Initial Evaluation For Post-COVID Vax Syndrome

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Name
Address
Sex
How long after your COVID vaccination did you first develop signs of an adverse reaction, such as fatigue at rest, excessive fatigue after exertion, "brain fog"?
How serious was your adverse vaccination reaction?
When did you first seek medical attention for your COVID vaccine adverse reaction?
Did anyone report your COVID vaccine adverse reaction to the CDC's Vaccine Adverse Event Reporting System (VAERS)?
General Symptoms
Neurological symptoms
Psychological symptoms
Decreased mobility due to pain or arthritis of hands, back, hips, or knees
Heart symptoms
Respiratory symptoms
Blood clotting disorders
Digestive symptoms
Autoimmune symptoms
Reproductive symptoms
New or recurrent cancer?
Overall, how would you rate your level of function?
New or recurrent cancer? (copy)
How many COVID vaccines have you had?
Which initial series did you have?
How many times do you think that you have had a COVID-19 infection, regardless of any test results?
How many illnesses have you had during which you tested positive of COVID-19?
Your age when you had your most recent COVID-19 infection
How long ago did you have your most recent COVID-19 infection?
When were you first treated for your COVID-19 infection?
Were you hospitalized for COVID-19 infection?
What medicines, if any, did you take or get for your COVID-19 infection? Check all that apply.
If you had a COVID-19 infection, how long after you started treatment was it until you considered yourself mostly or fully recovered?

Your height in feet and inches

Did you have any of these chronic conditions before any COVID vaccinations? Check all that apply.
Check if you are allergic to any of these:
Are you a member of any of these high-risk groups?
Do you have health insurance that will pay for common laboratory and x-ray tests performed by in network providers to evaluate you for Post COVID Vax Syndrome?
Your preferred pharmacy:
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This is a form to evaluate Post-COVID Vax Syndrome. Post-COVID Vax Syndrome applies to those who had a reaction to a COVID vaccne and who were never fully recovered after three months. The typical symptoms are (1) feeling fatigued most of the time, especially after physical activity and (2) "brain fog," a feeling of inability to think clearly. In addition to these, there may be other chronic symptoms involving other parts of the body. Many of these same symptoms can also occur as the result of a COVID-19 infection, in which we call it Post-COVID Syndrome. If you think that your symptoms are related to a COVID-19 vaccination from which you never fully recovered, continue with this form. If your symptoms more likely started after a COVID-19 infection, go back to the website and use that form..