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@@ -0,0 +1,85 @@
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+{
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+ "lines": [
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+ {
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+ "key": "onset",
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+ "helpText": "When did the problem begin?",
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+ "resultSummary": "Onset: {value}",
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+ "fieldType": "date"
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+ },
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+ {
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+ "key": "location",
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+ "helpText": "Where is the CC located?",
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+ "resultSummary": "Location: {value}",
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+ "fieldType": "time"
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+ },
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+ {
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+ "key": "duration",
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+ "helpText": "How long has the CC been going on for?",
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+ "resultSummary": "Duration: {value}",
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+ "fieldType": "text"
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+ },
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+ {
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+ "key": "characterization",
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+ "helpText": "How does the patient describe the CC?",
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+ "resultSummary": "Characterization: {value}",
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+ "fieldType": "text"
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+ },
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+ {
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+ "key": "alleviating_factors",
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+ "helpText": "What makes it better?",
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+ "resultSummary": "Alleviating factors: {value}",
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+ "fieldType": "text"
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+ },
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+ {
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+ "key": "aggravating_factors",
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+ "helpText": "What makes it worse?",
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+ "resultSummary": "Aggravating factors: {value}",
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+ "fieldType": "text"
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+ },
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+ {
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+ "key": "radiation",
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+ "helpText": "Does the CC move or stay in one location?",
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+ "resultSummary": "Radiation: {value}",
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+ "fieldType": "text"
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+ },
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+ {
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+ "key": "temporal_factor",
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+ "helpText": "Is the CC worse (or better) at a certain time of the day?",
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+ "resultSummary": "Temporal factor: {value}",
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+ "fieldType": "text"
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+ },
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+ {
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+ "key": "severity",
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+ "helpText": "Using a scale of 1 to 10, 1 being the least, 10 being the worst, how does the patient rate the CC?",
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+ "resultSummary": "Severity: {value}",
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+ "fieldType": "radios",
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+ "options": [1, 2, 3, 4, 5, 6, 7, 8, 9, 10]
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+ },
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+ {
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+ "key": "coping",
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+ "helpText": "How do you cope?",
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+ "resultSummary": "Coping: {value}",
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+ "fieldType": "text"
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+ },
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+ {
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+ "key": "emotional_impact",
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+ "helpText": "How does this affect you emotionally?",
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+ "resultSummary": "Emotional Impact: {value}",
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+ "fieldType": "text"
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+ }
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+ ],
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+ "dataMap": {
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+ "onset" : null,
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+ "location" : null,
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+ "duration" : null,
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+ "characterization" : null,
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+ "alleviating_factors" : null,
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+ "aggravating_factors" : null,
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+ "radiation" : null,
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+ "temporal_factor" : null,
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+ "severity" : null,
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+ "coping" : null,
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+ "emotional_impact" : null
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+ },
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+ "definition": null
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+}
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