Covid19 Vaccine Allergy Case Report (US)
To be completed by health professionals who wish to report case/s of COVID-19 vaccine allergy and collaborate on improving the current knowledge of COVID-19 vaccine allergy.
First name of reporting healthcare professional
Last name of reporting healthcare professional
Professional title of reporting healthcare professional
Certification of reporting healthcare professional
Email address (official email preferred)
Female
Male
Non-binary
Other, please specify:
If other sex, please specify
Race (Check all that apply)
Hispanic/Latino
Not Hispanic/Latino
Unknown
Current smoker
Former smoker
Never smoked
Unknown
Patient's state of residence (indicate state or territory of residence)
Alabama (AL) Alaska (AK) Arizona (AZ) Arkansas (AR) California (CA) Colorado (CO) Connecticut (CT) Delaware (DE) District of Columbia (DC) Florida (FL) Georgia (GA) Hawaii (HI) Idaho (ID) Illinois (IL) Indiana (IN) Iowa (IA) Kansas (KS) Kentucky (KY) Louisiana (LA) Maine (ME) Maryland (MD) Massachusetts (MA) Michigan (MI) Minnesota (MN) Mississippi (MS) Missouri (MO) Montana (MT) Nebraska (NE) Nevada (NV) New Hampshire (NH) New Jersey (NJ) New Mexico (NM) New York (NY) North Carolina (NC) North Dakota (ND) Ohio (OH) Oklahoma (OK) Oregon (OR) Pennsylvania (PA) Rhode Island (RI) South Carolina (SC) South Dakota (SD) Tennessee (TN) Texas (TX) Utah (UT) Vermont (VT) Virginia (VA) Washington (WA) West Virginia (WV) Wisconsin (WI) Wyoming (WY) American Samoa (AS) Guam (GU) Northern Mariana Islands (MP) Puerto Rico (PR) Virgin Islands (VI)
Patient's country of residence (If other than United States of America)
Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cabo Verde Cambodia Cameroon Canada Central African Republic Chad Chile China Colombia Comoros Congo (Congo-Brazzaville) Costa Rica Croatia Cuba Cyprus Czechia (Czech Republic) Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini (fmr. "Swaziland") Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Holy See Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar (formerly Burma) Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria North Korea North Macedonia Norway Oman Pakistan Palau Palestine State Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Sweden Switzerland Syria Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States of America Uruguay Uzbekistan Vanuatu Venezuela Vietnam Yemen Zambia Zimbabwe
Have you reported previously on this patient?
Yes
No
Which type of reaction did you report previously for this patient?
Immediate large local reactions
Delayed large local reactions
Urticaria and/or Angioedema
A potential case of anaphylaxis
Other. Please describe reaction:
When did the previous reaction occur?
When did the previous reaction occur? (Provide date of prior reaction)
Today M-D-Y
Did the patient receive at least one dose of a vaccination for COVID-19?
Yes
No
If yes, how many doses has the patient received to date?
1
2
Other. Please specify the number of vaccination doses received to date:
If other, please specify the number of vaccination doses received to date:
Date of vaccine administration
Today M-D-Y
Site of vaccine administration
Hospital
Vaccination Clinic
Health Care Center
Pharmacy
Nursing Home
Other:
What is the brand name of vaccine administered?
Pfizer-BioNTech COVID-19 Vaccine
Moderna COVID-19 Vaccine
COVID-19 Vaccine AstraZeneca
Johnson & Johnson/Ad26.COV2.S Vaccine
Other. Please provide vaccine name :
Unknown
Lot # of vaccine (if known):
How was the vaccine administered?
Full dose
Split dose
By desensitization
Other, explain administration method
Please describe method used in split dose administration.
Please describe method used for vaccine administration via desensitization.
If other, explain administration method.
Length of monitoring after dose administration
Not monitored after the dose
15 minutes
30 minutes
Over 30 minutes
Other:
Unknown
Right arm
Left arm
Other, specify area of injection:
Unknown
Specify other area of injection
Were any pre-medications taken prior to vaccination?
Yes
No
Unknown
List pre-medications taken prior to vaccination.
Was the patient seen by allergist prior to THIS dose of vaccine?
Yes
No
Describe the result of the pre-vaccination allergy consultation.
Please select the type of reaction that you reporting to the COVID-19 vaccine?
