Structure LinkID Text Cardinality Type Description & Constraints Questionnaire https://kind-lab.github.io/vbai-fhir/Questionnaire-qgenericdemographicsschema#2.2.0 demographics_session_id Questionnaire - Metadata: Session ID 0..1 string demographics_started_at Questionnaire Started At 0..1 string demographics_completed_at Questionnaire Completed At 0..1 string demographics_duration Questionnaire Duration (seconds) 0..1 string demographics_completed_by Who is completing this survey? 0..1 string city Address Information: City 0..1 string state_province State/Province 0..1 string zipcode Zipcode 0..1 string country Country 0..1 choice Options: 2 options gender_identity Patient Demographics: What is your gender identity? 0..1 choice Options: 5 options other_gender_identity If you selected "other" for gender identity, please specify: 0..1 string Enable When: gender_identity = 'other' specify_gender_identity Please specify gender identity 0..1 choice Enable When: gender_identity = 'female' gender_identity = 'male' Options: 2 options sexual_orientation What is your sexual orientation? 0..1 choice Options: 5 options other_sex_orientation If you selected "other" for sexual orientation, please specify: 0..1 string Enable When: sexual_orientation = 'other' race Which race category best describes you? Choose all that apply 0..1 string native_american_race American Indian or Alaska Native 0..1 string Enable When: race = 1 asian_race Asian 0..1 string Enable When: race = 2 black_race Black or African American 0..1 string Enable When: race = 3 pacific_islander_race Native Hawaiian or other Pacific Islander 0..1 string Enable When: race = 4 white_race White 0..1 string Enable When: race = 5 canadian_race Canadian Indigenous or Aboriginal 0..1 string Enable When: race = 6 other_race_specify If race not listed above, please specify: 0..1 string Enable When: race = 7 ethnicity What is your ethnic or cultural origin? 0..1 choice Options: 3 options hispanic_latino_selection Check all that apply 0..1 string Enable When: ethnicity = 'yes' edu_level Education: What is your highest level of education? 0..1 choice Options: 12 options other_edu_level If you selected "other" level of education, please specify: 0..1 string Enable When: edu_level = '11' hearing Disability Questions: Are you deaf or do you have serious difficulty hearing? 0..1 choice Options: 3 options vision Are you blind or do you have serious difficulty seeing, even when wearing glasses? 0..1 choice Options: 3 options cognition Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? 0..1 choice Options: 3 options mobility Do you have serious difficulty walking or climbing stairs? 0..1 choice Options: 3 options self_care Do you have difficulty dressing or bathing? 0..1 choice Options: 3 options independent_living Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping? 0..1 choice Options: 3 options employ_status Employment Status: What is your employment status? Choose all that apply 0..1 string other_employ_specify If you selected "other" employment status, please specify. 0..1 string Enable When: employ_status = 9 occupation What is your occupation? 0..1 string veteran Are you a veteran? 0..1 choice Options: 2 options household_income_usa Demographics - Optional: What was your total household income last year (USD)? Please include all sources of income, including pensions, dividends, alimony, child support, etc. 0..1 choice Enable When: country = '1' Options: 9 options financial_assistance_usa Do you receive a significant portion (>20%) of your income through federally-funded income assistance programs? Some examples of these programs are listed in the question below. 0..1 choice Enable When: country = '1' Options: 3 options assistance_programs_usa Do you take advantage of any of the following programs? Choose all that apply 0..1 string Enable When: country = '1' household_income_ca What was your total household income last year (CAD)? Please include all sources of income, including pensions, dividends, alimony, child support, etc. 0..1 choice Enable When: country = '2' Options: 9 options financial_assistance_ca Do you receive a significant portion (>20%) of your income through federally-funded income assistance programs? Some examples of these programs are listed below. 0..1 choice Enable When: country = '2' Options: 3 options assistance_programs_ca Do you take advantage of any of the following programs? Choose all that apply 0..1 string Enable When: country = '2' citizen Citizenship: Citizen 0..1 choice Options: 8 options marital_status What is your marital status? Choose all that apply 0..1 string housing_status What is your current housing status? 0..1 choice Options: 6 options household_count How many people live in your household?Please specify a number 0..1 string spouse_partner_sig_other Who lives with you? Choose all that apply: Spouse/partner/significant other 0..1 choice Enable When: household_count > 0 Options: 2 options children One or more children 0..1 choice Enable When: household_count > 0 Options: 2 options parent One or more parent 0..1 choice Enable When: household_count > 0 Options: 2 options grandparent One or more grandparent 0..1 choice Enable When: household_count > 0 Options: 2 options other_live_with Other 0..1 choice Enable When: household_count > 0 Options: 2 options others_household_specify If "others" live in your household, please specify: 0..1 string Enable When: other_live_with = '1' transportation_yn Do you have a reliable mode of transportation? 