Care Coordination and 360 Referrals (Proof of Concept)
0.1.0 - proof-of-concept United Kingdom flag

Care Coordination and 360 Referrals (Proof of Concept) - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

: Questionnaire - Exercise on referral: referrer's form

Draft as of 2026-11-03

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<Questionnaire xmlns="http://hl7.org/fhir">
  <id value="ExerciseReferralForm"/>
  <language value="en"/>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: Questionnaire ExerciseReferralForm</b></p><a name="ExerciseReferralForm"> </a><a name="hcExerciseReferralForm"> </a><table border="1" cellpadding="0" cellspacing="0" class="xhtTableBorder1"><tr class="xhtRowBorder2"><th scope="col" style="" class="hierarchy xhtCellBorder1"><a href="https://hl7.org/fhir/R4/formats.html#table" title="The linkID for the item">LinkID</a></th><th scope="col" style="" class="hierarchy xhtCellBorder1"><a href="https://hl7.org/fhir/R4/formats.html#table" title="Text for the item">Text</a></th><th scope="col" style="" class="hierarchy xhtCellBorder1"><a href="https://hl7.org/fhir/R4/formats.html#table" title="Minimum and Maximum # of times the item can appear in the instance">Cardinality</a></th><th scope="col" style="" class="hierarchy xhtCellBorder1"><a href="https://hl7.org/fhir/R4/formats.html#table" title="The type of the item">Type</a></th><th scope="col" style="" class="hierarchy xhtCellBorder1"><a href="https://hl7.org/fhir/R4/formats.html#table" title="Additional information about the item">Description &amp; Constraints</a><span style="float: right"><a href="https://hl7.org/fhir/R4/formats.html#table" title="Legend for this format"><img src="data:image/png;base64,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" alt="doco" style="background-color: inherit"/></a></span></th></tr><tr class="xhtRowBorder1 xhtRowEven"><td style="background-image: url(tbl_bck1.png)" class="hierarchy xhtCellBorder1 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon_q_root.gif" alt="" style="background-color: white; background-color: inherit" title="QuestionnaireRoot" class="hierarchy"/> ExerciseReferralForm</td><td style="" class="hierarchy xhtCellBorder1">Illustrative referral form completed by the referring clinician when the referral is made (ask at order entry). Items with a LOINC code are also sent as Observations.</td><td style="" class="hierarchy xhtCellBorder1"/><td style="" class="hierarchy xhtCellBorder1">Questionnaire</td><td style="" class="hierarchy xhtCellBorder1">https://fhir.acmeexample.org.uk/PatientCareCoordination/Questionnaire/ExerciseReferralForm#0.1.0</td></tr>
<tr class="xhtRowBorder1 xhtRowOdd"><td style="background-image: url(tbl_bck10.png)" id="item.reason" class="hierarchy xhtCellBorder1 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon-q-string.png" alt="" style="background-color: #F7F7F7; background-color: inherit" title="string" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">ExerciseReferralForm / </span>reason</td><td style="" class="hierarchy xhtCellBorder1">Reason for referral</td><td style="" class="hierarchy xhtCellBorder1">1..1</td><td style="" class="hierarchy xhtCellBorder1"><a href="https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string">string</a></td><td style="" class="hierarchy xhtCellBorder1"/></tr>
<tr class="xhtRowBorder1 xhtRowEven"><td style="background-image: url(tbl_bck10.png)" id="item.systolic" class="hierarchy xhtCellBorder1 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon-q-integer.png" alt="" style="background-color: white; background-color: inherit" title="integer" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">ExerciseReferralForm / </span>systolic</td><td style="" class="hierarchy xhtCellBorder1">Resting systolic blood pressure (mmHg)</td><td style="" class="hierarchy xhtCellBorder1">1..1</td><td style="" class="hierarchy xhtCellBorder1"><a href="https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-integer">integer</a></td><td style="" class="hierarchy xhtCellBorder1"/></tr>
<tr class="xhtRowBorder1 xhtRowOdd"><td style="background-image: url(tbl_bck10.png)" id="item.diastolic" class="hierarchy xhtCellBorder1 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon-q-integer.png" alt="" style="background-color: #F7F7F7; background-color: inherit" title="integer" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">ExerciseReferralForm / </span>diastolic</td><td style="" class="hierarchy xhtCellBorder1">Resting diastolic blood pressure (mmHg)</td><td style="" class="hierarchy xhtCellBorder1">1..1</td><td style="" class="hierarchy xhtCellBorder1"><a href="https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-integer">integer</a></td><td style="" class="hierarchy xhtCellBorder1"/></tr>
<tr class="xhtRowBorder1 xhtRowEven"><td style="background-image: url(tbl_bck10.png)" id="item.heart-rate" class="hierarchy xhtCellBorder1 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon-q-integer.png" alt="" style="background-color: white; background-color: inherit" title="integer" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">ExerciseReferralForm / </span>heart-rate</td><td style="" class="hierarchy xhtCellBorder1">Resting heart rate (beats per minute)</td><td style="" class="hierarchy xhtCellBorder1">0..1</td><td style="" class="hierarchy xhtCellBorder1"><a href="https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-integer">integer</a></td><td style="" class="hierarchy xhtCellBorder1"/></tr>
