Repository for Vaccine Adverse Effects V4.1.60

Anaphylaxis (Severe Allergy) >> Difficulty breathing


Symptom Information Ref #: 41560

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Source
Online Reporting   
Entry Method
  
Mandatory
Date First Discovered
  
Mandatory
Date Reported to Doctor
Symptom Type
Severity of Side-effect
  
Mandatory
External ID

Description

    
Please provide a detailed description about the side effects that were experienced after receiving the vaccine.
Include the above comment on the website's chart page? (Viewable to the public) 

Patient Details

Patient's country of residence    
State/Prov/Area of residence 
Gender that patient identifies with 
Female  
Male  
Other  
Clear
Patient's age group    
Ethnicity/Race       
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.  
        
        
       

Symptom Identification

Did your symptoms start gradually or appear suddenly?       
How long did the side effects last?    
Is there anything you found that reduces the symptoms? 
200 Character Limit; 200 Remaining

Outcomes

    
Select the outcome for this event from those listed below.
Temporary Discomfort   
Physician/Clinic Visit   
Emergency Treatment Required   
Admitted to Hospital   
Birth Defect (valid for mothers vaccinated during pregnacy)   
Permanently Disabled   
Death   
Unknown   

Clinic Location

Facility/Clinic where you received the vaccine 
Type of facility       
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
Heart Problems 
Click here to select Cardiac Problems
Diabetes 
Type 1  
Type 2  
Clear
Skin disorder 
Click here to select Skin issues
Degenerative disease 
Click here to select Degenerative Disorders
Cancer 
Click here to select Cancer Types
Other conditions 
Click here to select Other Pre-existing Conditions


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 







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