Repository for Vaccine Adverse Effects V4.1.60

Vaccine Side-effects >> Public Entered Symptoms

Patient Details

Patient's country of residence      This field is mandatory.  
State/Prov/Area of residence 
Gender that patient identifies with 
Female   This field is mandatory.  
Male  
Other  
Unknown  
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Patient's age group      This field is mandatory.  
Ethnicity/Race         This field is mandatory.  
Did the patient previously have COVID? 
Yes   This field is mandatory.  
No  
Unknown  
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If YES, how many months ago? 
If military member, select status 
Active Duty  
Reserve Member  
Veteran  
Other status     
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This form completed by    

Vaccines Administered During Office Visit

Vaccine Name  Manufacturer  Lot Number  Dose No. 
Enter all vaccines received (during the same office visit or as part of a set) that you believe could be responsible for the reported side-effect. 
       
    This field is mandatory.       This field is mandatory.       This field is mandatory.  
        
        
       

Include the above comment on the website's chart page? (Viewable to the public) 

Symptom Identification

Did the symptoms appear suddenly or start gradually?       
How long did the side effects last?    
Is there anything you found that reduces the symptoms? 
200 Character Limit; 200 Remaining
Were you informed about possible side-effects before receiving the vaccine? 
Yes - from the news  
Yes - from my primary-care physician  
Yes - from health care staff before vaccination  
No  

Clinic Location

Facility/Clinic name where vaccination received   This field is mandatory.  
Type of facility         This field is mandatory.  
Address of facility  (Enter any part of address & click 'Locate' to display map.) 
 

Enter address, city or state/province in the above field and click the 'Locate' button.
     
If treatment was required, enter the 2 fields below.   
     
Name of facility where treatment was received 
Length of time treatment was required (Days) 

Pre-existing Conditions

Please select any ailments that you had prior to accepting your most recent vaccine. If possible, check all that apply. 
   
Allergies 
Click here to select Allergy Types
Certain medications  
Clothing / fabics  
Food  
Latex  
Metals / jewelry  
Pets (Cats or Dogs)  
Pollen / dust / smoke  
Other allergy  
Heart Problems 
Click here to select Cardiac Problems
Angina  
Bypass  
Congestive heart failure  
Heart murmur  
High blood pressure  
High cholesterol  
Other heart related issue  
Diabetes 
Type 1  
Type 2  
Clear
Skin disorder 
Click here to select Skin issues
Chronic bruising  
Psoriasis  
Rosacea / redness  
Rashes / hives / shingles  
Other skin condition  
Degenerative disease 
Click here to select Degenerative Disorders
ALS  
Alzheimer's  
Huntington's  
Multiple Sclerosis  
Muscular Dystrophy  
Osteoporosis  
Parkinson's  
Rheumatoid Arthritis  
Other degenerative disorder  
Cancer 
Click here to select Cancer Types
Bowel / Colon  
Bone  
Brain  
Breast  
Leukemia  
Lymphoma  
Organ  
Skin  
Prostate  
Other cancer  
Other conditions 
Click here to select Other Pre-existing Conditions
Arthritis / joint pain  
Asthma  
Chronic Obstructive Pulmonary Disease (COPD)  
Hormonal imbalance  
Immunodeficiency  
Mental health condition  
Overweight  
Underweight  
Sleep apnea  

Were you pressured to get vaccinated in order to:

Keep your job  Employment industry:    
Attend school  Type of education:    
Travel  Type of travel:    
Play sports  Level of sport:    
Attend events     
Appease Family   
Other  Specify other reason 

Contact Information (optional)

I would like my name and contact information to be linked to this report.  
  Full Name 
  Email Address 
  Cell Number for Text Messages 


Description

    
Please provide a detailed description about the side effects that were experienced after receiving the vaccine.


Symptom Information Ref #: 1633219

 

SAMPLE FORM

This page is a sample form used to report vaccine side-effects at VaxxTracker.com. Close this browser window and return to the confirmation page.

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Source This field is automatically filled in based on the originating source where this form was loaded from.
Online Reporting   
Entry Method This field is automatically filled in based on the method that was used to access the entry form.
  
Mandatory
Vaccination Date Enter the date that the patient received the vaccination that is believed to be responsible for the adverse reaction entered below.
  
Mandatory
Date Issue First Discovered Select the date that the adverse reaction (side-effect) was first noticed.
  
Mandatory
Date Reported to Doctor If applicable, enter the date that the physician (or medical staff) was first made aware of the symptoms.
Referral Source Select the type of event. An event type cannot be selected that is not assigned to the selected category.
Loading previously selected types
Select a type using the drop down or search box below.
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Severity of Side-effect Select the severity that best describes how the symptoms affected your overall health and wellbeing.
  
Mandatory
External ID This field is used to store an optional referrence number that links to your external documentation.

Outcomes

    
Select the outcome for this event from those listed below.
Loading Outcomes


SAMPLE FORM

This page is a sample form used to report vaccine side-effects at VaxxTracker.com. Close this browser window and return to the confirmation page.