resourceType: Questionnaire
id: cdex-questionnaire-example2
meta:
  profile:
    - >-
      http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/dtr-std-questionnaire
  extension:
    - url: http://hl7.org/fhir/StructureDefinition/instance-name
      valueString: CDex Questionnaire Example2
    - url: http://hl7.org/fhir/StructureDefinition/instance-description
      valueMarkdown: >-
        This example is a simple data request Questionnaire used in the Task Based and Attachments transactions. It indicates that a verification signature is needed when completing the QuestionnaireResponse.  It is adapted from the Da Vinci DTR IG.
extension:
  - url: 'http://hl7.org/fhir/StructureDefinition/questionnaire-signatureRequired'
    valueCodeableConcept:
      coding:
        - system: 'urn:iso-astm:E1762-95:2013'
          code: '1.2.840.10065.1.12.1.5'
          display: 'Verification Signature'
name: HomeOxygenTherapyQuestionnaire
title: Home Oxygen Therapy Questionnaire
url: 'http://example.org/cdex-questionnaire-example2'
status: active
subjectType:
  - Patient
date: '2022-01-17'
item:
  - linkId: '1'
    text: >-
      Relevant Patient Diagnoses (conditions that might be expected to
      improve with oxygen therapy)
    type: text
    required: true
  - linkId: '2'
    text: Order Reason
    type: choice
    required: true
    answerOption:
      - valueCoding:
          system: 'http://example.org'
          code: '1'
          display: Initial or original order for certification
      - valueCoding:
          system: 'http://example.org'
          code: '2'
          display: Change in status
      - valueCoding:
          system: 'http://example.org'
          code: '3'
          display: Revision or change in equipment
      - valueCoding:
          system: 'http://example.org'
          code: '4'
          display: Replacement