Argonaut Questionnaire Implementation Guide (Release 1.0.0 )

This page is part of the Argonaut Questionnaire Implementation Guide (v1.0.0: Release) based on FHIR R3. This is the current published version. For a full list of available versions, see the Directory of published versions

XML Format: Questionnaire-questionnaire-example-dast

Download Raw xml


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    </extension>
    <linkId value="g1"/>
    <text value="Form"/>
    <type value="group"/>
    <required value="true"/>
    <item>
      <extension
                 url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
        <valueInteger value="0"/>
      </extension>
      <linkId value="g1.d"/>
      <text
            value="The following questions concern information about your possible involvement with drugs not including alcoholic beverages during the past 12 months. &quot;Drug abuse&quot; refers to (1) the use of prescribed or over-the-counter drugs in excess of the directions, and (2) any nonmedical use of drugs.

 The various classes of drugs may include cannabis (marijuana, hashish), solvents (e.g., paint thinner), tranquilizers (e.g., Valium), barbiturates, cocaine, stimulants (e.g., speed), hallucinogens (e.g., LSD) or narcotics (e.g., heroin). Remember that the questions do not include alcoholic beverages. 

Please answer every question. If you have difficulty with a statement, then choose the response that is mostly right."/>
      <type value="display"/>
    </item>
    <item>
      <extension
                 url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
        <valueInteger value="1"/>
      </extension>
      <linkId value="g1.q1"/>
      <code>
        <system value="http://loinc.org"/>
        <code value="68525-5"/>
      </code>
      <prefix value="1."/>
      <text
            value="Have you used drugs other than those required for medical reasons?"/>
      <type value="choice"/>
      <required value="true"/>
      <repeats value="false"/>
      <option>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue">
          <valueDecimal value="0"/>
        </extension>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="0"/>
        </extension>
        <valueCoding>
          <system value="http://loinc.org"/>
          <code value="LA32-8"/>
          <display value="No"/>
        </valueCoding>
      </option>
      <option>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue">
          <valueDecimal value="1"/>
        </extension>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="1"/>
        </extension>
        <valueCoding>
          <system value="http://loinc.org"/>
          <code value="LA33-6"/>
          <display value="Yes"/>
        </valueCoding>
      </option>
    </item>
    <item>
      <extension
                 url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
        <valueInteger value="2"/>
      </extension>
      <linkId value="g1.q2"/>
      <code>
        <system value="http://loinc.org"/>
        <code value="68526-3"/>
      </code>
      <prefix value="2."/>
      <text value="Do you abuse more than one drug at a time?"/>
      <type value="choice"/>
      <required value="true"/>
      <repeats value="false"/>
      <option>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue">
          <valueDecimal value="0"/>
        </extension>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="0"/>
        </extension>
        <valueCoding>
          <system value="http://loinc.org"/>
          <code value="LA32-8"/>
          <display value="No"/>
        </valueCoding>
      </option>
      <option>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue">
          <valueDecimal value="1"/>
        </extension>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="1"/>
        </extension>
        <valueCoding>
          <system value="http://loinc.org"/>
          <code value="LA33-6"/>
          <display value="Yes"/>
        </valueCoding>
      </option>
    </item>
    <item>
      <extension
                 url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
        <valueInteger value="3"/>
      </extension>
      <linkId value="g1.q3"/>
      <code>
        <system value="http://loinc.org"/>
        <code value="68527-1"/>
      </code>
      <prefix value="3."/>
      <text value="Are you unable to stop abusing drugs when you want to?"/>
      <type value="choice"/>
      <required value="true"/>
      <repeats value="false"/>
      <option>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue">
          <valueDecimal value="1"/>
        </extension>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="0"/>
        </extension>
        <valueCoding>
          <system value="http://loinc.org"/>
          <code value="LA32-8"/>
          <display value="No"/>
        </valueCoding>
      </option>
      <option>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue">
          <valueDecimal value="0"/>
        </extension>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="1"/>
        </extension>
        <valueCoding>
          <system value="http://loinc.org"/>
          <code value="LA33-6"/>
          <display value="Yes"/>
        </valueCoding>
      </option>
    </item>
    <item>
      <extension
