Adverse Reaction Report

You are not alone! Many people are coming forward with stories like yours, trying to find out what is happening to themselves or to a loved one. By compiling these stories, we hope to learn more about what’s going on, and hopefully find a way to halt the progression of these terrible symptoms, and ultimately stop this scourge.

Please tell us as much as you can about what is going on, every bit of information will help us piece together this frightening puzzle. The only required fields are your name and contact info, and the symptoms you have observed in the subject, but the more information you are able to provide, the more potential this project will have to help the people experiencing these debilitating side effects.

Subject's year of birth
Pre-existing conditions/co-morbidities:
How many doses of vaccine were administered?

One dose Two doses Two doses plus a booster
Date of first vaccine:
Date of second vaccine:
Date of booster:
Vaccine brand:

Pfizer Moderna Astra-Zeneca J&J Mixed Other
What vaccine did they get?

If different brands of vaccine were administered, which did they get?

First Dose	Second Dose	Actions

Do you know the batch numbers of the vaccines administered? (They may be on the vaccine card.)

Yes No

If you know the batch numbers, please add them here.

First dose	Second dose	Actions

When did symptoms begin?
Check all symptoms that have been observed:

Rapid cognitive decline Rapid motor decline Ataxia/trouble balancing and walking Speech difficulty Personality changes Aggression/agitation Visual disturbances Memory deficits Tremors Other neurological symptoms
Description of symptoms: *
Has a diagnosis been obtained?

Yes No
What was the diagnosis?
What was the date of diagnosis?
Is the subject still alive?

Yes No
Date of subject's death:

We're sorry for your loss.
Is there anything else you think we should know?
Your Name *

First

Last
Your Email Address *
Your Phone Number

Phone number is optional
Do you prefer to be contacted by phone, or by email?

Please call me Please email me
By signing here, you affirm that everything above is true to the best of your knowledge.

Clear

This is not required for submission but it may be helpful for documentation purposes.
I understand that no personally identifiable information should be provided about the subject being reported, and that no representations regarding privacy or data security are made. I understand that this website has no governmental or IRB affiliation, and must not substitute for either reporting to VAERS, V-SAFE or similar systems, nor should this report substitute for consulting a responsible medical practitioner. *

I understand Click here to confirm.