---
type: "example"
title: "Questionnaire Example: questionnaire-example-gcs"
resource: "Questionnaire"
example: "questionnaire-example-gcs"
---
# Questionnaire Example: questionnaire-example-gcs

## Example XML



```xml
<?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>
  <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="FHIR Project team"/>
  <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>
```