{
  "resourceType": "QuestionnaireResponse",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><span style=\"font-weight:bold;text-decoration:underline;\">Patient Information<br/></span> Surname: <br/>First Name: <br/>DOB: 1960-01-01<br/>Gender: Female<br/>Address (Line 1): <br/>City: <br/>Province: <br/>Postal Code: <br/><span style=\"font-weight:bold;text-decoration:underline;\">Exam(s) Requested</span> <span style=\"font-weight:bold;\"/> CT RequisitionandMRI Requisition<br/><span style=\"font-weight:bold;text-decoration:underline;\">Triage Considerations<br/></span> Requested Triage Priority <span style=\"font-weight:bold;color:#EE6B00;\">Routine</span><br/><span style=\"font-weight:bold;text-decoration:underline;\">CT Exam/Region(s) of Interest:</span> <span style=\"display:none;\">Neck</span> Neck,<span style=\"font-weight:bold;\">Specific area of interest</span> <br/>Neck angiographyandSoft Tissue Neck,<span style=\"display:none;\">Spine</span> Spine,<span style=\"font-weight:bold;\">Specific area of interest</span> <br/>Cervical Spine<br/><span style=\"font-weight:bold;\">CT Request: Clinical History / Indication<br/></span> <br/>Motor vehicle accident<br/><span style=\"font-weight:bold;text-decoration:underline;\">MRI Exam/Region(s) of Interest:</span> <span style=\"display:none;\">Neck</span> Neck<br/><span style=\"font-weight:bold;\">Specific area of interest</span> <br/>Neck angiographyandBrachial plexus<br/>Brachial Plexus: Bilateral<br/><span style=\"font-weight:bold;\">MRI Request: Clinical History / Indication<br/></span> <br/>Motor vehicle accident<br/><span style=\"font-weight:bold;text-decoration:underline;\">MRI Safety Screening<br/></span> <span style=\"display:none;\">None of the above</span> None of the above<br/><span style=\"font-weight:bold;text-decoration:underline;\"><p><b> Patient Safety Screening</b></p>\n<p> Select where applicable </p><br/></span> Renal Assessment Questions: No known kidney issues<br/>Known hypersensitivity to contrast agents: Unknown<br/><span style=\"display:none;\">Currently breastfeeding</span> Currently breastfeeding<br/>Patient Weight and Height<br/> Units: Metric (cm/kgs)<br/>Metric height and weight required<br/> Weight (kgs): 73<br/>Height (cm): 164<br/>Date of Weight/Height: 2026-08-30<br/><span style=\"font-weight:bold;text-decoration:underline;\">Scheduling<br/></span> Request specific appointment date or time interval based on: Clinical Reasons<br/>Specify Timeframe: <br/>Clinical Reasons: Patient navigation (eg., Before a specialist appointment) <br/>Preferred Consultant or Location<br/> <span style=\"display:none;\">Patient willing to travel for shorter wait time</span> Patient willing to travel for shorter wait time<br/>Referrer's Information<br/> Address (Line 1): <br/>City: <br/>Province: <br/>Postal Code: <br/>Signed: Dr. Bones<br/>Role: Family Physician<br/>referralService </div>"
  },
  "questionnaire": "http://ontariohealth.ca/fhir/eforms/Questionnaire/translations|1.1.0",
  "status": "completed",
  "subject": {
    "reference": "http://example.org/Patient/pat-53234",
    "display": "MOMO ABBAS"
  },
  "authored": "2026-08-30T21:33:21.444Z",
  "author": {
    "reference": "http://example.org/Practitioner/smart-Practitioner-71482713",
    "type": "Practitioner",
    "display": "Susan Clark"
  },
  "item": [
    {
      "linkId": "patient_header",
      "text": "Patient Information",
      "item": [
        {
          "linkId": "patient_surname",
          "text": "Surname:",
          "answer": [
            {
              "valueString": "Smith"
            }
          ]
        },
        {
          "linkId": "patient_firstname",
          "text": "First Name:",
          "answer": [
            {
              "valueString": "Jane"
            }
          ]
        },
        {
          "linkId": "patient_date_of_birth",
          "text": "DOB:",
          "answer": [
            {
              "valueDate": "1960-01-01"
            }
          ]
        },
        {
          "linkId": "patient_gender",
          "text": "Gender:",
          "answer": [
            {
              "valueCoding": {
                "system": "http://hl7.org/fhir/administrative-gender",
                "code": "female",
                "display": "Female"
              }
            }
          ]
        },
        {
          "linkId": "patient_address_line1",
          "text": "Address (Line 1):",
          "answer": [
            {
              "valueString": "123 Some Street"
            }
          ]
        },
        {
          "linkId": "patient_address_city",
