CVIRS – Citizens’ Vaccine Injury Reporting System

A comprehensive diagnostic tool designed by Truth For Health to identify patterns of vaccine induced damage across the population. The full report can take up to 30 minutes to complete. Be as complete as possible. The information you provide is critical in quantifying injury. Your responses will remain CONFIDENTIAL, anonymous, and the information you provide will not be shared outside of Truth For Health Foundation.

Contact Info & Consent - Step 1 of 14

Name *

First

Last

Date

Age

Date of Birth

SexSelect ResponseMaleFemale

Email *

Best Contact Number

Have you sought legal counsel for your vaccine injury?NoYes

Do you feel your vaccine injury is something that should be pursued legally?YesNo

May our Truth for Health Foundation team contact you about your vaccine injury?YesNo

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Please provide the type of facility where your vaccine shot (s) were administered (Check ALL that apply if you have had more than one shot):

• Pharmacy
• Hospital
• Doctor's Office
• Grocery store
• Church
• Vaccination Drive-through program
• Place of Employment
• Other (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?YesNo

What type of insurance do you have?

• Medicaid
• Medicare
• Tri-Care
• VA (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 ResponseYesNo

If not, please provide your name, contact info (copy)

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Did you have COVID confirmed prior to taking the shot?Select ResponseYesNo

Did you have suspected COVID prior to taking the shot?Select ResponseYesNo

Did you have COVID after taking the shot?Select ResponseYesNo

Reason for taking the shotSelect ResponseEmployer mandateMilitary mandateDesire to prevent infectionDesire to protect othersTravelFamily pressureSocial pressureCollege/University requirementNursing home requirementAssisted Living requirementRetirement Community requirementOther

If other please provide reason

Shot 1 type *PfizerModernaJohnson & JohnsonAstra ZenecaSinovacCovaxinCovishield

Shot 1 date received (if known)

Shot 1 Lot number (if known)

Shot 2 type (if taken)PfizerModernaJohnson & JohnsonAstra ZenecaSinovacCovaxinCovishield

Shot 2 date received (if known)

Shot 2 Lot number (if known)

Shot 3 type (if taken)PfizerModernaJohnson & JohnsonAstra ZenecaSinovacCovaxinCovishield

Shot 3 date received (if known)

Shot 3 Lot number (if known)

Shot 4 type (if taken)PfizerModernaJohnson & JohnsonAstra ZenecaSinovacCovaxinCovishield

Shot 4 date received (if known)

Shot 4 Lot number (if known)

Shot 5 type (if taken)PfizerModernaJohnson & JohnsonAstra ZenecaSinovacCovaxinCovishield

Shot 5 date received (if known)

Shot 5 Lot number (if known)

Shot 6 type (if taken)PfizerModernaJohnson & JohnsonAstra ZenecaSinovacCovaxinCovishield

Shot 6 date received (if known)

Shot 6 Lot number (if known)

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When 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 office
• Visit to emergency room or urgent care center
• Hospitalization
• Prolonged Hospitalization (COVID shot received in hospital)
• Life threatening illness
• Disability or permanent damage
• Patient Died
• Congenital anomaly or birth defect
• Miscarriage or still birth
• None of the above

Are Symptoms Still HappeningSelect ResponseYesNo

Known allergies to

• Medications
• Polyethylene glycol
• Food
• Environmental
• Other

Description of known allergies

Occupation

Racial backgroundSelect ResponseBlackHispanicCaucasianAsianNative AmericanOther

Were you pregnant at the time of the shotSelect ResponseYesNo

Have you ever had a vaccine reaction in the pastSelect ResponseYesNo

If so please specify

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Medical Conditions: NEW ONSET since your COVID shot (check all that apply)

