Release 4 5 Preview #3
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Questionnaire-example-gcs.json

FHIR Infrastructure Work Group Maturity Level : N/A Standards Status : Informative Compartments : Not linked to any defined compartments

Raw JSON ( canonical form + also see JSON Format Specification )

Glasgow Coma Score example form

{
  "resourceType": "Questionnaire",
  "id": "gcs",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: gcs</p><p><b>contained</b>: , , </p><p><b>url</b>: <b>http://hl7.org/fhir/Questionnaire/gcs</b></p><p><b>title</b>: Glasgow Coma Score</p><p><b>status</b>: draft</p><p><b>subjectType</b>: Patient</p><p><b>date</b>: 03/08/2015</p><p><b>publisher</b>: FHIR Project team</p><p><b>code</b>: Glasgow coma score total (Details: LOINC code 9269-2 = 'Glasgow coma score total', stated as 'null')</p><blockquote><p><b>item</b></p><p><b>linkId</b>: 1.1</p><p><b>code</b>: Glasgow coma score verbal (Details: LOINC code 9270-0 = 'Glasgow coma score verbal', stated as 'null')</p><p><b>type</b>: choice</p><p><b>answerValueSet</b>: <a>#verbal</a></p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 1.2</p><p><b>code</b>: Glasgow coma score motor (Details: LOINC code 9268-4 = 'Glasgow coma score motor', stated as 'null')</p><p><b>type</b>: choice</p><p><b>answerValueSet</b>: <a>#motor</a></p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 1.3</p><p><b>code</b>: Glasgow coma score eye opening (Details: LOINC code 9267-6 = 'Glasgow coma score eye opening', stated as 'null')</p><p><b>type</b>: choice</p><p><b>answerValueSet</b>: <a>#eye</a></p></blockquote></div>"

    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>url</b>: <code>http://hl7.org/fhir/Questionnaire/gcs</code></p><p><b>title</b>: Glasgow Coma Score</p><p><b>status</b>: draft</p><p><b>subjectType</b>: Patient</p><p><b>date</b>: 2015-08-03</p><p><b>publisher</b>: FHIR Project team</p><p><b>code</b>: <span>Glasgow coma score total</span></p><blockquote><p><b>item</b></p><p><b>linkId</b>: 1.1</p><p><b>code</b>: <span>Glasgow coma score verbal</span></p><p><b>type</b>: choice</p><p><b>answerValueSet</b>: <code>#verbal</code></p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 1.2</p><p><b>code</b>: <span>Glasgow coma score motor</span></p><p><b>type</b>: choice</p><p><b>answerValueSet</b>: <code>#motor</code></p></blockquote><blockquote><p><b>item</b></p><p><b>linkId</b>: 1.3</p><p><b>code</b>: <span>Glasgow coma score eye opening</span></p><p><b>type</b>: choice</p><p><b>answerValueSet</b>: <code>#eye</code></p></blockquote></div>"

  },
  "contained": [
    {
      "resourceType": "ValueSet",
      "id": "motor",
      "identifier": [
        {
          "system": "http://loinc.org",
          "value": "http://loinc.org/ValueSet/LL357-5"
        }
      ],
      "name": "GCS Motor Value Set",
      "status": "active",
      "description": "LOINC ANSWER LIST    (LL357-5)",
      "compose": {
        "include": [
          {
            "system": "http://loinc.org",
            "concept": [
              {
                "code": "LA6562-8",
                "display": "No motor response"
              },
              {
                "code": "LA6563-6",
                "display": "Extension to pain"
              },
              {
                "code": "LA6564-4",
                "display": "Flexion to pain"
              },
              {
                "code": "LA6565-1",
                "display": "Withdrawl from pain"
              },
              {
                "code": "LA6566-9",
                "display": "Localizing pain"
              },
              {
                "code": "LA6567-7",
                "display": "Obeys commands"
              }
            ]
          }
        ]
      }
    },
    {
      "resourceType": "ValueSet",
      "id": "verbal",
      "identifier": [
        {
          "system": "http://loinc.org",
          "value": "http://loinc.org/ValueSet/LL356-7"
        }
      ],
      "name": "GCS Verbal Value Set",
      "status": "active",
      "description": "LOINC ANSWER LIST    (LL356-7)",
      "compose": {
        "include": [
          {
            "system": "http://loinc.org",
            "concept": [
              {
                "code": "LA6557-8",
                "display": "No verbal response (>2yrs); no vocal response (<=2yrs)"
              },
              {
                "code": "LA6558-6",
                "display": "Incomprehensible sounds"
              },
              {
                "code": "LA6559-4",
                "display": "Inappropriate words"
              },
              {
                "code": "LA6560-2",
                "display": "Confused"
              },
              {
                "code": "LA6561-0",
                "display": "Oriented"
              }
            ]
          }
        ]
      }
    },
    {
      "resourceType": "ValueSet",
      "id": "eye",
      "identifier": [
        {
          "system": "http://loinc.org",
          "value": "http://loinc.org/ValueSet/LL355-9"
        }
      ],
      "name": "GCS Eye Value Set",
      "status": "active",
      "description": "LOINC ANSWER LIST    (LL355-9)",
      "compose": {
        "include": [
          {
            "system": "http://loinc.org",
            "concept": [
              {
                "code": "LA6553-7",
                "display": "No eye opening"
              },
              {
                "code": "LA6554-5",
                "display": "Eye opening to pain"
              },
              {
                "code": "LA6555-2",
                "display": "Eye opening to verbal command"
              },
              {
                "code": "LA6556-0",
                "display": "Eyes open spontaneously"
              }
            ]
          }
        ]
      }
    }
  ],
  "url": "http://hl7.org/fhir/Questionnaire/gcs",
  "title": "Glasgow Coma Score",
  "status": "draft",
  "subjectType": [
    "Patient"
  ],
  "date": "2015-08-03",
  "publisher": "FHIR Project team",
  "code": [
    {
      "system": "http://loinc.org",
      "code": "9269-2"
    }
  ],
  "item": [
    {
      "linkId": "1.1",
      "code": [
        {
          "system": "http://loinc.org",
          "code": "9270-0"
        }
      ],
      "type": "choice",
      "answerValueSet": "#verbal"
    },
    {
      "linkId": "1.2",
      "code": [
        {
          "system": "http://loinc.org",
          "code": "9268-4"
        }
      ],
      "type": "choice",
      "answerValueSet": "#motor"
    },
    {
      "linkId": "1.3",
      "code": [
        {
          "system": "http://loinc.org",
          "code": "9267-6"
        }
      ],
      "type": "choice",
      "answerValueSet": "#eye"
    }
  ]
}

Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.