---
type: "example"
title: "Questionnaire Example: questionnaire-example-f201-lifelines"
resource: "Questionnaire"
example: "questionnaire-example-f201-lifelines"
---
# Questionnaire Example: questionnaire-example-f201-lifelines

## Narrative

Lifelines Questionnaire 1 part 1
  1. Do you have allergies?
  2. General Questions:
    2.a) What is your gender?
    2.b) What is your date of birth?
    2.c) What is your country of birth?
    2.d) What is your marital status?
    3. Intoxications:
      3.a) Do you smoke?
      3.b) Do you drink alcohol?

## Example XML



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

<Questionnaire xmlns="http://hl7.org/fhir">
  <id value="f201"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">
      
      <pre>Lifelines Questionnaire 1 part 1
  1. Do you have allergies?
  2. General Questions:
    2.a) What is your gender?
    2.b) What is your date of birth?
    2.c) What is your country of birth?
    2.d) What is your marital status?
    3. Intoxications:
      3.a) Do you smoke?
      3.b) Do you drink alcohol?</pre>
    
    </div>
  </text>
  <url value="http://hl7.org/fhir/Questionnaire/f201"/>
  <identifier>
    <system value="urn:ietf:rfc:3986"/>
    <value value="urn:oid:2.16.840.1.113883.4.642.20.6"/>
  </identifier>
  <status value="active"/>
  <subjectType value="Patient"/>
  <date value="2010"/>
  <code>
    <system value="http://example.org/system/code/lifelines/nl"/>
    <code value="VL 1-1, 18-65_1.2.2"/>
    <display value="Lifelines Questionnaire 1 part 1"/>
  </code>
  <item>
    <linkId value="1"/>
    <text value="Do you have allergies?"/>
    <type value="boolean"/>
  </item>
  <item>
    <linkId value="2"/>
    <text value="General questions"/>
    <type value="group"/>
    <item>
      <linkId value="2.1"/>
      <text value="What is your gender?"/>
      <type value="string"/>
    </item>
    <item>
      <linkId value="2.2"/>
      <text value="What is your date of birth?"/>
      <type value="date"/>
    </item>
    <item>
      <linkId value="2.3"/>
      <text value="What is your country of birth?"/>
      <type value="string"/>
    </item>
    <item>
      <linkId value="2.4"/>
      <text value="What is your marital status?"/>
      <type value="string"/>
    </item>
  </item>
  <item>
    <linkId value="3"/>
    <text value="Intoxications"/>
    <type value="group"/>
    <item>
      <linkId value="3.1"/>
      <text value="Do you smoke?"/>
      <type value="boolean"/>
    </item>
    <item>
      <linkId value="3.2"/>
      <text value="Do you drink alchohol?"/>
      <type value="boolean"/>
    </item>
  </item>
</Questionnaire>
```