New Onset Conditions

• Addison's Disease
• Allergies
• Arrhythmias
• Atrial Fibrillation
• Autoimmune vasculitis
• Bell's Palsy (facial paralysis)
• Bronchitis
• Cancer
• Celiac Disease (gluten intolerance)
• Chronic kidney disease
• Chronic Obstructive Pulmonary Disease
• Congestive Heart Failure
• Crohn's Disease
• DVT (blood clots)
• Diabetes
• Encephalitis (brain inflammation/headaches)
• Epilepsy (seizures)
• Heart Disease
• Herpes Type 1
• Herpes Type 2
• HIV
• Hypertension (High Blood Pressure)
• Inflammatory Bowel Disease
• Kidney disease, acute
• Liver Disease
• Lupus
• Miscarriage
• Multiple sclerosis
• Myasthenia gravis
• Myocardial infarction (heart attack)
• Myocarditis
• Osteoarthritis
• Pericarditis
• Pernicious Anemia
• Pneumonia
• Preterm labor
• Psoriasis
• Psoriatic arthritis
• Pulmonary embolism
• Rheumatoid Arthritis
• Shingles
• Sjogren's syndrome
• Still birth
• Stroke
• Transient Ischemic Attacks (TIA)
• Thyroid Disorder
• Ulcerative Colitis

Since the COVID shot have you had WORSENING of any of the following EXISTING medical problems?

Worsening of Existing Conditions

• Addison's Disease
• Allergies
• Arrhythmias
• Atrial Fibrillation
• Autoimmune vasculitis
• Bronchitis
• Cancer
• Celiac Disease (gluten intolerance)
• Chronic Kidney Disease
• Chronic Obstructive Pulmonary Disease
• Congestive Heart Failure
• Crohn's Disease
• Diabetes
• Epilepsy (seizures)
• Herpes Type 1
• Herpes Type 2
• HIV
• Hypertension (High Blood Pressure)
• Inflammatory Bowel Disease
• Kidney disease, chronic
• Liver Disease
• Lupus
• Multiple sclerosis
• Myasthenia gravis
• Myocardial infarction (heart attack)
• Myocarditis
• Osteoarthritis
• Pericarditis
• Pernicious Anemia
• Pneumonia
• Psoriasis
• Psoriatic arthritis
• Rheumatoid Arthritis
• Shingles
• Sjogren's syndrome
• Stroke
• Transient Ischemic Attacks (TIA)
• Thyroid Disorder
• Ulcerative Colitis

Other Conditions Not Listed

If you developed a new cancer or recurrence of an existing cancer after the COVID shot please specify the type of cancer

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Current Prescription Medications: LIST ALL MEDICINES AND DOSES

New prescription medications that had to be started after the COVID shot(s)

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SINCE THE COVID SHOT, have you had any of the following symptoms?

Symptoms

• COVID symptoms or COVID Illness
• Decline in wellbeing
• Decline in health status
• Extreme fatigue
• Inability to participate in routine activities
• Loss of energy
• Unexplained pain
• Weakness
• Unexplained fevers
• Unexplained body sensations
• Night sweats
• Hot flashes
• Cold intolerance
• Heat intolerance
• Sensitive to temperature changes
• Change in ability to walk
• Change in thinking
• I no longer feel the way I used to
• Unexplained weight gain
• Unexplained weight loss
• Fragmented Sleep
• Can't sleep
• Insomnia

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Head, Eyes, Ears, Nose, Mouth and Throat

• Headaches, "fullness" inside head
• Headaches, migraine
• Headaches, tension
• Headaches, throbbing
• Headaches, other
• Dry or burning eyes
• Tunnel vision
• Blurred vision
• Loss of vision
• "Floaters"
• Visual pain
• Conjunctivitis (red eyes)
• Discharge from eyes
• Loss of taste
• Loss of smell
• Sensitive to light
• Sensitive to sound
• Sinusitis
• Sore throat
• Hoarseness
• Metallic taste
• White patches on tongue
• Tonsillitis
• Chronic ear infections
• Ringing in the ears
• Pain in mouth
• Sore tongue
• Ulcers in mouth
• Blisters in mouth
• Changes to tongue
• Ulcers on tongue
• Blisters on tongue
• Dry mouth
• Trouble swallowing
• "Lump in the throat"

