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 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. Submit