Glasgow Coma Score example form (id = "gcs")

<?xml version="1.0" encoding="UTF-8"?>

<Questionnaire xmlns="http://hl7.org/fhir">
  <id value="gcs"/> 
  <contained> 
    <ValueSet> 
      <id value="motor"/> 
      <identifier> 
        <system value="http://loinc.org"/> 
        <value value="http://loinc.org/ValueSet/LL357-5"/> 
      </identifier> 
      <name value="GCS Motor Value Set"/> 
      <status value="active"/> 
      <description value="LOINC ANSWER LIST    (LL357-5)"/> 
      <compose> 
        <include> 
          <system value="http://loinc.org"/> 
          <concept> 
            <code value="LA6562-8"/> 
            <display value="No motor response"/> 
          </concept> 
          <concept> 
            <code value="LA6563-6"/> 
            <display value="Extension to pain"/> 
          </concept> 
          <concept> 
            <code value="LA6564-4"/> 
            <display value="Flexion to pain"/> 
          </concept> 
          <concept> 
            <code value="LA6565-1"/> 
            <display value="Withdrawl from pain"/> 
          </concept> 
          <concept> 
            <code value="LA6566-9"/> 
            <display value="Localizing pain"/> 
          </concept> 
          <concept> 
            <code value="LA6567-7"/> 
            <display value="Obeys commands"/> 
          </concept> 
        </include> 
      </compose> 
    </ValueSet> 
  </contained> 
  <contained> 
    <ValueSet> 
      <id value="verbal"/> 
      <identifier> 
        <system value="http://loinc.org"/> 
        <value value="http://loinc.org/ValueSet/LL356-7"/> 
      </identifier> 
      <name value="GCS Verbal Value Set"/> 
      <status value="active"/> 
      <description value="LOINC ANSWER LIST    (LL356-7)"/> 
      <compose> 
        <include> 
          <system value="http://loinc.org"/> 
          <concept> 
            <code value="LA6557-8"/> 
            <display value="No verbal response (&gt;2yrs); no vocal response (&lt;=2yrs)"/> 
          </concept> 
          <concept> 
            <code value="LA6558-6"/> 
            <display value="Incomprehensible sounds"/> 
          </concept> 
          <concept> 
            <code value="LA6559-4"/> 
            <display value="Inappropriate words"/> 
          </concept> 
          <concept> 
            <code value="LA6560-2"/> 
            <display value="Confused"/> 
          </concept> 
          <concept> 
            <code value="LA6561-0"/> 
            <display value="Oriented"/> 
          </concept> 
        </include> 
      </compose> 
    </ValueSet> 
  </contained> 
  <contained> 
    <ValueSet> 
      <id value="eye"/> 
      <identifier> 
        <system value="http://loinc.org"/> 
        <value value="http://loinc.org/ValueSet/LL355-9"/> 
      </identifier> 
      <name value="GCS Eye Value Set"/> 
      <status value="active"/> 
      <description value="LOINC ANSWER LIST    (LL355-9)"/> 
      <compose> 
        <include> 
          <system value="http://loinc.org"/> 
          <concept> 
            <code value="LA6553-7"/> 
            <display value="No eye opening"/> 
          </concept> 
          <concept> 
            <code value="LA6554-5"/> 
            <display value="Eye opening to pain"/> 
          </concept> 
          <concept> 
            <code value="LA6555-2"/> 
            <display value="Eye opening to verbal command"/> 
          </concept> 
          <concept> 
            <code value="LA6556-0"/> 
            <display value="Eyes open spontaneously"/> 
          </concept> 
        </include> 
      </compose> 
    </ValueSet> 
  </contained> 
  <extension url="http://hl7.org/fhir/StructureDefinition/structuredefinition-wg">
    <valueCode value="fhir"/> 
  </extension> 
  <url value="http://hl7.org/fhir/Questionnaire/gcs"/> 
  <identifier> 
    <system value="urn:ietf:rfc:3986"/> 
    <value value="urn:oid:2.16.840.1.113883.4.642.20.5"/> 
  </identifier> 
  <name value="GlasgowComaScore"/> 
  <title value="Glasgow Coma Score"/> 
  <status value="draft"/> 
  <subjectType value="Patient"/> 
  <date value="2015-08-03"/> 
  <publisher value="HL7 International / FHIR Infrastructure"/> 
  <contact> 
    <telecom> 
      <system value="url"/> 
      <value value="http://www.hl7.org/Special/committees/fiwg"/> 
    </telecom> 
  </contact> 
  <description value="Glasgow Coma Score"/> 
  <code> 
    <system value="http://loinc.org"/> 
    <code value="9269-2"/> 
  </code> 
  <item> 
    <linkId value="1.1"/> 
    <code> 
      <system value="http://loinc.org"/> 
      <code value="9270-0"/> 
    </code> 
    <type value="coding"/> 
    <answerValueSet value="#verbal"/> 
  </item> 
  <item> 
    <linkId value="1.2"/> 
    <code> 
      <system value="http://loinc.org"/> 
      <code value="9268-4"/> 
    </code> 
    <type value="coding"/> 
    <answerValueSet value="#motor"/> 
  </item> 
  <item> 
    <linkId value="1.3"/> 
    <code> 
      <system value="http://loinc.org"/> 
      <code value="9267-6"/> 
    </code> 
    <type value="coding"/> 
    <answerValueSet value="#eye"/> 
  </item> 
</Questionnaire>