Vaccine Support Assessment Survey

Vaccine Support Assessment Form

This form is used to rate your health before and after vaccinations to determine if there are any negative lasting effects

If you would like to download a template for offline purposes, click here : Download Offline Vaccine Assessment
Upon submission, a link will be available to download a pdf copy of your response.
Check each time you wish to be reminded to retake this assessment
Rate your symptoms from 1 to 10. Give yourself a 1 if you never get these symptoms, a 10 if you struggle with these symptoms chronically, or any number in between as appropriate. If you already struggle with some of these symptoms below, write out everything you can about how you are struggling, rate how bad it is—elaborate so you have something concrete to go back to and you do not have to rely on your memory.
Respiration
Nerve Sensations
Mind
Brain
Immune System