          "text": "City:",
          "answer": [
            {
              "valueString": "Toronto"
            }
          ]
        },
        {
          "linkId": "patient_address_province",
          "text": "Province:",
          "answer": [
            {
              "valueString": "ON"
            }
          ]
        },
        {
          "linkId": "patient_address_postalcode",
          "text": "Postal Code:",
          "answer": [
            {
              "valueString": "M1M 1M1"
            }
          ]
        }
      ]
    },
    {
      "linkId": "847648250958",
      "text": "Select Exam Request",
      "item": [
        {
          "linkId": "medicalImaging_examRequest",
          "answer": [
            {
              "valueCoding": {
                "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                "code": "20390",
                "display": "CT Requisition"
              }
            },
            {
              "valueCoding": {
                "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                "code": "20391",
                "display": "MRI Requisition"
              }
            }
          ]
        },
        {
          "linkId": "medicalImaging_weightHeightRequirement",
          "text": "Weight/height requirement",
          "answer": [
            {
              "valueString": "MRI_HEIGHT_WEIGHT_REQUIRED"
            }
          ]
        }
      ]
    },
    {
      "linkId": "medicalImaging_referral_triageconsiderations",
      "text": "Triage Considerations",
      "item": [
        {
          "linkId": "medicalImaging_examRequest_triage",
          "text": "Requested Triage Priority",
          "answer": [
            {
              "valueString": "Routine"
            }
          ]
        }
      ]
    },
    {
      "linkId": "medicalImaging_referral_cds",
      "text": "Clinical Decision Support",
      "item": [
        {
          "linkId": "medicalImaging_examRequest_cds",
          "text": "Display Clinical Decision Support (CDS)",
          "answer": [
            {
              "valueString": "Hide"
            }
          ]
        }
      ]
    },
    {
      "linkId": "medicalImaging_examRequest_CT_group",
      "text": "Select CT Exam/Region(s) of Interest:",
      "item": [
        {
          "linkId": "medicalImaging_examRequest_CT_neck",
          "text": "Neck",
          "answer": [
            {
              "valueCoding": {
                "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                "code": "20396",
                "display": "Neck"
              }
            }
          ]
        },
        {
          "linkId": "medicalImaging_examRequest_CT_neck_group",
          "item": [
            {
              "linkId": "medicalImaging_examRequest_CT_neck_specificarea",
              "text": "Specific area of interest (optional)",
              "answer": [
                {
                  "valueCoding": {
                    "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                    "code": "20448",
                    "display": "Neck angiography"
                  }
                },
                {
                  "valueCoding": {
                    "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                    "code": "20414",
                    "display": "Soft Tissue Neck"
                  }
                }
              ]
            }
          ]
        },
        {
          "linkId": "medicalImaging_examRequest_CT_spine",
          "text": "Spine",
          "answer": [
            {
              "valueCoding": {
                "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                "code": "20397",
                "display": "Spine"
              }
            }
          ]
        },
        {
          "linkId": "medicalImaging_examRequest_CT_spine_group",
          "item": [
            {
              "linkId": "medicalImaging_examRequest_CT_spine_specificarea",
              "text": "Specific area of interest (optional)",
              "answer": [
                {
                  "valueCoding": {
                    "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                    "code": "20415",
                    "display": "Cervical Spine"
                  }
                }
              ]
            }
          ]
        },
        {
          "linkId": "medicalImaging_CT_CDS_Osteoarthritis_enabled",
          "text": "CT osteoarthritis CDS display condition",
          "answer": [
