Donate Now
Events
Covid Conversations
Child Vaccination
Protocols
Natural Antivirals
Shop
Contact
Events
Covid Conversations
Child Vaccination
Protocols
Natural Antivirals
Shop
Contact
Donate Now
Vaccine Injury Form
CIIHA
>
Vaccine Injury Form
Vaccine Injury Reporting System
This form aims to identify injuries sustained as a result of the coronavirus vaccine rollout in our community.
Step
1
of
5
20%
Patient Name
(Required)
Patient Telephone Number
(Required)
Patient Email Address
(Required)
Have you made a compliant to your doctor? If so, please provide the doctors name. If not, just say "No"
(Required)
Patient sex (Optional)
Please Select
Male
Female
Other
Patient date of birth (Optional)
YYYY slash MM slash DD
Patient height (Optional)
Patient weight (Optional)
Patient ethnicity (Optional)
Please let us know about the vaccine that you suspect to have caused the reaction(s). If you have had multiple COVID-19 vaccines, please select from the following:
COVID-19 mRNA Vaccine BNT162b2 (Pfizer- BioNTech)
Covid-19 Vaccine Moderna
Covid19 Vaccine AstraZeneca
Batch/Lot Number - if not known, enter 'Not Known'
(Required)
Was this your first or second dose?
(Required)
Please select
First
Second
When was the vaccine administered
(Required)
YYYY slash MM slash DD
Please enter the reaction, or reactions, that you think were caused by the vaccine, Please list reactions one at a time.
Since having the vaccine have you (as the patient), or the patient you are reporting about tested positive for COVID-19? (Optional)
Please select
Yes
No
Please further describe the reaction(s), for example sequence of events, any treatment received or any other relevant information (Optional)
Please do not add identifiable patient information to the free text
Please let us know how severely you, or the patient you are reporting about, were affected by the reaction(s)
Not considered serious (Optional)
Mild or slightly uncomfortable (Optional)
Uncomfortable, a nuisance or irritation, but able to carry on with everyday activities (Optional)
Had short term effect was bad enough to everyday activities (Optional)
Caused significant or long term incapacity (Optional)
Significant enough to lead you to seek advice from a healthcare professional (Optional)
Bad enough to be admitted to hospital (Optional)
Caused an abnormality in an unborn child (Optional)
Life threatening (Optional)
Caused death (Optional)
Please let us know if any other medicines were taken, either regularly or irregularly, within the last three months. In particular, the influenza vaccine, medicines for pain, inflammation, high blood pressure or those used in relation to COVID-19 (Optional)
Name of medicine(s)
(Required)
Reason for taking the medicine(s) (Optional)
When was the medicine administered? (Optional)
YYYY slash MM slash DD
When did you stop taking the medicine? (Optional)
YYYY slash MM slash DD
We would like to know if you have any illnesses, or are taking any medicines, that might affect your immune response. Please enter below (Optional)
Please provide any relevant medical history details (Optional)
Have you (as the patient), or the patient you are reporting about, had symptoms associated with COVID-19?
(Required)
Please select
Yes
No
Have you (as the patient), or the patient you are reporting about, tested positive for COVID-19?
(Required)
Please select
Yes
No
Date of COVID-19 test (Optional)
YYYY slash MM slash DD
Are you (as the patient), or the patient you are reporting about, currently enrolled in a study or clinical trial? Note that sponsors should continue to report via established routes for clinical trials
(Required)
Please select
Yes
No
If yes, please provide any details, such as the EudraCT number and/or the study name, if known, and the investigational drug (Optional)
By using this form you agree with the storage and handling of your data by this website.
(Required)
Yes I agree
CAPTCHA
