Vaccine History Form

Vaccine Symptom Form
Full Name*

First NameLast Name
What is your age?*
What is your gender?*
Email Address*
example@example.com
Your State:*
Check the symptoms that you experienced after the COVID-19 vaccine:*

Chest painRespiratory issuesSevere FatigueNumbness / TinglingStrokeMyocarditisSeizuresBrain FogCardiac ArrestPericarditisTremorsCOVID-19Trouble BreathingEncephalitisHemorrhageMenstrual irregularitiesVascular EmergencyGastrointestinal issuesAnaphylaxisShockSyncope or CollapseSevere bronchitisSevere coughingSevere respiratory issuesMiscarriageProblems with PregnancyGuillain-Barre SyndromeTransverse MyelitisAppendicitisMigrainesHemiplegic MigraineParalysis of any kindBells PalsyPulmonary EmbolishMyocardial Infarction
If you had other symptoms you'd like to share, please describe here:
Check if you are on Medicare and/or Medicaid:*

MedicareMedicaidNeither
Do you still experience these symptoms today?*

YesNo
Name and address of healthcare provider(s) who treated you for symptoms:*
Vaccine Date:*

MonthDayYear
Date
Vaccine Manufacturer:*
Vaccine Lot #
Name and address where you received the vaccine:*
How long after the vaccine did you start to experience these symptoms?*

ImmediatelyDays 1-7Days 8-14Days 15-301-3 months3-6 monthsover 6 months
Was a VAERS Report created for your adverse event?

YesNoNot sureYes but I only have temporary IDMy healthcare provider refused to submit a reportMy healthcare provider did not think the vaccine caused my symptomsReport was submitted but haven't heard anything back yet
Please describe the severity of your symptoms (check those that apply):

MildModerateSevereLife-threateningImpacts my life moderatelyImpacts my life greatlyI am unable to work or attend schoolI am unable to perform activities of daily livingI can function but it is difficultI am disabled
Should be Empty:

Vaccine Symptom Form