SIRVA - Shoulder Injury Related to Vaccine Administration | MCTLaw

  • SIRVA Questionnaire

  • Did you have a COVID-19 related vaccine injury?*
  • Did you experience shoulder pain WITHIN 48 hours of getting the shot?*
  • Is the vaccine you got listed below?*
    • 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?*
  • Has this been an ongoing problem for at least 6 months or have you had surgery on your shoulder?*
  • In the two years BEFORE you the vaccine shot, did you get any treatment for injuries to that shoulder?*
  • Should be Empty: