COVID-19 & Vaccination
COVID-19 Back-to-Normal Study:
Name or anonymous ID & approximate age
Have you ever tested for COVID-19?
Vaccination Status
Clear selection
When approximately did you get vaccinated?
Vaccine name or manufacturer
Clear selection
Have you experienced any of these side effects hours or up to 10 days after your most recent dose? Check all that apply. Examples of less common side effects: abdominal pain, diarrhea, tingling/numbing, sweating, changes in smell/taste
Injection site pain
Sore arm
Swelling of the lymph nodes in the same arm as the injection
General Muscle Pain
Joint Pain
Nausea or Vomiting
Flu-like symptoms
Rash outside of injection site
Eye, Ear, Oral symptoms
In the past 14 days have you been in close proximity to anyone who has tested positive for COVID-19 or experienced: fever/chills, body aches, nausea, diarrhea , dry cough, difficulty breathing, sore throat, new loss of taste or smell?
Clear selection
Did you have any long-term effects of coronavirus disease, if applicable?
Did you have any long-term effects of COVID-19 vaccine?
Did COVID-19 vaccine exacerbated or relived your pre-existing health conditions (flare-ups vs remission), if applicable?
Please list medical conditions, medications, supplements, dietary restrictions - anything, you think, could affect your reaction to vaccines
Any other thoughts or comments regarding this survey or the study in general?
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