How Many? Please list all COVID-19 Injections received
None 1 2 3 or more
COVID-19 Injection History (list all) Provide as much information as possible,
please
How has your health been impacted by each of these shots?
Have you received a diagnosis from a licensed health professional for any of the changes in your
health?
If so, what were the dates and diagnoses you received? What treatments have you received or used for
each of
these diagnoses? Please provide as much information as possible.
Have you been told by a licensed health professional that your difficulties are related to COVID-19
injections? Please provide as much detail as possible.
What is your current health status? Please indicate any chronic (long-standing) conditions that you
have
and any medications you take.
Please provide any additional information you think might be relevant.
Are you currently receiving treatment for any new conditions which developed after COVID-19
injections?
Yes No
Was there any change in conditions you were experiencing before you received COVID-19 Injections? If so,
please describe in as much detail as possible.
Please describe in as much detail as possible your reactions and responses to each COVID-19
injection.
Prior(Pre-COVID-19 Injection) Health Conditions and Concerns
Current Health Conditions and Conditions
Please indicate any serious conditions which you have had in the past but no longer have (asthma,
cancer,
hepatitis, etc.) and indicate treatment received (none, chemotherapy and radiation, immunoglobulin,
etc.)
Did you receive one or more new medical diagnosis after receiving COVID-19 Injection(s)? If so, what
were
the dates and diagnoses you received? What treatments have you received or used for each of these
diagnoses.
Please provide as much information as possible
Did you develop new problems or difficulties which did not receive a medical diagnosis after
receiving
COVID-19 Injection(s)? If so, please describe those problems or difficulties and any treatments you
received or
have used for each of these diagnoses.
Has/have your current condition(s) been identified as Post COVID-19 Vaccine-induced or Post COVID-19
Vaccine-Related by a Licensed Health Professional? If so, please provide details.
What is your current health status? Please indicate any chronic (long-standing) conditions that you
have
and any medications you take.
Please indicate how any pre-existing conditions changed (got worse, got better, etc.) after COVID-19
injections, if any, or contact with injected people if you have not had any COVID-19 injections)
Please list all prescription and Over the Counter (OTC)medications
Please list each drug you take, the dosage and the number of times per day you take it. (For separation you can use "," for exp: covaxinl, covexin2)
Are you in contact with people who had the COVID-19 Injection?
Yes No
What is your relationship with each of the COVID-19 injected people you live, work or socialize with? (For example, spouse, caregiver, co-workers, roommates, etc.)
Please list all prescription and Over the Counter (OTC)medications Please list your symptoms in rank order (most significant first, least significant last) and indicate
a
number from 1-10 next to the symptom (1 = barely noticeable, 10 = as intense as possible)
1 2 3 4 5 6 7 8 9 10
Please provide any additional information you think might be relevant.
How has your health been impacted by close contact with one or more people who received COVID-19
injections? Please provide as much information as possible.
Have you received a diagnosis from a licensed health professional for any of the changes in your
health? If so, what were the dates and diagnoses you received? What treatments have you received or used
for each of these diagnoses? Please provide as much information as possible.
Have you been told by a licensed health professional that your difficulties are related to COVID-19
injections? Please provide as much detail as possible.
What is your current health status? Please indicate any chronic (long-standing) conditions that you have
and any medications you take.
Please provide any additional information you think might be relevant.