                 url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
        <valueInteger value="4"/>
      </extension>
      <linkId value="g1.q4"/>
      <code>
        <system value="http://loinc.org"/>
        <code value="68528-9"/>
      </code>
      <prefix value="4."/>
      <text
            value="Have you ever had blackouts or flashbacks as a result of drug use?"/>
      <type value="choice"/>
      <required value="true"/>
      <repeats value="false"/>
      <option>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue">
          <valueDecimal value="0"/>
        </extension>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="0"/>
        </extension>
        <valueCoding>
          <system value="http://loinc.org"/>
          <code value="LA32-8"/>
          <display value="No"/>
        </valueCoding>
      </option>
      <option>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue">
          <valueDecimal value="1"/>
        </extension>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="1"/>
        </extension>
        <valueCoding>
          <system value="http://loinc.org"/>
          <code value="LA33-6"/>
          <display value="Yes"/>
        </valueCoding>
      </option>
    </item>
    <item>
      <extension
                 url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
        <valueInteger value="5"/>
      </extension>
      <linkId value="g1.q5"/>
      <code>
        <system value="http://loinc.org"/>
        <code value="68529-7"/>
      </code>
      <prefix value="5."/>
      <text value="Do you ever feel bad or guilty about your drug use?"/>
      <type value="choice"/>
      <required value="true"/>
      <repeats value="false"/>
      <option>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue">
          <valueDecimal value="0"/>
        </extension>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="0"/>
        </extension>
        <valueCoding>
          <system value="http://loinc.org"/>
          <code value="LA32-8"/>
          <display value="No"/>
        </valueCoding>
      </option>
      <option>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue">
          <valueDecimal value="1"/>
        </extension>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="1"/>
        </extension>
        <valueCoding>
          <system value="http://loinc.org"/>
          <code value="LA33-6"/>
          <display value="Yes"/>
        </valueCoding>
      </option>
    </item>
    <item>
      <extension
                 url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
        <valueInteger value="6"/>
      </extension>
      <linkId value="g1.q6"/>
      <code>
        <system value="http://loinc.org"/>
        <code value="68530-5"/>
      </code>
      <prefix value="6."/>
      <text
            value="Does your spouse (or parents) ever complain about your involvement with drugs?"/>
      <type value="choice"/>
      <required value="true"/>
      <repeats value="false"/>
      <option>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue">
          <valueDecimal value="0"/>
        </extension>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="0"/>
        </extension>
        <valueCoding>
          <system value="http://loinc.org"/>
          <code value="LA32-8"/>
          <display value="No"/>
        </valueCoding>
      </option>
      <option>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue">
          <valueDecimal value="1"/>
        </extension>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="1"/>
        </extension>
        <valueCoding>
          <system value="http://loinc.org"/>
          <code value="LA33-6"/>
          <display value="Yes"/>
        </valueCoding>
      </option>
    </item>
    <item>
      <extension
                 url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
        <valueInteger value="7"/>
      </extension>
      <linkId value="g1.q7"/>
      <code>
        <system value="http://loinc.org"/>
        <code value="68531-3"/>
      </code>
      <prefix value="7."/>
      <text value="Have you neglected your family because of your use of drugs?"/>
      <type value="choice"/>
      <required value="true"/>
      <repeats value="false"/>
      <option>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue">
          <valueDecimal value="0"/>
        </extension>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="0"/>
        </extension>
        <valueCoding>
          <system value="http://loinc.org"/>
          <code value="LA32-8"/>
          <display value="No"/>
        </valueCoding>
      </option>
      <option>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue">
          <valueDecimal value="1"/>
        </extension>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="1"/>
        </extension>
        <valueCoding>
          <system value="http://loinc.org"/>
          <code value="LA33-6"/>
          <display value="Yes"/>
        </valueCoding>
      </option>
    </item>
    <item>
      <extension
                 url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
        <valueInteger value="8"/>
      </extension>
      <linkId value="g1.q8"/>
      <code>
        <system value="http://loinc.org"/>
        <code value="68532-1"/>
