{
  "resourceType": "Questionnaire",
  "id": "home-o2-questionnaire",
  "meta": {
    "profile": [
      "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/dtr-questionnaire-r4"
    ]
  },
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p>This form is used to collect information from the provider on Home Oxygen Therapy.</p></div>"
  },
  "extension": [
    {
      "url": "http://hl7.org/fhir/StructureDefinition/cqf-library",
      "valueCanonical": "#HomeOxygenTherapy-prepopulation"
    }
  ],
  "url": "http://hl7.org/fhir/us/davinci-dtr/Questionnaire/home-o2-questionnaire",
  "version": "1.0.0",
  "name": "HomeOxygenTherapyQuestionnaire",
  "title": "Home Oxygen Therapy Order Template",
  "status": "draft",
  "subjectType": [
    "Patient"
  ],
  "date": "2019-03-11T00:00:00+00:00",
  "publisher": "HL7 Clinical Decision Support Work Group",
  "contact": [
    {
      "telecom": [
        {
          "system": "url",
          "value": "http://www.hl7.org/Special/committees/dss"
        }
      ]
    }
  ],
  "jurisdiction": [
    {
      "coding": [
        {
          "system": "urn:iso:std:iso:3166",
          "code": "US"
        }
      ]
    }
  ],
  "item": [
    {
      "linkId": "1",
      "text": "Patient Information",
      "type": "group",
      "item": [
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/StructureDefinition/cqf-expression",
              "valueExpression": {
                "language": "text/cql",
                "expression": "PatientLastName"
              }
            }
          ],
          "linkId": "1.1",
          "text": "Last Name",
          "type": "string",
          "required": true
        },
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/StructureDefinition/cqf-expression",
              "valueExpression": {
                "language": "text/cql",
                "expression": "PatientMiddleInitial"
              }
            }
          ],
          "linkId": "1.3",
          "text": "Middle Initial",
          "type": "text",
          "required": false
        },
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/StructureDefinition/cqf-expression",
              "valueExpression": {
                "language": "text/cql",
                "expression": "PatientFirstName"
              }
            }
          ],
          "linkId": "1.2",
          "text": "First Name",
          "type": "string",
          "enableWhen": [
            {
              "question": "1.3",
              "operator": "=",
              "answerString": "S"
            }
          ],
          "required": true
        },
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/StructureDefinition/cqf-expression",
              "valueExpression": {
                "language": "text/cql",
                "expression": "PatientDateOfBirth"
              }
            }
          ],
          "linkId": "1.4",
          "text": "Date Of Birth",
          "type": "date",
          "required": true
        },
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/StructureDefinition/cqf-expression",
              "valueExpression": {
                "language": "text/cql",
                "expression": "PatientGender"
              }
            }
          ],
          "linkId": "1.5",
          "text": "Gender",
          "type": "choice",
          "required": true,
          "answerValueSet": "http://hl7.org/fhir/ValueSet/administrative-gender"
        }
      ]
    }
  ]
}