Have you experienced side effects after getting vaccinated? Tell your story here. First Name *Last Name *Email *Nationality *Date of Birth *2124212321222121212021192118211721162115211421132112211121102109210821072106210521042103210221012100209920982097209620952094209320922091209020892088208720862085208420832082208120802079207820772076207520742073207220712070206920682067206620652064206320622061206020592058205720562055205420532052205120502049204820472046204520442043204220412040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519240102030405060708091011120102030405060708091011121314151617181920212223242526272829303132Race *American IndianAsianBlackHispanicNative HawaiianWhiteOtherSex *FemaleMaleDate of Vaccination *Reason For Vaccination Took one for the team, voluntaryEmployer mandateMilitary mandatePrison mandateOther reasonWhere did you get Vaccinated? *Facility Website URL Vaccine Type *COVID19 AstraZenecaCOVID19 JanssenCOVID19 ModeRNACOVID19 Pfizer-BioNTechHPV Gardasil 9OtherIf "Other" List Vaccine Type Vaccine Injury Severity *Life threatening reactionDisability or permanent damageMedical care was requiredPain or discomfortVaccine Injury Type *Cardiac Harm (myocarditis)Birth DefectImmune ResponseNeurological HarmPost Injection PainReproductive HarmSudden Termintion of PregnancyOtherAdditional Information MessageSubmit