            {
              "valueBoolean": false
            }
          ]
        }
      ]
    },
    {
      "linkId": "medicalImaging_CT_clinicalindication_CTrefnote",
      "text": "CT Request: Clinical History / Indication",
      "item": [
        {
          "linkId": "medicalImaging_CT_clinicalindication_text",
          "text": "Reason for exam (please also include presenting symptom(s), relevant underlying diagnosis and therapies, where applicable)",
          "answer": [
            {
              "valueString": "Motor vehicle accident"
            }
          ]
        }
      ]
    },
    {
      "linkId": "medicalImaging_examRequest_MRI_group_MRIrefnote",
      "text": "Select MRI Exam/Region(s) of Interest:",
      "item": [
        {
          "linkId": "medicalImaging_examRequest_MRI_neck",
          "text": "Neck",
          "answer": [
            {
              "valueCoding": {
                "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                "code": "20468",
                "display": "Neck"
              }
            }
          ]
        },
        {
          "linkId": "medicalImaging_examRequest_MRI_neck_group",
          "item": [
            {
              "linkId": "medicalImaging_examRequest_MRI_neck_specificarea",
              "text": "Specific area of interest (optional)",
              "answer": [
                {
                  "valueCoding": {
                    "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                    "code": "20541",
                    "display": "Neck angiography"
                  }
                },
                {
                  "valueCoding": {
                    "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                    "code": "20488",
                    "display": "Brachial plexus"
                  }
                }
              ]
            },
            {
              "linkId": "medicalImaging_examRequest_MRI_neck_specificarea_brachial",
              "text": "Brachial Plexus:",
              "answer": [
                {
                  "valueCoding": {
                    "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                    "code": "21323",
                    "display": "Bilateral"
                  }
                }
              ]
            }
          ]
        },
        {
          "linkId": "medicalImaging_MRI_CDS_Osteoarthritis_enabled",
          "text": "MRI osteoarthritis CDS display condition",
          "answer": [
            {
              "valueBoolean": false
            }
          ]
        }
      ]
    },
    {
      "linkId": "medicalImaging_MRI_clinicalindication_MRIrefnote",
      "text": "MRI Request: Clinical History / Indication",
      "item": [
        {
          "linkId": "medicalImaging_MRI_clinicalindication_text",
          "text": "Reason for exam (please also include presenting symptom(s), relevant underlying diagnosis and therapies, where applicable)",
          "answer": [
            {
              "valueString": "Motor vehicle accident"
            }
          ]
        }
      ]
    },
    {
      "linkId": "medicalImaging_MRIsafety_group_MRIrefnote",
      "text": "MRI Safety Screening",
      "item": [
        {
          "linkId": "MRI_safety_none",
          "text": "None of the above",
          "answer": [
            {
              "valueString": "None of the above"
            }
          ]
        }
      ]
    },
    {
      "linkId": "medicalImaging_patientsafety_group",
      "text": "Patient Safety Screening\n Select where applicable",
      "item": [
        {
          "linkId": "medicalImaging_patientsafety_renal",
          "text": "Renal Assessment Questions:",
          "answer": [
            {
              "valueCoding": {
                "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                "code": "21283",
                "display": "No known kidney issues"
              }
            }
          ]
        },
        {
          "linkId": "medicalImaging_patientsafety_knownhypersensitivity",
          "text": "Known hypersensitivity to contrast agents:",
          "answer": [
            {
              "valueString": "Unknown"
            }
          ]
        },
        {
          "linkId": "medicalImaging_patientsafety_breastfeeding",
          "text": "Currently breastfeeding",
          "answer": [
            {
              "valueCoding": {
                "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                "code": "21293",
