Follow-Up SIRVA Survey

Please fill this out ONLY IF you have already answered the original SIRVA Survey. The original SIRVA Survey is longer, takes more time, and will help us gather more information about who gets SIRVA and why.

The purpose of this Follow-Up Survey is if you answered the original SIRVA Survey and would like to update us with changes to your condition that will help us understand how to treat SIRVA and how long it lasts.

Did you fill out the SIRVA Survey?

Yes

No: Please take the primary SIRVA Survey first! http://www.sirvasurvey.org/survey

Clear selection

What was the date of your vaccination?

YYYY

Which of the following diagnoses have you received from a medical practitioner related to your SIRVA? Check all that apply.

Bursitis

Tendonitis

Impingement of the shoulder

Rotator cuff tear

Supraspinatus tear

Teres minor tear

Biceps tendon tear

Bone/humerus damage or edema

Elevated white blood cell count

Other:

Since your initial response to the SIRVA Survey, have you:

Recovered completely (YAY!)

Improved a lot, but not recovered

Improved a little

No change in symptoms

Gotten a little worse

Gotten a lot worse

Clear selection

IF you have recovered from SIRVA, how long did it take (from the date of vaccination)?

Less than 1 month

1-2 months

2-6 months

6 months-1 year

1-2 years

2+ years

N/A: have not recovered yet

Clear selection

Since your initial response to the SIRVA Survey, what has changed? Please describe any of the following: New information or diagnosis about your injury, New type of treatment attempted (and results - did it help?), Change in symptoms, etc.

Is there anything else that you want to add that might help us understand SIRVA recovery better? Thank you for your time and for filling out this survey.

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