{
  "resourceType": "QuestionnaireResponse",
  "language": "fr",
  "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": "Renseignements sur le patient",
      "item": [
        {
          "linkId": "patient_surname",
          "text": "Nom de famille :",
          "answer": [
            {
              "valueString": "Smith"
            }
          ]
        },
        {
          "linkId": "patient_firstname",
          "text": "Prénom :",
          "answer": [
            {
              "valueString": "Jane"
            }
          ]
        },
        {
          "linkId": "patient_date_of_birth",
          "text": "Date de naissance :",
          "answer": [
            {
              "valueDate": "1960-01-01"
            }
          ]
        },
        {
          "linkId": "patient_gender",
          "text": "Genre :",
          "answer": [
            {
              "valueCoding": {
                "system": "http://hl7.org/fhir/administrative-gender",
                "code": "female",
                "display": "Féminin"
              }
            }
          ]
        },
        {
          "linkId": "patient_address_line1",
          "text": "Adresse (ligne 1) :",
          "answer": [
            {
              "valueString": "123 Some Street"
            }
          ]
        },
        {
          "linkId": "patient_address_city",
          "text": "Ville :",
          "answer": [
            {
              "valueString": "Toronto"
            }
          ]
        },
        {
          "linkId": "patient_address_province",
          "text": "Province :",
          "answer": [
            {
              "valueString": "ON"
            }
          ]
        },
        {
          "linkId": "patient_address_postalcode",
          "text": "Code postal :",
          "answer": [
            {
              "valueString": "M1M 1M1"
            }
          ]
        }
      ]
    },
    {
      "linkId": "847648250958",
      "text": "Sélectionner la demande d'examen",
      "item": [
        {
          "linkId": "medicalImaging_examRequest",
          "answer": [
            {
              "valueCoding": {
                "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                "code": "20390",
                "display": "Demande de TDM"
              }
            },
            {
              "valueCoding": {
                "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                "code": "20391",
                "display": "Demande d'IRM"
              }
            }
          ]
        },
        {
          "linkId": "medicalImaging_weightHeightRequirement",
          "text": "Exigence de poids/taille",
          "answer": [
            {
              "valueString": "MRI_HEIGHT_WEIGHT_REQUIRED"
            }
          ]
        }
      ]
    },
    {
      "linkId": "medicalImaging_referral_triageconsiderations",
      "text": "Considérations de triage",
      "item": [
        {
          "linkId": "medicalImaging_examRequest_triage",
          "text": "Priorité de triage demandée",
          "answer": [
            {
              "valueString": "Routine",
              "_valueString": {
                "extension": [
                  {
                    "url": "http://hl7.org/fhir/StructureDefinition/translation",
                    "extension": [
                      {
                        "url": "lang",
                        "valueCode": "fr"
                      },
                      {
                        "url": "content",
                        "valueString": "De routine"
                      }
                    ]
                  }
                ]
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "medicalImaging_referral_cds",
      "text": "Aide à la décision clinique",
      "item": [
        {
          "linkId": "medicalImaging_examRequest_cds",
          "text": "Afficher l'aide à la décision clinique (ADC)",
          "answer": [
            {
              "valueString": "Hide",
              "_valueString": {
                "extension": [
                  {
                    "url": "http://hl7.org/fhir/StructureDefinition/translation",
                    "extension": [
                      {
                        "url": "lang",
                        "valueCode": "fr"
                      },
                      {
                        "url": "content",
                        "valueString": "Masquer"
                      }
                    ]
                  }
                ]
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "medicalImaging_examRequest_CT_group",
      "text": "Sélectionner l'examen/la ou les régions de TDM d'intérêt :",
      "item": [
        {
          "linkId": "medicalImaging_examRequest_CT_neck",
          "text": "Cou",
          "answer": [
            {
              "valueCoding": {
                "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                "code": "20396",
                "display": "Cou"
              }
            }
          ]
        },
        {
          "linkId": "medicalImaging_examRequest_CT_neck_group",
          "item": [
            {
              "linkId": "medicalImaging_examRequest_CT_neck_specificarea",
              "text": "Région d'intérêt précise (facultatif)",
              "answer": [
                {
                  "valueCoding": {
                    "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                    "code": "20448",
                    "display": "Angiographie du cou"
                  }
                },
                {
                  "valueCoding": {
                    "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                    "code": "20414",
                    "display": "Tissus mous du cou"
                  }
                }
              ]
            }
          ]
        },
        {
          "linkId": "medicalImaging_examRequest_CT_spine",
          "text": "Colonne vertébrale",
          "answer": [
            {
              "valueCoding": {
                "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                "code": "20397",
                "display": "Colonne vertébrale"
              }
            }
          ]
        },
        {
          "linkId": "medicalImaging_examRequest_CT_spine_group",
          "item": [
            {
              "linkId": "medicalImaging_examRequest_CT_spine_specificarea",
              "text": "Région d'intérêt précise (facultatif)",
              "answer": [
                {
                  "valueCoding": {
