{ "type": "smart-health-checkin-request", "version": "1", "id": "replace-with-a-unique-id", "purpose": "Pre-visit check-in", "fhirVersions": [ "4.0.1" ], "items": [ { "id": "semaglutide", "title": "How your new medicine is going", "summary": "A short check-in from your doctor about the semaglutide shots you started about a month ago.", "content": { "kind": "form.fhir", "questionnaireCanonical": "https://smart-health-checkin.org/connectathon/Questionnaire/semaglutide-4-week-checkin.json", "questionnaire": { "resourceType": "Questionnaire", "text": { "status": "generated", "div": "

Semaglutide 4-week check-in

  1. How many weekly shots have you taken so far?
  2. Have you missed a shot or taken one more than 2 days late?
  3. What got in the way?
  4. Any trouble with the pen or the shots? Check any that apply, or describe it in your own words.
  5. In the past week, how much nausea have you had?
  6. In the past week, have you vomited?
  7. How have your bowels been?
  8. Are you able to drink enough fluids each day?
  9. How has your appetite changed?
  10. Have you had spells of feeling shaky, sweaty, or confused that went away after eating?
  11. Have you had any of these? Check all that apply.
  12. The usual plan is to step up to the next dose after 4 weeks. How do you feel about that?
  13. What questions do you have for me about this medicine?
" }, "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?" } ] } }, "accept": [ "application/fhir+json" ] } ] }