      </code>
      <prefix value="8."/>
      <text
            value="Have you engaged in illegal activities in order to obtain drugs?"/>
      <type value="choice"/>
      <required value="true"/>
      <repeats value="false"/>
      <option>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue">
          <valueDecimal value="0"/>
        </extension>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="0"/>
        </extension>
        <valueCoding>
          <system value="http://loinc.org"/>
          <code value="LA32-8"/>
          <display value="No"/>
        </valueCoding>
      </option>
      <option>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue">
          <valueDecimal value="1"/>
        </extension>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="1"/>
        </extension>
        <valueCoding>
          <system value="http://loinc.org"/>
          <code value="LA33-6"/>
          <display value="Yes"/>
        </valueCoding>
      </option>
    </item>
    <item>
      <extension
                 url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
        <valueInteger value="9"/>
      </extension>
      <linkId value="g1.q9"/>
      <code>
        <system value="http://loinc.org"/>
        <code value="68533-9"/>
      </code>
      <prefix value="9."/>
      <text
            value="Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?"/>
      <type value="choice"/>
      <required value="true"/>
      <repeats value="false"/>
      <option>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue">
          <valueDecimal value="0"/>
        </extension>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="0"/>
        </extension>
        <valueCoding>
          <system value="http://loinc.org"/>
          <code value="LA32-8"/>
          <display value="No"/>
        </valueCoding>
      </option>
      <option>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue">
          <valueDecimal value="1"/>
        </extension>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="1"/>
        </extension>
        <valueCoding>
          <system value="http://loinc.org"/>
          <code value="LA33-6"/>
          <display value="Yes"/>
        </valueCoding>
      </option>
    </item>
    <item>
      <extension
                 url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
        <valueInteger value="10"/>
      </extension>
      <linkId value="g1.q10"/>
      <code>
        <system value="http://loinc.org"/>
        <code value="68534-7"/>
      </code>
      <prefix value="10."/>
      <text
            value="Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)?"/>
      <type value="choice"/>
      <repeats value="false"/>
      <option>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue">
          <valueDecimal value="0"/>
        </extension>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="0"/>
        </extension>
        <valueCoding>
          <system value="http://loinc.org"/>
          <code value="LA32-8"/>
          <display value="No"/>
        </valueCoding>
      </option>
      <option>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/questionnaire-ordinalValue">
          <valueDecimal value="1"/>
        </extension>
        <extension
                   url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
          <valueInteger value="1"/>
        </extension>
        <valueCoding>
          <system value="http://loinc.org"/>
          <code value="LA33-6"/>
          <display value="Yes"/>
        </valueCoding>
      </option>
    </item>
  </item>
  <item>
    <extension
               url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden">
      <valueBoolean value="true"/>
    </extension>
    <extension
               url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
      <valueInteger value="1"/>
    </extension>
    <extension url="http://hl7.org/fhir/StructureDefinition/designNote">
      <valueMarkdown
                     value="this is hidden text/should not be displayed to the user"/>
    </extension>
    <linkId value="g2"/>
    <text value="Scoring Instructions"/>
    <type value="group"/>
    <required value="true"/>
    <item>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/questionnaire-hidden">
        <valueBoolean value="true"/>
      </extension>
      <extension
                 url="http://fhir.org/guides/argonaut/questionnaire/StructureDefinition/extension-itemOrder">
        <valueInteger value="0"/>
      </extension>
      <extension url="http://hl7.org/fhir/StructureDefinition/designNote">
        <valueMarkdown
                       value="this is hidden text/should not be displayed to the user"/>
      </extension>
      <linkId value="g2.d"/>
      <text
            value="Scoring: Score 1 point for each question answered “Yes,” except for question 3 for which
a “No” receives 1 point.

Interpretation of Score:
Score Degree of Problems Related to Drug Abuse Suggested Action
0 No problems reported None at this time
1‐2 Low level Monitor, re‐assess at a later date
3‐5 Moderate level Further investigation
6‐8 Substantial level Intensive assessment
9‐10 Severe level Intensive assessment"/>
      <type value="display"/>
    </item>
  </item>
</Questionnaire>