<tr class="xhtRowBorder1 xhtRowOdd"><td style="background-image: url(tbl_bck10.png)" id="item.bmi" class="hierarchy xhtCellBorder1 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon-q-decimal.png" alt="" style="background-color: #F7F7F7; background-color: inherit" title="decimal" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">ExerciseReferralForm / </span>bmi</td><td style="" class="hierarchy xhtCellBorder1">Body mass index</td><td style="" class="hierarchy xhtCellBorder1">0..1</td><td style="" class="hierarchy xhtCellBorder1"><a href="https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-decimal">decimal</a></td><td style="" class="hierarchy xhtCellBorder1"/></tr>
<tr class="xhtRowBorder1 xhtRowEven"><td style="background-image: url(tbl_bck10.png)" id="item.conditions" class="hierarchy xhtCellBorder1 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon-q-string.png" alt="" style="background-color: white; background-color: inherit" title="string" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">ExerciseReferralForm / </span>conditions</td><td style="" class="hierarchy xhtCellBorder1">Relevant conditions</td><td style="" class="hierarchy xhtCellBorder1">0..*</td><td style="" class="hierarchy xhtCellBorder1"><a href="https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-string">string</a></td><td style="" class="hierarchy xhtCellBorder1"/></tr>
<tr class="xhtRowBorder1 xhtRowOdd"><td style="background-image: url(tbl_bck10.png)" id="item.suitable" class="hierarchy xhtCellBorder1 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon-q-boolean.png" alt="" style="background-color: #F7F7F7; background-color: inherit" title="boolean" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">ExerciseReferralForm / </span>suitable</td><td style="" class="hierarchy xhtCellBorder1">Is the patient medically suitable for supervised exercise?</td><td style="" class="hierarchy xhtCellBorder1">1..1</td><td style="" class="hierarchy xhtCellBorder1"><a href="https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-boolean">boolean</a></td><td style="" class="hierarchy xhtCellBorder1"/></tr>
<tr class="xhtRowBorder1 xhtRowEven"><td style="background-image: url(tbl_bck00.png)" id="item.precautions" class="hierarchy xhtCellBorder1 xhtCellNoWrap"><img src="tbl_spacer.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="tbl_vjoin_end.png" alt="" style="background-color: inherit" class="hierarchy"/><img src="icon-q-text.png" alt="" style="background-color: white; background-color: inherit" title="text" class="hierarchy"/> <span style="position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0, 0, 0, 0); white-space: nowrap; border: 0" class="sr-only">ExerciseReferralForm / </span>precautions</td><td style="" class="hierarchy xhtCellBorder1">Precautions or exercise restrictions</td><td style="" class="hierarchy xhtCellBorder1">0..1</td><td style="" class="hierarchy xhtCellBorder1"><a href="https://hl7.org/fhir/R4/codesystem-item-type.html#item-type-text">text</a></td><td style="" class="hierarchy xhtCellBorder1"/></tr>
<tr><td colspan="5" class="hierarchy"><br/><a href="https://hl7.org/fhir/R4/formats.html#table" title="Legend for this format"><img src="data:image/png;base64,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" alt="doco" style="background-color: inherit"/> Documentation for this format</a></td></tr></table></div>
  </text>
  <url
       value="https://fhir.acmeexample.org.uk/PatientCareCoordination/Questionnaire/ExerciseReferralForm"/>
  <version value="0.1.0"/>
  <name value="ExerciseReferralForm"/>
  <title value="Exercise on referral - referrer's form"/>
  <status value="draft"/>
  <experimental value="true"/>
  <subjectType value="Patient"/>
  <date value="2026-11-03T05:48:20+00:00"/>
  <publisher value="Kevin Mayfield"/>
  <contact>
    <telecom>
      <system value="url"/>
      <value
             value="https://github.com/KevinMayfield/PatientCareCoordination"/>
    </telecom>
  </contact>
  <description
               value="Illustrative referral form completed by the referring clinician when the referral is made (ask at order entry). Items with a LOINC code are also sent as Observations."/>
  <jurisdiction>
    <coding>
      <system value="urn:iso:std:iso:3166"/>
      <code value="GB"/>
      <display value="United Kingdom of Great Britain and Northern Ireland"/>
    </coding>
  </jurisdiction>
  <item>
    <linkId value="reason"/>
    <text value="Reason for referral"/>
    <type value="string"/>
    <required value="true"/>
  </item>
  <item>
    <linkId value="systolic"/>
    <code>
      <system value="http://loinc.org"/>
      <code value="8480-6"/>
      <display value="Systolic blood pressure"/>
    </code>
    <text value="Resting systolic blood pressure (mmHg)"/>
    <type value="integer"/>
    <required value="true"/>
  </item>
  <item>
    <linkId value="diastolic"/>
    <code>
      <system value="http://loinc.org"/>
      <code value="8462-4"/>
      <display value="Diastolic blood pressure"/>
    </code>
    <text value="Resting diastolic blood pressure (mmHg)"/>
    <type value="integer"/>
    <required value="true"/>
  </item>
  <item>
    <linkId value="heart-rate"/>
    <code>
      <system value="http://loinc.org"/>
      <code value="8867-4"/>
      <display value="Heart rate"/>
    </code>
    <text value="Resting heart rate (beats per minute)"/>
    <type value="integer"/>
  </item>
  <item>
    <linkId value="bmi"/>
    <code>
      <system value="http://loinc.org"/>
      <code value="39156-5"/>
      <display value="Body mass index (BMI) [Ratio]"/>
    </code>
    <text value="Body mass index"/>
    <type value="decimal"/>
  </item>
  <item>
    <linkId value="conditions"/>
    <text value="Relevant conditions"/>
    <type value="string"/>
    <repeats value="true"/>
  </item>
  <item>
    <linkId value="suitable"/>
    <text value="Is the patient medically suitable for supervised exercise?"/>
    <type value="boolean"/>
    <required value="true"/>
  </item>
  <item>
    <linkId value="precautions"/>
    <text value="Precautions or exercise restrictions"/>
    <type value="text"/>
  </item>
</Questionnaire>