Vaccine Injury Report - Truth for Health Foundation

Name *

First

Last

Date

Age

Date of Birth

Sex

Email *

Best Contact Number

Have you sought legal counsel for your vaccine injury?

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

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

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):

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?

What type of insurance do you have?

Please provide name of Private Insurance Carrier (if any):

Is the filer the same as the injured?

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

Did you have COVID confirmed prior to taking the shot?

Did you have suspected COVID prior to taking the shot?

Did you have COVID after taking the shot?

Reason for taking the shot

If other please provide reason

Shot 1 type *

Shot 1 date received (if known)

Shot 1 Lot number (if known)

Shot 2 type (if taken)

Shot 2 date received (if known)

Shot 2 Lot number (if known)

Shot 3 type (if taken)

Shot 3 date received (if known)

Shot 3 Lot number (if known)

Shot 4 type (if taken)

Shot 4 date received (if known)

Shot 4 Lot number (if known)

Shot 5 type (if taken)

Shot 5 date received (if known)

Shot 5 Lot number (if known)

Shot 6 type (if taken)

Shot 6 date received (if known)

Shot 6 Lot number (if known)

When did your adverse event or symptoms begin?

Outcome of the adverse event or symptoms (check all that apply) (copy)

Are Symptoms Still Happening

Known allergies to

Description of known allergies

Occupation

Racial background

Were you pregnant at the time of the shot

Have you ever had a vaccine reaction in the past

If so please specify

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

New Onset Conditions

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

Worsening of Existing Conditions

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

Current Prescription Medications: LIST ALL MEDICINES AND DOSES

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

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

Symptoms

Head, Eyes, Ears, Nose, Mouth and Throat

Hematological

Respiratory

Heart and Vascular

Chest and Breast: Applies to women and men

Digestive

Endocrine

Reproductive and Bladder

Musculoskeletal

Skin

Neurological

Psychological Changes

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.

Citizens’ Vaccine Injury Reporting System

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

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

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