New Post-COVID Vax Injury Patient History – BayCare Medical Group of California

New Post-COVID Vax Injury History

This is a form to evaluate Post-COVID Vax Injury Syndrome, also known as Long COVID. Post-COVID Syndrome Vax Injury Syndrome applies to those who had a COVID vaccine and who were never fully recovered from it 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 symptoms, 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 Infection Syndrome. The two syndromes have similar symptoms since both are probably caused by the persistence of the inflammatory COVID spike protein in various organs of the body, whether the spike protein came from a COVID infection or a COVID vaccine. The persistent spike protein then causes inflammation in various organs, including the heart, lungs, brain, and the blood vessels of those organs. Treatment aims to clear the spike protein and, in the meantime, reduce the inflammation caused by the remaining spike protein. Because the two syndromes are so similar and because many people have persistent spike protein from both infection and vaccination, we often just call it Post COVID Syndrome. If you think that your symptoms are related to a COVID-19 vaccine injury from which you never fully recovered, continue with this form. If your symptoms started after a COVID-19 infection and you had not received any COVID-19 vaccinations, go back to the website and use that form. If you are not sure what caused your symptoms but you have had a COVID vaccine, use this form.

Demographics

Patient First Name

Patient Last Name

Patient Street Address

Patient City

Patient State

Patient Zip Code

Patient Birthdate

Today's Date

Patient Age (click here)

Patient Phone

Patient Email

Patient Sex

Female

Male

COVD-19 Vaccination History

How many COVID vaccines have you had?

One of initial series

Two (initial series)

Initial series plus one booster

Initial series plus two boosters

Initial series plus three or more boosters

Which initial series did you have?

Pfizer

Moderna

Astra Zeneca

Johnson & Johnson

General Health

Please list all of your chronic medical problems besides your Post-COVID Infection Syndrome:

Please list all the times you have had to stay in a hospital overnight, the main reason you were there, and how long you were there:

Please list all the surgical procedures or operations for which you have to be sedated or put to sleep, the dates of those surgeries, and any complications:

Please list all the prescription drugs that you are taking at this time and the reasons that you take them:

Please list all the drugs and foods to which you are allergic:

Social History

Do you have a spouse or significant other relationship at this time?

Yes

Spouse or significant other's first name:

Spouse or significant other's last name:

Are you employed, attending school, or doing volunteer work at this time? Check all that apply.

Briefly, what kind of employment do you have at this time?

Briefly, what kind of school do you attend at this time?

Briefly, what kind of volunteer work do you attend at this time?

Do You Have Any Other Comments Or Questions Or Is There Anything Else That You Wish To Mention?

If you wish to attach any medical records or other files, please drop them here. Maximum of 10 files totaling 25 MB, allowed file types include pdf and jpg.

Maximum file size: 25MB

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Submission Date:

File Name:

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New Post-COVID Vax Injury History

New Post-COVID Vax Injury History

Demographics

Post-COVID Vax History

COVD-19 Vaccination History

COVID-19 Infection History

Review Of Symptoms

General Health

Social History