                    "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                    "code": "20415",
                    "display": "Colonne cervicale"
                  }
                }
              ]
            }
          ]
        },
        {
          "linkId": "medicalImaging_CT_CDS_Osteoarthritis_enabled",
          "text": "CT osteoarthritis CDS display condition",
          "answer": [
            {
              "valueBoolean": false
            }
          ]
        }
      ]
    },
    {
      "linkId": "medicalImaging_CT_clinicalindication_CTrefnote",
      "text": "Demande de TDM : antécédents cliniques / indication",
      "item": [
        {
          "linkId": "medicalImaging_CT_clinicalindication_text",
          "text": "Motif de l'examen (veuillez aussi indiquer le ou les symptômes présents, le diagnostic sous-jacent pertinent et les traitements, le cas échéant)",
          "answer": [
            {
              "valueString": "Motor vehicle accident"
            }
          ]
        }
      ]
    },
    {
      "linkId": "medicalImaging_examRequest_MRI_group_MRIrefnote",
      "text": "Sélectionner l'examen/la ou les régions d'IRM d'intérêt :",
      "item": [
        {
          "linkId": "medicalImaging_examRequest_MRI_neck",
          "text": "Cou",
          "answer": [
            {
              "valueCoding": {
                "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                "code": "20468",
                "display": "Cou"
              }
            }
          ]
        },
        {
          "linkId": "medicalImaging_examRequest_MRI_neck_group",
          "item": [
            {
              "linkId": "medicalImaging_examRequest_MRI_neck_specificarea",
              "text": "Région d'intérêt précise (facultatif)",
              "answer": [
                {
                  "valueCoding": {
                    "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                    "code": "20541",
                    "display": "Angiographie du cou"
                  }
                },
                {
                  "valueCoding": {
                    "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                    "code": "20488",
                    "display": "Plexus brachial"
                  }
                }
              ]
            },
            {
              "linkId": "medicalImaging_examRequest_MRI_neck_specificarea_brachial",
              "text": "Plexus brachial :",
              "answer": [
                {
                  "valueCoding": {
                    "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                    "code": "21323",
                    "display": "Bilatéral"
                  }
                }
              ]
            }
          ]
        },
        {
          "linkId": "medicalImaging_MRI_CDS_Osteoarthritis_enabled",
          "text": "MRI osteoarthritis CDS display condition",
          "answer": [
            {
              "valueBoolean": false
            }
          ]
        }
      ]
    },
    {
      "linkId": "medicalImaging_MRI_clinicalindication_MRIrefnote",
      "text": "Demande d'IRM : antécédents cliniques / indication",
      "item": [
        {
          "linkId": "medicalImaging_MRI_clinicalindication_text",
          "text": "Motif de l'examen (veuillez aussi indiquer le ou les symptômes présents, le diagnostic sous-jacent pertinent et les traitements, le cas échéant)",
          "answer": [
            {
              "valueString": "Motor vehicle accident"
            }
          ]
        }
      ]
    },
    {
      "linkId": "medicalImaging_MRIsafety_group_MRIrefnote",
      "text": "Dépistage de sécurité pour l'IRM",
      "item": [
        {
          "linkId": "MRI_safety_none",
          "text": "Aucune de ces réponses",
          "answer": [
            {
              "valueString": "None of the above",
              "_valueString": {
                "extension": [
                  {
                    "url": "http://hl7.org/fhir/StructureDefinition/translation",
                    "extension": [
                      {
                        "url": "lang",
                        "valueCode": "fr"
                      },
                      {
                        "url": "content",
                        "valueString": "Aucune de ces réponses"
                      }
                    ]
                  }
                ]
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "medicalImaging_patientsafety_group",
      "text": "Dépistage relatif à la sécurité du patient\n Sélectionner s'il y a lieu",
      "item": [
        {
          "linkId": "medicalImaging_patientsafety_renal",
          "text": "Questions d'évaluation rénale :",
          "answer": [
            {
              "valueCoding": {
                "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                "code": "21283",
                "display": "Aucun problème rénal connu"
              }
            }
          ]
        },
        {
          "linkId": "medicalImaging_patientsafety_knownhypersensitivity",
          "text": "Hypersensibilité connue aux produits de contraste :",
          "answer": [
            {
              "valueString": "Unknown",
              "_valueString": {
                "extension": [
                  {
                    "url": "http://hl7.org/fhir/StructureDefinition/translation",
                    "extension": [
                      {
                        "url": "lang",
                        "valueCode": "fr"
                      },
                      {
                        "url": "content",
                        "valueString": "Inconnu"
                      }
                    ]
                  }
                ]
              }
            }
          ]
        },
        {
          "linkId": "medicalImaging_patientsafety_breastfeeding",
          "text": "Allaite actuellement",
          "answer": [
            {
              "valueCoding": {
                "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                "code": "21293",
                "display": "Allaite actuellement"
              }
            }
          ]
        },
        {
          "linkId": "medicalImaging_weight_height",
          "text": "Poids et taille du patient",
          "item": [
            {
              "linkId": "medicalImaging_weight_height_units",
              "text": "Unités :",
              "answer": [
                {
                  "valueString": "Metric (cm/kgs)",
                  "_valueString": {
                    "extension": [
                      {
