CVIRS - Citizens' Vaccine Injury Reporting System

Vax Injury Medical Questionnaire

Contact Info & Consent - Step 1 of 14

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?

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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?

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?

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

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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)

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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 Happening

Known allergies to

Medications
Polyethylene glycol
Food
Environmental
Other

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

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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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CVIRS – 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?

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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?

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