE (Sodium Polystyrene Sulfonate)" | |
| }, | |
| { | |
| "code": "MED-42", | |
| "text": "KLONOPIN (Clonazepam)" | |
| }, | |
| { | |
| "code": "MED-43", | |
| "text": "Lactose" | |
| }, | |
| { | |
| "code": "MED-44", | |
| "text": "LASIX (Furosemide)" | |
| }, | |
| { | |
| "code": "MED-45", | |
| "text": "LEVAQUIN (Levofloxacin)" | |
| }, | |
| { | |
| "code": "MED-46", | |
| "text": "LIBRIUM (Chlordiazepoxide)" | |
| }, | |
| { | |
| "code": "MED-47", | |
| "text": "Lidocaine, Local" | |
| }, | |
| { | |
| "code": "MED-48", | |
| "text": "LIPITOR (Atorvastatin)" | |
| }, | |
| { | |
| "code": "MED-49", | |
| "text": "LOPRESSOR (Metroprolol)" | |
| }, | |
| { | |
| "code": "MED-50", | |
| "text": "LOVENOX (Enoxaparin)" | |
| }, | |
| { | |
| "code": "MED-51", | |
| "text": "MELLARIL (Thioridazine)" | |
| }, | |
| { | |
| "code": "MED-36", | |
| "text": "MOTRIN/ADVIL (Ibuprofen)" | |
| }, | |
| { | |
| "code": "MED-59", | |
| "text": "NORVASC (Amlodipine)" | |
| }, | |
| { | |
| "code": "MED-98", | |
| "text": "OMNICEF (Cefdinir)" | |
| }, | |
| { | |
| "code": "MED-96", | |
| "text": "Penicillin" | |
| }, | |
| { | |
| "code": "MED-61", | |
| "text": "PEPCID (Famotidine)" | |
| }, | |
| { | |
| "code": "MED-62", | |
| "text": "PERMITIL (Fluphenazine)" | |
| }, | |
| { | |
| "code": "MED-65", | |
| "text": "PLAVIX (Clopidogrel)" | |
| }, | |
| { | |
| "code": "MED-67", | |
| "text": "PREVACID (Lansoprazole)" | |
| }, | |
| { | |
| "code": "MED-68", | |
| "text": "PROLIXIN (Fluphenazine)" | |
| }, | |
| { | |
| "code": "MED-70", | |
| "text": "REGLAN (Metoclopramide)" | |
| }, | |
| { | |
| "code": "MED-71", | |
| "text": "RESTORIL (Temazepam)" | |
| }, | |
| { | |
| "code": "MED-53", | |
| "text": "ROBAXIN (Methocarbamol)" | |
| }, | |
| { | |
| "code": "MED-72", | |
| "text": "SENOKOT (Senna)" | |
| }, | |
| { | |
| "code": "MED-73", | |
| "text": "SERAX (Oxazepam)" | |
| }, | |
| { | |
| "code": "MED-74", | |
| "text": "SERENTIL (Mesoridazine)" | |
| }, | |
| { | |
| "code": "MED-66", | |
| "text": "SLOW-K (Potassium)" | |
| }, | |
| { | |
| "code": "MED-75", | |
| "text": "SOLU MEDROL (Methylprednisolone )" | |
| }, | |
| { | |
| "code": "MED-77", | |
| "text": "STELAZINE (Trifluoperazine)" | |
| }, | |
| { | |
| "code": "MED-79", | |
| "text": "SYNTHROID (Thyroxin)" | |
| }, | |
| { | |
| "code": "MED-15", | |
| "text": "TEGRETOL (Carbamazepine)" | |
| }, | |
| { | |
| "code": "MED-82", | |
| "text": "THORAZINE (Chlorpromazine)" | |
| }, | |
| { | |
| "code": "MED-83", | |
| "text": "TOPROL (Metoprolol)" | |
| }, | |
| { | |
| "code": "MED-84", | |
| "text": "TRANXENE (Clorazepate)" | |
| }, | |
| { | |
| "code": "MED-85", | |
| "text": "TRILAFON (Perphenazie)" | |
| }, | |
| { | |
| "code": "MED-86", | |
| "text": "TYLENOL (Acetaminophen)" | |
| }, | |
| { | |
| "code": "MED-25", | |
| "text": "VALIUM (Diastat)" | |
| }, | |
| { | |
| "code": "MED-87", | |
| "text": "VALIUM (Diazepam)" | |
| }, | |
| { | |
| "code": "MED-89", | |
| "text": "VASOTEC (Enalapril)" | |
| }, | |
| { | |
| "code": "MED-90", | |
| "text": "VITAMIN K1 (Phytonadione)" | |
| }, | |
| { | |
| "code": "MED-91", | |
| "text": "XANAX (Alprazolam)" | |
| }, | |
| { | |
| "code": "MED-92", | |
| "text": "ZAROXOLYN (Metolazone)" | |
| }, | |
| { | |
| "code": "MED-93", | |
| "text": "ZOLOFT (Sertraline)" | |
| }, | |
| { | |
| "code": "MED-94", | |
| "text": "ZOSYN (Piperacillin/Tazobactam)" | |
| }, | |
| { | |
| "code": "MED-95", | |
| "text": "ZYPREXA (Olanzapine)" | |
| } | |
| ], | |
| "questionCardinality": { | |
| "min": "1", | |
| "max": "1" | |
| } | |
| }, | |
| { | |
| "dataType": "TX", | |
| "question": "Comment", | |
| "codeList": [ | |
| { | |
| "system": "Custom", | |
| "code": "allergy_comment", | |
| "display": "Comment" | |
| } | |
| ], | |
| "questionCode": "allergy_comment", | |
| "questionCodeSystem": "Custom", | |
| "linkId": "/allergies/allergy_comment", | |
| "questionCardinality": { | |
| "max": "1", | |
| "min": "1" | |
| }, | |
| "answerCardinality": { | |
| "min": "0", | |
| "max": "1" | |
| } | |
| } | |
| ], | |
| "answerCardinality": { | |
| "min": "0", | |
| "max": "1" | |
| } | |
| } | |
| ], | |
| "codeList": [], | |
| "answerCardinality": { | |
| "min": "0", | |
| "max": "1" | |
| } | |
| }, | |
| { | |
| "header": true, | |
| "dataType": "SECTION", | |
| "question": "PAST MEDICAL HISTORY:", | |
| "codeList": [ | |
| { | |
| "system": "Custom", | |
| "code": "conditions", | |
| "display": "PAST MEDICAL HISTORY" | |
| } | |
| ], | |
| "questionCode": "conditions", | |
| "questionCodeSystem": "Custom", | |
| "linkId": "/conditions", | |
| "questionCardinality": { | |
| "max": "*", | |
| "min": "1" | |
| }, | |
| "displayControl": { | |
| "questionLayout": "horizontal" | |
| }, | |
| "items": [ | |
| { | |
| "externallyDefined": "https://clinicaltables.nlm.nih.gov/api/conditions/v3/search", | |
| "dataType": "CWE", | |
| "question": "PAST MEDICAL HISTORY", | |
| "codeList": [ | |
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