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: Questionnaire</b><a name=\"gcs\"> </a></p><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Resource Questionnaire &quot;gcs&quot; </p></div><p><b>url</b>: <code>http://hl7.org/fhir/Questionnaire/gcs</code></p><p><b>identifier</b>: id: urn:oid:2.16.840.1.113883.4.642.20.5</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>: 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>: coding</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>: Glasgow coma score motor (Details: LOINC code 9268-4 = 'Glasgow coma score motor', stated as 'null')</p><p><b>type</b>: coding</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>: Glasgow coma score eye opening (Details: LOINC code 9267-6 = 'Glasgow coma score eye opening', stated as 'null')</p><p><b>type</b>: coding</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",
  "identifier" : [{
    "system" : "urn:ietf:rfc:3986",
    "value" : "urn:oid:2.16.840.1.113883.4.642.20.5"
  }],
  "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" : "coding",
    "answerValueSet" : "#verbal"
  },
  {
    "linkId" : "1.2",
    "code" : [{
      "system" : "http://loinc.org",
      "code" : "9268-4"
    }],
    "type" : "coding",
    "answerValueSet" : "#motor"
  },
  {
    "linkId" : "1.3",
    "code" : [{
      "system" : "http://loinc.org",
      "code" : "9267-6"
    }],
    "type" : "coding",
    "answerValueSet" : "#eye"
  }]
}