                "display": "Currently breastfeeding"
              }
            }
          ]
        },
        {
          "linkId": "medicalImaging_weight_height",
          "text": "Patient Weight and Height",
          "item": [
            {
              "linkId": "medicalImaging_weight_height_units",
              "text": "Units:",
              "answer": [
                {
                  "valueString": "Metric (cm/kgs)"
                }
              ]
            },
            {
              "linkId": "medicalImaging_weight_height_required_metric",
              "text": "Metric height and weight required",
              "item": [
                {
                  "linkId": "medicalImaging_weight_height_required_metric_kg",
                  "text": "Weight (kgs):",
                  "answer": [
                    {
                      "valueDecimal": 73
                    }
                  ]
                },
                {
                  "linkId": "medicalImaging_weight_height_required_metric_cm",
                  "text": "Height (cm):",
                  "answer": [
                    {
                      "valueDecimal": 164
                    }
                  ]
                }
              ]
            },
            {
              "linkId": "medicalImaging_weight_height_date",
              "text": "Date of Weight/Height:",
              "answer": [
                {
                  "valueDate": "2026-08-30"
                }
              ]
            }
          ]
        }
      ]
    },
    {
      "linkId": "medicalImaging_scheduling_",
      "text": "Scheduling",
      "item": [
        {
          "linkId": "medicalImaging_scheduling",
          "text": "Request specific appointment date or time interval based on:",
          "answer": [
            {
              "valueString": "Clinical Reasons"
            }
          ]
        },
        {
          "linkId": "medicalImaging_scheduling_clinicalreasons_other",
          "text": "Specify Timeframe:",
          "answer": [
            {
              "valueString": "2 weeks"
            }
          ]
        },
        {
          "linkId": "medicalImaging_scheduling_clinicalreasons",
          "text": "Clinical Reasons:",
          "answer": [
            {
              "valueString": "Patient navigation (eg., Before a specialist appointment) "
            }
          ]
        }
      ]
    },
    {
      "linkId": "pref_consultant_group",
      "item": [
        {
          "linkId": "preferredconsultlocation_header",
          "text": "Preferred Consultant or Location",
          "item": [
            {
              "linkId": "preferredconsultlocation_willingtotravel",
              "text": "Patient willing to travel for shorter wait time",
              "answer": [
                {
                  "valueString": "Patient willing to travel for shorter wait time"
                }
              ]
            }
          ]
        }
      ]
    },
    {
      "linkId": "602618746069",
      "text": "Referrer's Information",
      "item": [
        {
          "linkId": "referrer_address_line1",
          "text": "Address (Line 1):",
          "answer": [
            {
              "valueString": "456 Another Street"
            }
          ]
        },
        {
          "linkId": "referrer_address_city",
          "text": "City:",
          "answer": [
            {
              "valueString": "Toronto"
            }
          ]
        },
        {
          "linkId": "referrer_address_province",
          "text": "Province:",
          "answer": [
            {
              "valueString": "ON"
            }
          ]
        },
        {
          "linkId": "referrer_address_postalcode",
          "text": "Postal Code:",
          "answer": [
            {
              "valueString": "M2M 2M2"
            }
          ]
        },
        {
          "linkId": "referrer_signature",
          "text": "Signed:",
          "answer": [
            {
              "valueString": "Dr. Bones"
            }
          ]
        },
        {
          "linkId": "referrer_role",
          "text": "Role:",
          "answer": [
            {
              "valueCoding": {
                "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                "code": "21276",
                "display": "Family Physician"
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "referralService",
      "text": "referralService",
      "answer": [
        {
          "valueString": "CT | MRI"
        }
      ]
    }
  ]
}