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Hematological

• Low white blood cells
• Low hemoglobin
• Low hematocrit
• Low red blood cells
• Low platelets
• High white blood cells
• High hemoglobin
• High hematocrit
• High D-Dimer
• Elevated Troponin
• Abnormal cells
• Change in liver function
• Change in kidney function

Respiratory

• Shortness of breath
• Painful breathing
• Difficulty breathing during activity
• Wheezing
• Recurrent infections
• Recurrent colds, flu
• Unexplained cough
• Coughing up blood

Heart and Vascular

• Chest pain or pressure
• Heart palpitations
• Irregular heartbeat
• Rapid heart rate
• Pounding heart
• Slow heart rate
• Murmur
• Pain running up left arm
• Pain in left jaw
• Low blood pressure
• High blood pressure
• High cholesterol
• Blood clots
• Vericose veins
• Pain in leg(s)

Chest and Breast: Applies to women and men

• New lumps in breast(s)
• Sore, or swollen breasts
• Discharge from breasts
• Nipple swelling/pain
• Changes to skin of nipples
• Rash on the breast
• Rash on chest

Digestive

• Unexplained loss of appetite
• Unusual increase in appetite
• Indigestion
• Gas
• Nausea
• Diarrhea
• Constipation
• Vomiting
• Vomiting blood
• Abdominal pain/cramping
• Rectal pain
• Blood in stool
• Hemorrhoids
• Jaundice
• Brittle and ridged nails
• Bleeding gums

Endocrine

• Low blood sugar
• High blood sugar
• Thinning scalp hair
• Loss of body hair
• Excess body hair
• Decreased sweating
• Increased sweating
• Slow metabolism
• Abnormal weight gain
• Unexplained weight loss
• Heat intolerance
• Cold intolerance
• Hot flashes
• Night sweats
• Skin discoloration

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Reproductive and Bladder

• Bladder infections
• Frequent urination
• Urinary leakage
• Urgency to urinate
• Pain on urination
• Blood in urine
• Clots in urine
• Difficulty urinating
• Recurrent bladder infections
• Recurrent yeast infections
• Incontinence
• Mass in bladder
• Blood clots in bladder
• Dryness of vagina
• Periods have stopped
• Irregular periods
• Light periods
• Heavy periods
• Clotting with periods
• Excessively painful periods
• Prolonged postpartum bleeding
• Erectile dysfunction
• Penile pain
• Fertility changes
• Miscarriages

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Musculoskeletal

• Joint pain
• Backache
• Neck pain
• Loss of height
• Numbness and tingling
• Restless legs in sleep
• Leg pain
• Hip pain
• Bone pain
• Sore muscles
• Reduced range of motion
• Stiff joints
• Difficulty walking
• Muscle spasms
• Muscle twitches
• Muscle weakness

Skin

• Acne
• Boils, blisters
• Bruising
• Cysts
• Dry/scaly skin
• Eczema
• Hives
• Itching, crawling skin
• Mole(s) changes
• Pigment changes
• Rashes
• Wounds not healing

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Neurological

• New onset seizures
• Trembling
• Twitching
• Numbness
• Tingling
• Burning sensations
• Electric shock sensations
• "Pins and needles" sensation
• Crawling sensation
• Involuntary muscle contractions
• Unexplained pain
• Loss of strength
• Difficulty moving body
• Clumsiness
• Change in balance
• Loss of coordination
• Dizziness
• Vertigo
• Fainting spells
• Brain "Fog"
• Difficulty concentrating
• Confusion
• Forgetfulness/Memory loss
• Slowed speech
• Insomnia
• Restless, fragmented sleep
• Sleepiness (daytime)
• Brain lesions

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Psychological Changes

• Aggression
• Anger outbursts
• Irritability
• Anxiety attacks
• Abnormal thoughts
• Depression
• Excessive fear
• Obsession/compulsions
• Hopelessness
• Social withdrawal
• Elevated mood
• Mood swings
• Despair
• Panic attacks
• Suicidal thoughts
• Suspiciousness
• Nightmares
• Sleepwalking
• Increased worry
• Crying spells
• Guilt feelings

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Additional 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.

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