Medical - Legal Help, Uncategorized, VaccineCVIRS – Citizens’ Vaccine Injury Reporting SystemDr. Lee VlietUpdated on January 29, 2024December 12, 2020 Share Vax Injury Medical Questionnaire Please enable JavaScript in your browser to complete this form.Contact Info & Consent - Step 1 of 14Name *FirstLastDateAgeDate of BirthSexSelect ResponseMaleFemaleEmail *Best Contact NumberHave you sought legal counsel for your vaccine injury?NoYesDo you feel your vaccine injury is something that should be pursued legally?YesNoMay our Truth for Health Foundation team contact you about your vaccine injury?YesNoNextSave and Continue LaterPlease provide the type of facility where your vaccine shot (s) were administered (Check ALL that apply if you have had more than one shot):PharmacyHospitalDoctor's OfficeGrocery storeChurchVaccination Drive-through programPlace of EmploymentOther (List below)Please provide names of the facility or facilities where your vaccine shot(s) were administered:Did the facility where your vaccine was administered ask you to show your INSURANCE CARD?YesNoWhat type of insurance do you have?MedicaidMedicareTri-CareVA (Veterans Administration)Private Insurance (List Carrier Below)Please provide name of Private Insurance Carrier (if any):Is the filer the same as the injured?Select ResponseYesNoIf not, please provide your name, contact info (copy)NextSave and Continue LaterDid you have COVID confirmed prior to taking the shot?Select ResponseYesNoDid you have suspected COVID prior to taking the shot?Select ResponseYesNoDid you have COVID after taking the shot?Select ResponseYesNoReason for taking the shotSelect ResponseEmployer mandateMilitary mandateDesire to prevent infectionDesire to protect othersTravelFamily pressureSocial pressureCollege/University requirementNursing home requirementAssisted Living requirementRetirement Community requirementOtherIf other please provide reasonShot 1 type *PfizerModernaJohnson & JohnsonAstra ZenecaSinovacCovaxinCovishieldShot 1 date received (if known)Shot 1 Lot number (if known)Shot 2 type (if taken)PfizerModernaJohnson & JohnsonAstra ZenecaSinovacCovaxinCovishieldShot 2 date received (if known)Shot 2 Lot number (if known)Shot 3 type (if taken)PfizerModernaJohnson & JohnsonAstra ZenecaSinovacCovaxinCovishieldShot 3 date received (if known)Shot 3 Lot number (if known)Shot 4 type (if taken)PfizerModernaJohnson & JohnsonAstra ZenecaSinovacCovaxinCovishieldShot 4 date received (if known)Shot 4 Lot number (if known)Shot 5 type (if taken)PfizerModernaJohnson & JohnsonAstra ZenecaSinovacCovaxinCovishieldShot 5 date received (if known)Shot 5 Lot number (if known)Shot 6 type (if taken)PfizerModernaJohnson & JohnsonAstra ZenecaSinovacCovaxinCovishieldShot 6 date received (if known)Shot 6 Lot number (if known)NextSave and Continue LaterWhen did your adverse event or symptoms begin?Outcome of the adverse event or symptoms (check all that apply) (copy)Visit to doctor or other health professional’s officeVisit to emergency room or urgent care centerHospitalizationProlonged Hospitalization (COVID shot received in hospital)Life threatening illnessDisability or permanent damagePatient DiedCongenital anomaly or birth defectMiscarriage or still birthNone of the aboveAre Symptoms Still HappeningSelect ResponseYesNoKnown allergies to MedicationsPolyethylene glycolFoodEnvironmentalOtherDescription of known allergiesOccupationRacial backgroundSelect ResponseBlackHispanicCaucasianAsianNative AmericanOtherWere you pregnant at the time of the shotSelect ResponseYesNoHave you ever had a vaccine reaction in the pastSelect ResponseYesNoIf so please specifyNextSave and Continue LaterMedical Conditions: NEW ONSET since your COVID shot (check all that apply)New Onset ConditionsAddison's DiseaseAllergiesArrhythmiasAtrial FibrillationAutoimmune vasculitisBell's Palsy (facial paralysis)BronchitisCancerCeliac Disease (gluten intolerance)Chronic kidney diseaseChronic Obstructive Pulmonary DiseaseCongestive Heart FailureCrohn's DiseaseDVT (blood clots)DiabetesEncephalitis (brain inflammation/headaches)Epilepsy (seizures)Heart DiseaseHerpes Type 1Herpes Type 2HIVHypertension (High Blood Pressure)Inflammatory Bowel DiseaseKidney disease, acuteLiver DiseaseLupusMiscarriageMultiple sclerosisMyasthenia gravisMyocardial infarction (heart attack)MyocarditisOsteoarthritisPericarditisPernicious AnemiaPneumoniaPreterm laborPsoriasisPsoriatic arthritisPulmonary embolismRheumatoid ArthritisShinglesSjogren's syndromeStill birthStrokeTransient Ischemic Attacks (TIA)Thyroid DisorderUlcerative ColitisSince the COVID shot have you had WORSENING of any of the following EXISTING medical problems?Worsening of Existing ConditionsAddison's DiseaseAllergiesArrhythmiasAtrial FibrillationAutoimmune vasculitisBronchitisCancerCeliac Disease (gluten intolerance)Chronic Kidney DiseaseChronic Obstructive Pulmonary DiseaseCongestive Heart FailureCrohn's DiseaseDiabetesEpilepsy (seizures)Herpes Type 1Herpes Type 2HIVHypertension (High Blood Pressure)Inflammatory Bowel DiseaseKidney disease, chronicLiver DiseaseLupusMultiple sclerosisMyasthenia gravisMyocardial infarction (heart attack)MyocarditisOsteoarthritisPericarditisPernicious AnemiaPneumoniaPsoriasisPsoriatic arthritisRheumatoid ArthritisShinglesSjogren's