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  narrative.div: LinkId Text Cardinality Type Description & Constraints mypainquestionnaire Questionnaire A questionnaire to use with the MyPAIN application for a patient to assess their pain levels, locations, and treatments for use in consultation with a clinician to determine further treatments. 1 My Pain Location. We’d like to ask you a few questions about your pain and how it is affecting your life. Please describe the location(s) of any pain you have had in the past 7 days. 0..1 group 1.1 Head. What type of HEAD pain? 0..1 choice Options: 6 options 1.2 Neck. What type of NECK pain? 0..1 choice Options: 6 options 1.3 Shoulders. What type of SHOULDERS pain? 0..1 choice Options: 6 options 1.4 Arms. What type of ARMS pain? 0..1 choice Options: 6 options 1.5 Upper Back. What type of UPPER BACK pain? 0..1 choice Options: 6 options 1.6 Lower Back. What type of LOWER BACK pain? 0..1 choice Options: 6 options 1.7 Hands. What type of HANDS pain? 0..1 choice Options: 6 options 1.8 Abdomen. What type of ABDOMEN pain? 0..1 choice Options: 6 options 1.9 Pelvis. What type of PELVIS pain? 0..1 choice Options: 6 options 1.10 Hips. What type of HIPS pain? 0..1 choice Options: 6 options 1.11 Upper Legs. What type of UPPER LEGS pain? 0..1 choice Options: 6 options 1.12 Knees. What type of KNEES pain? 0..1 choice Options: 6 options 1.13 Lower Legs. What type of LOWER LEGS pain? 0..1 choice Options: 6 options 1.14 Feet. What type of FEET pain? 0..1 choice Options: 6 options 1.15 Everywhere. What type of EVERYWHERE pain? 0..1 choice Options: 6 options 1.16 Other, please describe. Other, please describe 0..1 text 2 My Pain Intensity. Thinking about your overall pain, in the past 7 days, please respond to the questions below: 0..1 group 2.1 How intense was your pain at its worst? 0..1 choice Options: 5 options 2.2 How intense was your average pain? 0..1 choice Options: 5 options 2.3 What is your level of pain right now? 0..1 choice Options: 5 options 3 My Pain Interference. Thinking about your overall…
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    coding.code:
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      coding.display:
        value: Drop down
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    coding.code:
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  coding.code:
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    coding.code:
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      coding.code:
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      coding.code:
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        value: Always
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  questionnaire.item.link id:
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  questionnaire.item.code:
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      value: http://fhir.org/guides/cqf/cds4cpm/CodeSystem/mypain-questionnaire-codes
    coding.code:
      value: mpq-1018
    coding.display:
      value: How often have Herbal or nutritional pain relievers (such as ginseng or kava kava) that you have used in the last 6 months helped with your pain?
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  questionnaire.item.text:
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  questionnaire.item.type:
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      coding.code:
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      coding.code:
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      coding.display:
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    extension.value codeable concept:
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    extension.value canonical:
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  questionnaire.item.link id:
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    coding.code:
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    coding.display:
      value: How often have Cremes, lotions, gels or patches applied to the skin (for example Bengay, Tiger Balm or BioFreeze) that you have used in the last 6 months helped with your pain?
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value: drop-down

value: Drop down

value: drop-down

value: Drop down

value: drop-down

value: Drop down

value: mpqr-1002

value: Always

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  coding.code:
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    value: Have you used any Other items you can buy without a prescription from your doctor to help with your pain in the last 6 months? Please describe
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  value: text
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  coding.code:
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  coding.display:
    value: Have you used any of the following prescription medications to help with your pain in the last 6 months?
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    coding.code:
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    coding.display:
      value: How often have prescription Opioid medications (such as hydrocodone, oxycodone, codeine, morphine and fentanyl) helped with your pain in the last 6 months?
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    value: Opioid medications (such as hydrocodone, oxycodone, codeine, morphine and fentanyl)
  questionnaire.item.text:
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  questionnaire.item.type:
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      coding.code:
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  questionnaire.item.answer option:
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  questionnaire.item.link id:
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    coding.code:
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      value: How often have prescription Cortisone injections (a shot to relieve inflammation) helped with your pain in the last 6 months?
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    value: Procedure or Injection (such as a shot to relieve inflammation)
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    extension.value canonical:
      value: http://fhir.org/guides/cqf/cds4cpm/ValueSet/three-item-likert
      link: http://fhir.org/guides/cqf/cds4cpm/ValueSet/three-item-likert
  questionnaire.item.link id:
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    coding.code:
      value: mpq-1022
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      value: How often have prescription Non-opioid medications as prescribed by a doctor (such as Celebrex, Cymbalta) helped with your pain in the last 6 months?
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value: drop-down

value: Drop down

value: drop-down

value: Drop down

value: drop-down

value: Drop down

value: mpqr-1002

value: Always

index: 3
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      value: Drop down
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  coding.code:
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    value: How often has Medical marijuana helped with your pain in the last 6 months?
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    coding.code:
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      value: Always

index: 4
questionnaire.item.link id:
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  coding.code:
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  coding.display:
    value: Have you used any Other prescription medications to help with your pain in the last 6 months?: Please describe
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  value: Other, please describe
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  value: Other, please describe
questionnaire.item.type:
  value: text
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questionnaire.item.link id:
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  coding.code:
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    value: Have you tried any of the following new therapies to help with your pain in the last 6 months (select all that apply)?
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      codeable concept.coding:
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      codeable concept.text:
        value: Drop down
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    extension.value canonical:
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  questionnaire.item.link id:
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    coding.code:
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      value: How often has Yoga helped with your pain in the last 6 months?
  questionnaire.item.prefix:
    value: Yoga
  questionnaire.item.text:
    value: Did it work?
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    value: choice
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  questionnaire.item.answer option:
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questionnaire.item.link id:
  value: 10.4
questionnaire.item.code:
  index: 0
  coding.system:
    value: http://fhir.org/guides/cqf/cds4cpm/CodeSystem/mypain-questionnaire-codes
  coding.code:
    value: mpq-1060
  coding.display:
    value: How often has CBD oil helped with your pain in the last 6 months?
questionnaire.item.prefix:
  value: CBD oil
questionnaire.item.text:
  value: Did it work?
questionnaire.item.type:
  value: choice
questionnaire.item.required:
  value: false
questionnaire.item.answer option:
  index: 0
  questionnaire.item.answer option.value coding:
    coding.system:
      value: http://fhir.org/guides/cqf/cds4cpm/CodeSystem/mypain-questionnaireresponse-codes
    coding.code:
      value: mpqr-1000
    coding.display:
      value: Never
questionnaire.item.answer option:
  index: 1
  questionnaire.item.answer option.value coding:
    coding.system:
      value: http://fhir.org/guides/cqf/cds4cpm/CodeSystem/mypain-questionnaireresponse-codes
    coding.code:
      value: mpqr-1001
    coding.display:
      value: Sometimes
questionnaire.item.answer option:
  index: 2
  questionnaire.item.answer option.value coding:
    coding.system:
      value: http://fhir.org/guides/cqf/cds4cpm/CodeSystem/mypain-questionnaireresponse-codes
    coding.code:
      value: mpqr-1002
    coding.display:
      value: Always

index: 4
element.extension:
  index: 0
  extension.url:
    value: http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl
  extension.value codeable concept:
    codeable concept.coding:
      index: 0
      coding.system:
        value: http://hl7.org/fhir/questionnaire-item-control
      coding.code:
        value: drop-down
      coding.display:
        value: Drop down
    codeable concept.text:
      value: Drop down
element.extension:
  index: 1
  extension.url:
    value: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-answerValueSetSource
  extension.value canonical:
    value: http://fhir.org/guides/cqf/cds4cpm/ValueSet/three-item-likert
    link: http://fhir.org/guides/cqf/cds4cpm/ValueSet/three-item-likert
questionnaire.item.link id:
  value: 10.5
questionnaire.item.code:
  index: 0
  coding.system:
    value: http://fhir.org/guides/cqf/cds4cpm/CodeSystem/mypain-questionnaire-codes
  coding.code:
    value: mpq-1033
  coding.display:
    value: How often has Music therapy helped with your pain in the last 6 months?
questionnaire.item.prefix:
  value: Music therapy
questionnaire.item.text:
  value: Did it work?
questionnaire.item.type:
  value: choice
questionnaire.item.required:
  value: false
questionnaire.item.answer option:
  index: 0
  questionnaire.item.answer option.value coding:
    coding.system:
      value: http://fhir.org/guides/cqf/cds4cpm/CodeSystem/mypain-questionnaireresponse-codes
    coding.code:
      value: mpqr-1000
    coding.display:
      value: Never
questionnaire.item.answer option:
  index: 1
  questionnaire.item.answer option.value coding:
    coding.system:
      value: http://fhir.org/guides/cqf/cds4cpm/CodeSystem/mypain-questionnaireresponse-codes
    coding.code:
      value: mpqr-1001
    coding.display:
      value: Sometimes
questionnaire.item.answer option:
  index: 2
  questionnaire.item.answer option.value coding:
    coding.system:
      value: http://fhir.org/guides/cqf/cds4cpm/CodeSystem/mypain-questionnaireresponse-codes
    coding.code:
      value: mpqr-1002
    coding.display:
      value: Always

