{
  "resourceType": "Questionnaire",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Semaglutide 4-week check-in</b></p><ol><li>How many weekly shots have you taken so far?</li><li>Have you missed a shot or taken one more than 2 days late?</li><li>What got in the way?</li><li>Any trouble with the pen or the shots? Check any that apply, or describe it in your own words.</li><li>In the past week, how much nausea have you had?</li><li>In the past week, have you vomited?</li><li>How have your bowels been?</li><li>Are you able to drink enough fluids each day?</li><li>How has your appetite changed?</li><li>Have you had spells of feeling shaky, sweaty, or confused that went away after eating?</li><li>Have you had any of these? Check all that apply.</li><li>The usual plan is to step up to the next dose after 4 weeks. How do you feel about that?</li><li>What questions do you have for me about this medicine?</li></ol></div>"
  },
  "url": "https://smart-health-checkin.org/connectathon/Questionnaire/semaglutide-4-week-checkin.json",
  "version": "1",
  "name": "SemaglutideFourWeekCheckin",
  "title": "Semaglutide 4-week check-in",
  "status": "draft",
  "subjectType": [
    "Patient"
  ],
  "date": "2026-09-25",
  "publisher": "SMART Health IT (connectathon example)",
  "description": "Example physician-authored follow-up form for a patient about 4 weeks after starting weekly semaglutide. Asks only what the patient's record can't answer: how the shots are going, side effects, red-flag symptoms, and readiness to step up the dose. Synthetic example for the KTC SMART Health Check-in connectathon; not clinical guidance.",
  "item": [
    {
      "linkId": "intro",
      "type": "display",
      "text": "You started semaglutide (Ozempic or Wegovy) about a month ago. These questions help me see how it's going before your visit. It takes about 3 minutes."
    },
    {
      "linkId": "doses-taken",
      "type": "integer",
      "text": "How many weekly shots have you taken so far?"
    },
    {
      "linkId": "missed",
      "type": "choice",
      "text": "Have you missed a shot or taken one more than 2 days late?",
      "answerOption": [
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "no",
            "display": "No"
          }
        },
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "once",
            "display": "Once"
          }
        },
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "more",
            "display": "More than once"
          }
        }
      ]
    },
    {
      "linkId": "missed-why",
      "type": "text",
      "text": "What got in the way?",
      "enableWhen": [
        {
          "question": "missed",
          "operator": "=",
          "answerCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "once",
            "display": "Once"
          }
        },
        {
          "question": "missed",
          "operator": "=",
          "answerCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "more",
            "display": "More than once"
          }
        }
      ],
      "enableBehavior": "any"
    },
    {
      "linkId": "pen-trouble",
      "type": "open-choice",
      "text": "Any trouble with the pen or the shots? Check any that apply, or describe it in your own words.",
      "answerOption": [
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "setup",
            "display": "Trouble setting the dose or attaching the needle"
          }
        },
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "site",
            "display": "Pain, bruising, or a lump where I inject"
          }
        },
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "supply",
            "display": "Trouble getting refills or needles"
          }
        }
      ],
      "repeats": true
    },
    {
      "linkId": "nausea",
      "type": "choice",
      "text": "In the past week, how much nausea have you had?",
      "answerOption": [
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "none",
            "display": "None"
          }
        },
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "mild",
            "display": "Mild, it doesn't change what I do"
          }
        },
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "moderate",
            "display": "Moderate, I eat less or change plans because of it"
          }
        },
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "severe",
            "display": "Severe, hard to get through the day"
          }
        }
      ]
    },
    {
      "linkId": "vomiting",
      "type": "choice",
      "text": "In the past week, have you vomited?",
      "answerOption": [
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "no",
            "display": "No"
          }
        },
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "1-2",
            "display": "Once or twice"
          }
        },
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "more",
            "display": "More than twice"
          }
        }
      ]
    },
    {
      "linkId": "bowels",
      "type": "choice",
      "text": "How have your bowels been?",
      "answerOption": [
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "normal",
            "display": "About normal"
          }
        },
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "constipated",
            "display": "Constipated"
          }
        },
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "loose",
            "display": "Loose or diarrhea"
          }
        },
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "both",
            "display": "Going back and forth"
          }
        }
      ]
    },
    {
      "linkId": "fluids",
      "type": "boolean",
      "text": "Are you able to drink enough fluids each day?"
    },
    {
      "linkId": "appetite",
      "type": "choice",
      "text": "How has your appetite changed?",
      "answerOption": [
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "much-less",
            "display": "Much less hungry, I get full quickly"
          }
        },
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "bit-less",
            "display": "A bit less hungry"
          }
        },
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "same",
            "display": "About the same"
          }
        },
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "more",
            "display": "Hungrier than before"
          }
        }
      ]
    },
    {
      "linkId": "low-sugar",
      "type": "boolean",
      "text": "Have you had spells of feeling shaky, sweaty, or confused that went away after eating?"
    },
    {
      "linkId": "red-flags",
      "type": "choice",
      "repeats": true,
      "text": "Have you had any of these? Check all that apply.",
      "answerOption": [
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "belly-pain",
            "display": "Severe belly pain that won't go away, sometimes going into the back"
          }
        },
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "cant-keep-fluids",
            "display": "Vomiting so much you can't keep fluids down"
          }
        },
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "yellow",
            "display": "Yellow skin or eyes"
          }
        },
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "neck",
            "display": "A lump or swelling in your neck, or new trouble swallowing"
          }
        },
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "vision",
            "display": "New blurry vision"
          }
        }
      ]
    },
    {
      "linkId": "red-flags-note",
      "type": "display",
      "text": "If you checked any of these, please call the office today rather than waiting for your visit.",
      "enableWhen": [
        {
          "question": "red-flags",
          "operator": "exists",
          "answerBoolean": true
        }
      ]
    },
    {
      "linkId": "next-dose",
      "type": "choice",
      "text": "The usual plan is to step up to the next dose after 4 weeks. How do you feel about that?",
      "answerOption": [
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "ready",
            "display": "Ready to go up"
          }
        },
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "wait",
            "display": "I'd like to stay at this dose a while longer"
          }
        },
        {
          "valueCoding": {
            "system": "https://smart-health-checkin.org/connectathon/CodeSystem/semaglutide-checkin",
            "code": "discuss",
            "display": "I'm not sure, let's talk about it"
          }
        }
      ]
    },
    {
      "linkId": "questions",
      "type": "text",
      "text": "What questions do you have for me about this medicine?"
    }
  ]
}