New Post-COVID Vax Injury History

New Post-COVID Vax Injury History

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 Sex

Post-COVID Vax History

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?

COVD-19 Vaccination History

How many COVID vaccines have you had?
Which initial series did you have?

COVID-19 Infection History

How many times do you think that you have had a COVID-19 infection, regardless of any test results?
How many COVID-like illnesses have you had during which you tested positive for COVID-19 infection?
How fully have you recovered from that most recent COVID infection?
When were you first treated for your most recent COVID-19 infection?
Were you hospitalized for your COVID-19 infection?
Were you hospitalized in intensive care for your COVID-19 infection?
Did you require a mechanical ventilator to breathe when you hospitalized in intensive care for your COVID-19 infection?
Did you receive any prescription medications for the treatment of your COVID-19 infection at the time of it? Check all that apply.
Did you receive any non-prescription medications for the treatment of your COVID-19 infection at the time of it? Check all that apply
How long after you started treatment was it until you began to feel better?

Review Of Symptoms

General Symptoms (check all that apply)
Neurological symptoms (check all that apply)
Psychological symptoms (check all that apply)
Decreased mobility due to pain or arthritis of hands, back, hips, or knees
Heart symptoms (check all that apply)
Respiratory symptoms
Blood clotting disorders
Digestive symptoms (click all that apply)
New onset autoimmune symptoms (click all that apply)
Reproductive symptoms (check all that apply)
New or recurrent cancer

General Health

Social History

Do you have a spouse or significant other relationship at this time?
Are you employed, attending school, or doing volunteer work at this time? Check all that apply.

Maximum file size: 25MB

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