index: 5
questionnaire.item.link id:
  value: 10.6
questionnaire.item.code:
  index: 0
  coding.system:
    value: http://fhir.org/guides/cqf/cds4cpm/CodeSystem/mypain-questionnaire-codes
  coding.code:
    value: mpq-1034
  coding.display:
    value: Have you tried any Other new treatments to help with your pain in the last 6 months? Please describe
questionnaire.item.prefix:
  value: Other, please describe
questionnaire.item.text:
  value: Other, please describe
questionnaire.item.type:
  value: text
questionnaire.item.required:
  value: false

index: 10
questionnaire.item.link id:
  value: 11
questionnaire.item.code:
  index: 0
  coding.system:
    value: http://fhir.org/guides/cqf/cds4cpm/CodeSystem/mypain-questionnaire-codes
  coding.code:
    value: about-my-goals
  coding.display:
    value: We’d like to know more about you and your goals.
questionnaire.item.code:
  index: 1
  coding.system:
    value: http://fhir.org/guides/cqf/cds4cpm/CodeSystem/mypain-questionnaire-codes
  coding.code:
    value: mpq-1035
  coding.display:
    value: What are your most important activity goals? For example: I’d like to be able to walk without pain.
questionnaire.item.prefix:
  value: About My Goals
questionnaire.item.text:
  value: We’d like to know more about you and your goals. What are your most important activity goals? For example: I’d like to be able to walk without pain.
questionnaire.item.type:
  value: text
questionnaire.item.required:
  value: false

index: 11
questionnaire.item.link id:
  value: 12
questionnaire.item.code:
  index: 0
  coding.system:
    value: http://fhir.org/guides/cqf/cds4cpm/CodeSystem/mypain-questionnaire-codes
  coding.code:
    value: about-my-goals
  coding.display:
    value: We’d like to know more about you and your goals.
questionnaire.item.code:
  index: 1
  coding.system:
    value: http://fhir.org/guides/cqf/cds4cpm/CodeSystem/mypain-questionnaire-codes
  coding.code:
    value: mpq-1036
  coding.display:
    value: What are the biggest barriers to achieving your activity goals? For example: I have a lot of stress from work which makes my pain worse.
questionnaire.item.prefix:
  value: About My Goals
questionnaire.item.text:
  value: What are the biggest barriers to achieving your activity goals? For example: I have a lot of stress from work which makes my pain worse.
questionnaire.item.type:
  value: text
questionnaire.item.required:
  value: false

index: 12
questionnaire.item.link id:
  value: 13
questionnaire.item.code:
  index: 0
  coding.system:
    value: http://fhir.org/guides/cqf/cds4cpm/CodeSystem/mypain-questionnaire-codes
  coding.code:
    value: mpq-1061
  coding.display:
    value: Did the patient view the 4 flat tires video
questionnaire.item.prefix:
  value: Managing Chronic Pain
questionnaire.item.text:
  value: Below is a link to a video produced by the American Chronic Pain Association about living with chronic pain. We’d like to suggest you watch the video to help you prepare for your upcoming visit. This video can help you prepare to ask questions that are important to you when you visit with your provider.
questionnaire.item.type:
  value: text

index: 13
questionnaire.item.link id:
  value: 14
questionnaire.item.code:
  index: 0
  coding.system:
    value: http://fhir.org/guides/cqf/cds4cpm/CodeSystem/mypain-questionnaire-codes
  coding.code:
    value: mpq-1062
  coding.display:
    value: Did the patient access the US Chronic Pain website
questionnaire.item.prefix:
  value: Managing Chronic Pain
questionnaire.item.text:
  value: The website linked below provides some information from the U.S. Pain Foundation about the causes and diagnosis of pain in general, treatment options and self management and well-being when living with pain. This information can help you prepare to ask questions that are important to you when you visit with your provider.
questionnaire.item.type:
  value: text

index: 14
questionnaire.item.link id:
  value: 15
questionnaire.item.code:
  index: 0
  coding.system:
    value: http://fhir.org/guides/cqf/cds4cpm/CodeSystem/mypain-questionnaire-codes
  coding.code:
    value: mypain-feedback
  coding.display:
    value: Feedback about your use of MyPAIN
questionnaire.item.prefix:
  value: MyPAIN Feedback
questionnaire.item.text:
  value: Please indicate your level of agreement with the following statement:
questionnaire.item.type:
  value: group
questionnaire.item.required:
  value: false
questionnaire.item.item:
  index: 0
  element.extension:
    index: 0
    extension.url:
      value: http://hl7.org/fhir/StructureDefinition/questionnaire-itemControl
    extension.value codeable concept:
      codeable concept.coding:
        index: 0
      codeable concept.text:
        value: Drop down
  element.extension:
    index: 1
    extension.url:
      value: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-answerValueSetSource
    extension.value canonical:
      value: http://loinc.org/vs/LL1606-4
      link: http://loinc.org/vs/LL1606-4
  questionnaire.item.link id:
    value: 15.1
  questionnaire.item.code:
    index: 0
    coding.system:
      value: http://fhir.org/guides/cqf/cds4cpm/CodeSystem/mypain-questionnaire-codes
    coding.code:
      value: mpq-1063
    coding.display:
      value: Please indicate your level of agreement with the following statement: Using the MyPAIN tool has helped me begin preparing for a conversation with my provider about managing my pain.
  questionnaire.item.text:
    value: Using the MyPAIN tool has helped me begin preparing for a conversation with my provider about managing my pain.
  questionnaire.item.type:
    value: choice
  questionnaire.item.required:
    value: false
  questionnaire.item.answer option:
    index: 0
    questionnaire.item.answer option.value coding:
      coding.system:
        value: https://loinc.org/LL1606-4/
      coding.code:
        value: LA15238-1
      coding.display:
        value: Disagree a lot
  questionnaire.item.answer option:
    index: 1
    questionnaire.item.answer option.value coding:
      coding.system:
        value: https://loinc.org/LL1606-4/
      coding.code:
        value: LA15239-9
      coding.display:
        value: Disagree a little
  questionnaire.item.answer option:
    index: 2
    questionnaire.item.answer option.value coding:
      coding.system:
        value: https://loinc.org/LL1606-4/
      coding.code:
        value: LA15240-7
      coding.display:
        value: Neither agree nor disagree
  questionnaire.item.answer option:
    index: 3
    questionnaire.item.answer option.value coding:
      coding.system:
        value: https://loinc.org/LL1606-4/
      coding.code:
        value: LA15241-5
      coding.display:
        value: Agree a little
  questionnaire.item.answer option:
    index: 4
    questionnaire.item.answer option.value coding:
      coding.system:
        value: https://loinc.org/LL1606-4/
      coding.code:
        value: LA15242-3
      coding.display:
        value: Agree a lot

value: drop-down

value: Drop down

index: 15
questionnaire.item.link id:
  value: 16
questionnaire.item.code:
  index: 0
  coding.system:
    value: http://fhir.org/guides/cqf/cds4cpm/CodeSystem/mypain-questionnaire-codes
  coding.code:
    value: mpq-1064
  coding.display:
    value: Do you have any other feedback or thoughts to share on your use of MyPAIN?
questionnaire.item.code:
  index: 1
  coding.system:
    value: http://fhir.org/guides/cqf/cds4cpm/CodeSystem/mypain-questionnaire-codes
  coding.code:
    value: mypain-feedback
  coding.display:
    value: Feedback on your use of MyPAIN
questionnaire.item.prefix:
  value: MyPAIN Feedback
questionnaire.item.text:
  value: Do you have any other feedback or thoughts to share on your use of MyPAIN?
questionnaire.item.type:
  value: text
questionnaire.item.required:
  value: false