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Vaccine Support Assessment Survey

If you would rather download a blank pdf and fill it out offline, you can do so here: [download id=”6526″]

Vaccine Support Assessment Form

Take this test as a benchmark to compare how you're feeling down the road.

Disclaimer: By filling out this form and clicking submit, you are allowing your data to be stored on our website for the use of creating a pdf copy to be emailed back to you at the email you provided. Aside from the necessary storage and usage of your information to create said pdf, we do not store, share, or sell any of your information.

*

I have read, understood, and agree to the above disclaimer

Email *

Confirm Email *

Confirm email

Name

Date

Vaccine Support Assessment Test
Take this test before vaccinations and compare to 1, 3, 6, and 12 months after vaccination.

Score each question: 1-10; 1 is never, 10 is always.

I have difficulty taking a deep breath *

1

2

3

4

5

6

7

8

9

10

I feel asthmatic *

1

2

3

4

5

6

7

8

9

10

I have allergies *

1

2

3

4

5

6

7

8

9

10

Nerve Sensations

It feels like my face is numb *

1

2

3

4

5

6

7

8

9

10

It feels like my extremities are numb *

1

2

3

4

5

6

7

8

9

10

I have difficulty swallowing *

1

2

3

4

5

6

7

8

9

10

It feels like my eyes are paralyzed *

1

2

3

4

5

6

7

8

9

10

I feel weakness in my legs *

1

2

3

4

5

6

7

8

9

10

I feel clumsy while walking *

1

2

3

4

5

6

7

8

9

10

Mind

I have negative thoughts of suicide *

1

2

3

4

5

6

7

8

9

10

I have racing thoughts *

1

2

3

4

5

6

7

8

9

10

I have trouble sleeping at night *

1

2

3

4

5

6

7

8

9

10

I have trouble resting *

1

2

3

4

5

6

7

8

9

10

I am fidgety *

1

2

3

4

5

6

7

8

9

10

I am an angry person *

1

2

3

4

5

6

7

8

9

10

I have negative thoughts *

1

2

3

4

5

6

7

8

9

10

I am fearful *

1

2

3

4

5

6

7

8

9

10

I like to be alone *

1

2

3

4

5

6

7

8

9

10

I fixate on things *

1

2

3

4

5

6

7

8

9

10

I am shy and uncomfortable around people *

1

2

3

4

5

6

7

8

9

10

Brain

I have a hard time thinking *

1

2

3

4

5

6

7

8

9

10

I have a hard time formulating my words *

1

2

3

4

5

6

7

8

9

10

I mean one word and I say another *

1

2

3

4

5

6

7

8

9

10

I forget where I parked my car *

1

2

3

4

5

6

7

8

9

10

I lose my car keys *

1

2

3

4

5

6

7

8

9

10

I get more tired than I used to *

1

2

3

4

5

6

7

8

9

10

I get more tired driving than I used to *

1

2

3

4

5

6

7

8

9

10

Immune System

My stomach is upset *

1

2

3

4

5

6

7

8

9

10

I am constipated (less than 1 stool/day) *

1

2

3

4

5

6

7

8

9

10

I have diarrhea *

1

2

3

4

5

6

7

8

9

10

I have allergy symptoms *

1

2

3

4

5

6

7

8

9

10

I have reactions to foods I eat *

1

2

3

4

5

6

7

8

9

10

I have reactions to perfumes and smells *

1

2

3

4

5

6

7

8

9

10

I get skin rashes *

1

2

3

4

5

6

7

8

9

10

I have panic attacks *

1

2

3

4

5

6

7

8

9

10

I have heart palpitations *

1

2

3

4

5

6

7

8

9

10

I have swollen joints *

1

2

3

4

5

6

7

8

9

10

I get colds *

1

2

3

4

5

6

7

8

9

10

I get stomach cramps *

1

2

3

4

5

6

7

8

9

10

I get sore throats *

1

2

3

4

5

6

7

8

9

10

I get sinus infections *

1

2

3

4

5

6

7

8

9

10

I have asthma attacks *

1

2

3

4

5

6

7

8

9

10

I get earaches *

1

2

3

4

5

6

7

8

9

10

I get headaches *

1

2

3

4

5

6

7

8

9

10

I have been diagnosed with an auto-immune disease

Yes

No

We recommend adding details for your most serious health complaint here:

Website/URL

If you are human, leave this field blank.

Contact Information

PO 924, Palmer Lake, CO 80133
719-481-4594
719-481-2205
office@healthrestored.com

Site Links

Home
What We Do
Workshops
- Aggressive Health Solutions Workshop
  - AHS Workshop Resources
- “Mommy, be my doctor” Workshop
Speaker
Testimonies
Resources
Shop
About Us
Log In

Home
What We Do
Workshops
- Aggressive Health Solutions Workshop
  - AHS Workshop Resources
- “Mommy, be my doctor” Workshop
Speaker
Testimonies
Resources
Shop
About Us
Log In

Vaccine Support Assessment Form

Contact Information

Site Links

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