                        "url": "http://hl7.org/fhir/StructureDefinition/translation",
                        "extension": [
                          {
                            "url": "lang",
                            "valueCode": "fr"
                          },
                          {
                            "url": "content",
                            "valueString": "Système métrique (cm/kg)"
                          }
                        ]
                      }
                    ]
                  }
                }
              ]
            },
            {
              "linkId": "medicalImaging_weight_height_required_metric",
              "text": "Taille et poids requis en unités métriques",
              "item": [
                {
                  "linkId": "medicalImaging_weight_height_required_metric_kg",
                  "text": "Poids (kg) :",
                  "answer": [
                    {
                      "valueDecimal": 73
                    }
                  ]
                },
                {
                  "linkId": "medicalImaging_weight_height_required_metric_cm",
                  "text": "Taille (cm) :",
                  "answer": [
                    {
                      "valueDecimal": 164
                    }
                  ]
                }
              ]
            },
            {
              "linkId": "medicalImaging_weight_height_date",
              "text": "Date de la mesure du poids/de la taille :",
              "answer": [
                {
                  "valueDate": "2026-08-30"
                }
              ]
            }
          ]
        }
      ]
    },
    {
      "linkId": "medicalImaging_scheduling_",
      "text": "Planification",
      "item": [
        {
          "linkId": "medicalImaging_scheduling",
          "text": "Demander une date de rendez-vous précise ou un intervalle de temps en fonction de :",
          "answer": [
            {
              "valueString": "Clinical Reasons",
              "_valueString": {
                "extension": [
                  {
                    "url": "http://hl7.org/fhir/StructureDefinition/translation",
                    "extension": [
                      {
                        "url": "lang",
                        "valueCode": "fr"
                      },
                      {
                        "url": "content",
                        "valueString": "Raisons cliniques"
                      }
                    ]
                  }
                ]
              }
            }
          ]
        },
        {
          "linkId": "medicalImaging_scheduling_clinicalreasons_other",
          "text": "Préciser le délai :",
          "answer": [
            {
              "valueString": "2 weeks"
            }
          ]
        },
        {
          "linkId": "medicalImaging_scheduling_clinicalreasons",
          "text": "Raisons cliniques :",
          "answer": [
            {
              "valueString": "Patient navigation (eg., Before a specialist appointment) ",
              "_valueString": {
                "extension": [
                  {
                    "url": "http://hl7.org/fhir/StructureDefinition/translation",
                    "extension": [
                      {
                        "url": "lang",
                        "valueCode": "fr"
                      },
                      {
                        "url": "content",
                        "valueString": "Accompagnement du patient (p. ex. avant un rendez-vous avec un spécialiste)"
                      }
                    ]
                  }
                ]
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "pref_consultant_group",
      "item": [
        {
          "linkId": "preferredconsultlocation_header",
          "text": "Consultant ou lieu préféré",
          "item": [
            {
              "linkId": "preferredconsultlocation_willingtotravel",
              "text": "Le patient est prêt à se déplacer pour obtenir un délai d'attente plus court",
              "answer": [
                {
                  "valueString": "Patient willing to travel for shorter wait time",
                  "_valueString": {
                    "extension": [
                      {
                        "url": "http://hl7.org/fhir/StructureDefinition/translation",
                        "extension": [
                          {
                            "url": "lang",
                            "valueCode": "fr"
                          },
                          {
                            "url": "content",
                            "valueString": "Le patient est prêt à se déplacer pour obtenir un délai d'attente plus court"
                          }
                        ]
                      }
                    ]
                  }
                }
              ]
            }
          ]
        }
      ]
    },
    {
      "linkId": "602618746069",
      "text": "Renseignements sur le demandeur",
      "item": [
        {
          "linkId": "referrer_address_line1",
          "text": "Adresse (ligne 1) :",
          "answer": [
            {
              "valueString": "456 Another Street"
            }
          ]
        },
        {
          "linkId": "referrer_address_city",
          "text": "Ville :",
          "answer": [
            {
              "valueString": "Toronto"
            }
          ]
        },
        {
          "linkId": "referrer_address_province",
          "text": "Province :",
          "answer": [
            {
              "valueString": "ON"
            }
          ]
        },
        {
          "linkId": "referrer_address_postalcode",
          "text": "Code postal :",
          "answer": [
            {
              "valueString": "M2M 2M2"
            }
          ]
        },
        {
          "linkId": "referrer_signature",
          "text": "Signé :",
          "answer": [
            {
              "valueString": "Dr. Bones"
            }
          ]
        },
        {
          "linkId": "referrer_role",
          "text": "Rôle :",
          "answer": [
            {
              "valueCoding": {
                "system": "http://ontariohealth.ca/fhir/eforms/CodeSystem/example-referral-form-codes",
                "code": "21276",
                "display": "Médecin de famille"
              }
            }
          ]
        }
      ]
    },
    {
      "linkId": "referralService",
      "text": "referralService",
      "answer": [
        {
          "valueString": "CT | MRI"
        }
      ]
    }
  ]
}