Post Vaccination Questionnaire
This is a voluntary survey and designed to help public health understand the possible side effects of COVID-19 vaccine.
1. Which vaccine did you receive?
Pfizer-BioNTech
Moderna
Johnson & Johnson's Janssen
Other
2. Which dose of vaccine did you receive?
First dose
Second dose
3. Your Age
4. Your Gender
Please Select
Male
Female
N/A
5. After receiving the vaccine, did you experience any of the following side effects. (Please select all that apply.)
Pain around the injection site
Swelling on the arm where shot was received
Fever
Chills
Exhausted
Headache
Flu-like symptoms
Muscle pain
Vomiting or nausea
Fast heartbeat
No side effect
Other
6. How long did you experience the side effects?
6-12 hours
12-24 hours
1-2 days
More than 2 days
7. Did you have a severe allergic reaction that required medical intervention?
Yes
No
Please describe this allergic reaction.
8. Please provide further information if you have any.
Please verify that you are human.
*
Submit
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