0..1 choice Options: 2 options primary_transportation What is your primary mode of transportation? 0..1 choice Enable When: transportation_yn = '1' Options: 8 options other_transportation If you selected "other" transportation, please specify. 0..1 string Enable When: primary_transportation = '8' Documentation for this format Options Sets Answer options for country USA Canada Answer options for gender_identity Female gender identity Male gender identity Non-binary or genderqueer gender identity Other Prefer not to answer Answer options for specify_gender_identity Cis: same gender as the sex assigned at birth Trans Answer options for sexual_orientation Bisexual Heterosexual Homosexual Other (Please specify) Prefer not to answer Answer options for ethnicity Hispanic or Latino Not Hispanic or Latino Prefer not to answer Answer options for edu_level No formal education Some elementary school Some secondary or high school education High School or secondary school degree complete Some college education Associate's or technical degree complete College or baccalaureate degree complete Some post-baccalaureate education Graduate or professional degree complete Doctoral or post graduate education Other Prefer not to answer Answer options for hearing No Yes Prefer not to answer Answer options for vision No Yes Prefer not to answer Answer options for cognition No Yes Prefer not to answer Answer options for mobility No Yes Prefer not to answer Answer options for self_care No Yes Prefer not to answer Answer options for independent_living No Yes Prefer not to answer Answer options for veteran Yes No Answer options for household_income_usa < $15,000 $15,000 to $29,999 $30,000 to $$49,999 $50,000 to $99,999 $100,000 to $149,999 $150,000 to $199,999 $200,000 to $249,999 >$250,000 Prefer not to answer Answer options for financial_assistance_usa No Yes Prefer not to answer Answer options for household_income_ca < $15,000 $15,000 to $29,999 $30,000 to $$49,999 $50,000 to $99,999 $100,000 to $149,999 $150,000 to $199,999 $200,000 to $249,999 >$250,000 Prefer not to answer Answer options for financial_assistance_ca No Yes Prefer not to answer Answer options for citizen Citizen Permanent resident (Green card holder) Non-citizen US/Canadian national Refugee Asylum seeker Non-immigrant student Non-immigrant worker Prefer not to answer Answer options for housing_status Assisted living Own home Rent home Skilled nursing facility/nursing home Unhoused-temporarily Unhoused-permanently Answer options for spouse_partner_sig_other Yes No Answer options for children Yes No Answer options for parent Yes No Answer options for grandparent Yes No Answer options for other_live_with Yes No Answer options for transportation_yn Yes No Answer options for primary_transportation Personal vehicle Shared vehicle Public transportation Ride with someone else Ride service Bicycle/Motorbike Walking Other (Please specify)
Patient Demographics: What is your gender identity?
Non-binary or genderqueer gender identity
If you selected "other" for gender identity, please specify:
Cis: same gender as the sex assigned at birth
If you selected "other" for sexual orientation, please specify:
Which race category best describes you? Choose all that apply
Native Hawaiian or other Pacific Islander
If race not listed above, please specify:
Education: What is your highest level of education?
High School or secondary school degree complete
Associate's or technical degree complete
College or baccalaureate degree complete
Graduate or professional degree complete
If you selected "other" level of education, please specify:
Disability Questions: Are you deaf or do you have serious difficulty hearing?
Are you blind or do you have serious difficulty seeing, even when wearing glasses?
Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
Do you have serious difficulty walking or climbing stairs?
Do you have difficulty dressing or bathing?
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?
Employment Status: What is your employment status? Choose all that apply
If you selected "other" employment status, please specify.
Demographics - Optional: What was your total household income last year (USD)? Please include all sources of income, including pensions, dividends, alimony, child support, etc.
Do you receive a significant portion (>20%) of your income through federally-funded income assistance programs? Some examples of these programs are listed in the question below.
Do you take advantage of any of the following programs? Choose all that apply
What was your total household income last year (CAD)? Please include all sources of income, including pensions, dividends, alimony, child support, etc.
Do you receive a significant portion (>20%) of your income through federally-funded income assistance programs? Some examples of these programs are listed below.
What is your marital status? Choose all that apply
How many people live in your household?Please specify a number
Who lives with you? Choose all that apply: Spouse/partner/significant other
If "others" live in your household, please specify:
Do you have a reliable mode of transportation?
What is your primary mode of transportation?
If you selected "other" transportation, please specify.