( ! )
Notice: Undefined index: q in /var/www/html/pvf.php on line
9
Call Stack
#
Time
Memory
Function
Location
1
0.0006
229400
{main}( )
.../pvf.php
:
0
Post Vaccination Form
Details of Post Vaccination
Details of Post Vaccination
*
First Name
*
Last Name
*
Patient Date of Birth
*
Vaccine Name
Manufacturer
Dose Number
Date & Time of Vaccination
Lot Number
Route
Body Site
Result or Outcome of Post Vaccination(S)
Describe Adverse Events / AESI / AEFI
Anaphylaxis
Arthalgia
Blurred Vision
Chest Pain
Decreased apetite
Excessive Sweating
Fever
Injection Site Pain
Injection Site Swelling
Joint Pain
Leg Swelling
Lymphadenpathy
Myalgia
Nausea
Persisent Abdominal Pain
Seizures
Severe or Persistent Headaches
Shortness of Breath
Skin Bruising
Thrombocytopenia
Thromboembolic Events
Thrombosis
Tinnitus
Medical test and laboratory result related to the adverse events(s): (Include Dates)
Has the patient recovered from the adverse event(s)?
Yes
No
Result or Outcomes of adverse event(s): Check all that apply
Doctor or other healthcare professional office/clinic visit
Emergency room department or urgent care
Hospitalization
Prolongation of existing hospitalization (Vaccine received during existing hospitalization)
Life threatening illness (immediate risk of death from the event)
Disability or permanent damange
Patient died
Congenital anomaly or birth defect
Non of the above
Hospitalization?
No. of Days
Hospital Name
City
State
Patient died?
Additional Information
Patient Affected by Covid?
Yes
No
Severity of Infection
Mild
Moderate
Severe
Has the patient ever had an adverse event following any previous vaccine?
Yes
No
Severe
Complete only for U.S. Military/Department of defense related reports
Status at Vaccination
--Select Status--
Active Duty
Reserve
National Guard
Beneficiary
Other
Vaccinated at Military/DoD Site
Yes
No
Cancel
Submit
Loading