Neonate record from New South Wales, Australia "My Personal Health Record" example

{
  "resourceType" : "Questionnaire",
  "id" : "bb",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n      <pre>\n        <b>Birth details - To be completed by health professional</b>\n  Name of child: ____________________________________\n            Sex: __\n            \n  Neonatal Information\n    Birth Weight (kg): ___________\n    Birth Length (cm): ___________\n    Vitamin K given  : __\n             1st dose: ___________\n             2nd dose: ___________\n    Hep B given      : __\n      Date given     : ___________\n    Abnormalities noted at birth:\n      _______________________________________________\n      </pre>\n    </div>"
  },
  "url" : "http://hl7.org/fhir/Questionnaire/bb",
  "identifier" : [{
    "system" : "urn:ietf:rfc:3986",
    "value" : "urn:oid:2.16.840.1.113883.4.642.20.4"
  }],
  "title" : "NSW Government My Personal Health Record",
  "status" : "draft",
  "subjectType" : ["Patient"],
  "date" : "2013-02-19",
  "publisher" : "New South Wales Department of Health",
  "jurisdiction" : [{
    "coding" : [{
      "system" : "urn:iso:std:iso:3166",
      "code" : "AU"
    }]
  }],
  "item" : [{
    "linkId" : "birthDetails",
    "text" : "Birth details - To be completed by health professional",
    "type" : "group",
    "item" : [{
      "linkId" : "group",
      "type" : "group",
      "item" : [{
        "linkId" : "nameOfChild",
        "text" : "Name of child",
        "type" : "string"
      },
      {
        "linkId" : "sex",
        "text" : "Sex",
        "type" : "coding",
        "answerOption" : [{
          "valueCoding" : {
            "code" : "F"
          }
        },
        {
          "valueCoding" : {
            "code" : "M"
          }
        }]
      }]
    },
    {
      "linkId" : "neonatalInformation",
      "text" : "Neonatal Information",
      "type" : "group",
      "item" : [{
        "linkId" : "birthWeight",
        "text" : "Birth weight (kg)",
        "type" : "decimal"
      },
      {
        "linkId" : "birthLength",
        "text" : "Birth length (cm)",
        "type" : "decimal"
      },
      {
        "linkId" : "vitaminKgiven",
        "text" : "Vitamin K given",
        "type" : "coding",
        "answerOption" : [{
          "valueCoding" : {
            "code" : "INJECTION"
          }
        },
        {
          "valueCoding" : {
            "code" : "INTRAVENOUS"
          }
        },
        {
          "valueCoding" : {
            "code" : "ORAL"
          }
        }],
        "item" : [{
          "linkId" : "vitaminKgivenDoses",
          "type" : "group",
          "enableWhen" : [{
            "question" : "vitaminKgiven",
            "operator" : "exists",
            "answerBoolean" : true
          }],
          "item" : [{
            "linkId" : "vitaminKDose1",
            "text" : "1st dose",
            "type" : "dateTime"
          },
          {
            "linkId" : "vitaminKDose2",
            "text" : "2nd dose",
            "type" : "dateTime"
          }]
        }]
      },
      {
        "linkId" : "hepBgiven",
        "text" : "Hep B given y / n",
        "type" : "boolean",
        "item" : [{
          "linkId" : "hepBgivenDate",
          "text" : "Date given",
          "type" : "date"
        }]
      },
      {
        "linkId" : "abnormalitiesAtBirth",
        "text" : "Abnormalities noted at birth",
        "type" : "string"
      }]
    }]
  }]
}