Post-Vaccination Questionnaire
When did you get vaccinated?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What type of dose did you received?
First Dose
Second Dose
What type of vaccine did you get?
Johnson&Johnson
Moderna
Pfizer
Other
Kindly rate the process of receiving the vaccine? 10-highest and 1-lowest
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Within 24 hours, what are the discomforts you felt after receiving the vaccine within? Please describe below:
Please select the side effects you experienced: (Select all that apply)
Tenderness at the injection site
Swelling at the injection site
Redness at the injection site
Headache or Muscle Ache
Joint Pain
Chills
Nausea
Vomiting
Tiredness
Fever (temperature above 37.8°C)
Other
In regards to the question above, how long did the side effects persists? (Number of hours or number of days)
Did you need experienced any allergic reaction?
Yes
No
Any comments, suggestions, or feedback
What is your age?
What is your gender?
Male
Female
What is your race?
What is your ethnicity?
Submit
Should be Empty: