SIRVA - Shoulder Injury Related to Vaccine Administration

SIRVA Questionnaire
Did you have a COVID-19 related vaccine injury?*

YesNo
Did you experience shoulder pain WITHIN 48 hours of getting the shot?*

YESNO
What year did you get the vaccine?*
Is the vaccine you got listed below?*

YESNO
- Influenza/Flu
- Tetanus – DTaP, Tdap, DTP-hib
- Pertussis – DTaP, TDAP, DTP-hib
- Measles, Mumps and Rubella (MMR)
- Hib – Haemophilus Influenzae Type B
- Chicken Pox – Varicella
- Rotavirus
- HPV
- Hepatitis A
- Pneumococcal – Pneumonia
- Hepatitis B
- Meningococcal/Meningitis
- Polio
Did you see a doctor for treatment of the shoulder injury from the vaccine shot?*

YESNO
Has this been an ongoing problem for at least 6 months or have you had surgery on your shoulder?*

YESNO
In the two years BEFORE you the vaccine shot, did you get any treatment for injuries to that shoulder?*

YESNO
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Should be Empty:

SIRVA Questionnaire