COVID-19 VACCINE side effects form
Dear citizens of Kurdistan Region/Iraq.
As the country is going through the COVID-19 pandemic and vaccination is the best way to overcome it, the ministry of health has started the vaccination campaign.
Some side effects have been shown after vaccination, but most of the side effects (if they develop) are temporary and gradually disappear. In case of severe side effects please contact a health service provider.
The following form has been prepared to collect information regarding side effects that may happen as a result of taking a COVID-19 vaccine. Please fill it out when any symptom develops, and we will reply according to the severity of each case.
Thank you for your cooperation.
KMCA-Ministery of health-Kurdistan
Patient name *
date of birth *
Datum
Gender *
Phone number *
Date of vaccination *
Datum
City *
Name of vaccination center/ place *
brand of the vaccine *
Vaccination card code *
Have you been infected with COVID-19 before *
Do you suffer from any other medical condition? *
If yes, please specify *
Are you on any medication? or did you receive any medication on the day of the vaccination? *
If yes, please mention them *
On the day of the vaccination did you have any of these symptoms *
Obligatorisk
With which dose did side effect start *
Did you have any of these symptoms at the site of the injection? *
Obligatorisk
Did you suffer from any of the following after receiving the vaccine? *
Obligatorisk
After the vaccination, which day the side effect started and how long did it last for *
Please specify the period of time for each symptom by clicking on the box in front of them, starting from the day they appeared and until the day they disappeared
First day
Second day
Third day
Fourth day
fifth day or more
Fever
Fatigue
Headache
Muscle pain
Chills
Joints pain
Nausea
Vomiting
Swollen lymph nodes
Unexpected bruising
Tiny red spot on the skin
Shortness of breath
Stomachache
Others
None
Please, specify the other symptoms
Did you receive any treatment to resolve these symptoms? *
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