syndromeStrokeTransient Ischemic Attacks (TIA)Thyroid DisorderUlcerative ColitisOther Conditions Not ListedIf you developed a new cancer or recurrence of an existing cancer after the COVID shot please specify the type of cancerNextSave and Continue LaterCurrent Prescription Medications: LIST ALL MEDICINES AND DOSESNew prescription medications that had to be started after the COVID shot(s)NextSave and Continue LaterSINCE THE COVID SHOT, have you had any of the following symptoms?SymptomsCOVID symptoms or COVID IllnessDecline in wellbeingDecline in health statusExtreme fatigueInability to participate in routine activitiesLoss of energyUnexplained painWeaknessUnexplained feversUnexplained body sensationsNight sweatsHot flashesCold intoleranceHeat intoleranceSensitive to temperature changesChange in ability to walkChange in thinkingI no longer feel the way I used toUnexplained weight gainUnexplained weight lossFragmented SleepCan't sleepInsomniaNextSave and Continue LaterHead, Eyes, Ears, Nose, Mouth and ThroatHeadaches, "fullness" inside headHeadaches, migraineHeadaches, tensionHeadaches, throbbingHeadaches, otherDry or burning eyesTunnel visionBlurred visionLoss of vision"Floaters"Visual painConjunctivitis (red eyes)Discharge from eyesLoss of tasteLoss of smellSensitive to lightSensitive to soundSinusitisSore throatHoarsenessMetallic tasteWhite patches on tongueTonsillitisChronic ear infectionsRinging in the earsPain in mouthSore tongueUlcers in mouthBlisters in mouthChanges to tongueUlcers on tongueBlisters on tongueDry mouthTrouble swallowing"Lump in the throat"NextSave and Continue LaterHematologicalLow white blood cellsLow hemoglobinLow hematocritLow red blood cellsLow plateletsHigh white blood cellsHigh hemoglobinHigh hematocritHigh D-DimerElevated TroponinAbnormal cellsChange in liver functionChange in kidney functionRespiratoryShortness of breathPainful breathingDifficulty breathing during activityWheezingRecurrent infectionsRecurrent colds, fluUnexplained coughCoughing up bloodHeart and VascularChest pain or pressureHeart palpitationsIrregular heartbeatRapid heart ratePounding heartSlow heart rateMurmurPain running up left armPain in left jawLow blood pressureHigh blood pressureHigh cholesterolBlood clotsVericose veinsPain in leg(s)Chest and Breast: Applies to women and menNew lumps in breast(s)Sore, or swollen breastsDischarge from breastsNipple swelling/painChanges to skin of nipplesRash on the breastRash on chestDigestiveUnexplained loss of appetiteUnusual increase in appetiteIndigestionGasNauseaDiarrheaConstipationVomitingVomiting bloodAbdominal pain/crampingRectal painBlood in stoolHemorrhoidsJaundiceBrittle and ridged nailsBleeding gumsEndocrineLow blood sugarHigh blood sugarThinning scalp hairLoss of body hairExcess body hairDecreased sweatingIncreased sweatingSlow metabolismAbnormal weight gainUnexplained weight lossHeat intoleranceCold intoleranceHot flashesNight sweatsSkin discolorationNextSave and Continue LaterReproductive and BladderBladder infectionsFrequent urinationUrinary leakageUrgency to urinatePain on urinationBlood in urineClots in urineDifficulty urinatingRecurrent bladder infectionsRecurrent yeast infectionsIncontinenceMass in bladderBlood clots in bladderDryness of vaginaPeriods have stoppedIrregular periodsLight periodsHeavy periodsClotting with periodsExcessively painful periodsProlonged postpartum bleedingErectile dysfunctionPenile painFertility changesMiscarriagesNextSave and Continue LaterMusculoskeletalJoint painBackacheNeck painLoss of heightNumbness and tinglingRestless legs in sleepLeg painHip painBone painSore musclesReduced range of motionStiff jointsDifficulty walkingMuscle spasmsMuscle twitchesMuscle weaknessSkinAcneBoils, blistersBruisingCystsDry/scaly skinEczemaHivesItching, crawling skinMole(s) changesPigment changesRashesWounds not healingNextSave and Continue LaterNeurologicalNew onset seizuresTremblingTwitchingNumbnessTinglingBurning sensationsElectric shock sensations"Pins and needles" sensationCrawling sensationInvoluntary muscle contractionsUnexplained painLoss of strengthDifficulty moving bodyClumsinessChange in balanceLoss of coordinationDizzinessVertigoFainting spellsBrain "Fog"Difficulty concentratingConfusionForgetfulness/Memory lossSlowed speechInsomniaRestless, fragmented sleepSleepiness (daytime)Brain lesionsNextSave and Continue LaterPsychological ChangesAggressionAnger outburstsIrritabilityAnxiety attacksAbnormal thoughtsDepressionExcessive fearObsession/compulsionsHopelessnessSocial withdrawalElevated moodMood swingsDespairPanic attacksSuicidal thoughtsSuspiciousnessNightmaresSleepwalkingIncreased worryCrying spellsGuilt feelingsNextSave and Continue LaterAdditional Comments:Upon submission of the COVID Shot Adverse Event Report to Truth For Health Foundation we will add you to our E-mail list to receive alerts and reports on our work. This list is managed by MailChimp and you may unsubscribe at any time.SubmitSave and Continue Later Your form entry has been saved and a unique link has been created which you can access to resume this form. Enter your email address to receive the link via email. Alternatively, you can copy and save the link below. Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted. Copy Link Email * Send Link