A potential case of non-anaphylactic allergic reaction
A potential case of anaphylaxis
Please select the type of non-anaphylactic reaction that you are reporting to the COVID-19 vaccine?
Immediate large local reactions
Delayed large local reactions
Urticaria and/or Angioedema
Other. Please describe reaction:
Please describe the reaction.
Did the patient experience an immediate vaccine reaction (i.e., less than 4 hours after receiving vaccine)?
Yes
No
Unknown
Time between administration and reaction
Immediate symptoms, less than 1 hour
Immediate symptoms, more than 1 hour but less than 4 hours
Non-immediate symptoms, more than 4 hours but less than 24 hours
Delayed symptoms, more than 24 hours
Unknown
How many minutes after administration of the vaccine did symptoms begin?
What symptoms did the patient experience? (Check all that apply)
Change in sensation (where)
Low oxygen saturation (define)
If swelling, describe area of body:
If other reaction, please specify.
Upload any pictures of the reaction below.
Please do not upload any full face photographs or photographs that can be used to identify the individual .
Reaction Photo 1 Reaction Photo 2 Reaction Photo 3 Reaction Photo 4 Reaction Photo 5
If you have photos of the reaction, please upload it here:
If you have photos of the reaction, please upload it here:
If you have photos of the reaction, please upload it here:
If you have photos of the reaction, please upload it here:
If you have photos of the reaction, please upload it here:
Day of symptom onset (give in days)
For example:
Day 0 - On the day of vaccination
Day 1 - 1 day after vaccination
Day 2 - 2 days after vaccination
Day 0 (On the day of vaccination)
Day 1 (2nd day after vaccination)
Day 2 (3rd day after vaccination)
Day 3 (4th day after vaccination)
Day 4 (5th day after vaccination)
>5 days after vaccination
Other, specify day of symptom onset:
Specify day of symptom onset
Today M-D-Y
Symptoms at the site of injection
If swelling, describe area of body
Describe rash and area of rash
What is your estimate of the maximum diameter of the large local reaction?
Add unit of measurement
When did symptoms improve?
When did symptoms improve?
Today M-D-Y
Did the patient take any medications (topical or oral) for THIS reaction?
Yes
No
If the patient experienced post vaccination symptoms other than the local reaction, list symptoms. (Check all that apply)
Specify the area of the body
Upload any pictures of the large local reaction below.
Please do not upload any full face photographs or photographs that can be used to identify the individual .
Reaction photo 1 Reaction photo 2 Reaction photo 3 Reaction photo 4 Reaction photo 5
Local reaction photo (#1)
Local reaction photo (#2)
Local reaction photo (#3)
Local reaction photo (#4)
Local reaction photo (#5)
Did symptoms resolve completely?
Yes
No
Please describe details of any lingering symptoms.
When did symptoms resolve?
On the day of vaccination
2nd day after vaccination
3rd day after vaccination
4-5th day after vaccination
>5 days after vaccination
Other, specify the day the symptoms resolved:
Specify the day the symptoms resolved
When did symptoms resolve?
Today M-D-Y
Are you reporting any vital signs associated with the reaction?
Yes
No
Date of vital signs (relative to vaccine administration)
Today M-D-Y
Time of vital signs (relative to vaccine administration)
Now H:M
Temperature (Fahrenheit):
Diastolic blood pressure:
Respiratory rate (at presentation):
Percent O2 saturation on room air (at presentation):
How long until symptoms resolved?
Less than 1 hour
1-2 hours
2-6 hours
6-12 hours
12-24 hours
1-2 days
2-4 days
5-7 days
More than 1 week
Unknown
Did the patient receive any treatment? (Check all that apply)
Yes, H1 Antihistamines
Yes, Epinephrine shot
Yes, Epinephrine drip
Yes, Steroids orally
Yes, Steroids intravenously
Yes, Topical steroids
Yes, H2 Blockers
No, Treatment not needed, symptoms resolved on their own
Yes, Other:
How many intramuscular epinephrine doses were used to treat the reaction?
1
2
3
More than 3
Where was the patient treated for this reaction? (Check all that apply)
Specify treatment location.
Did the patient have blood drawn at the time of reaction?
Yes
No
Did the patient have any laboratory tests [e.g. for Polyethylene Glycol IGE, Tryptase level, Complement testing] done ?
Yes
No
Which of the following laboratory tests were carried out?
Tryptase level (baseline)
Complement split products
Polyethylene glycol (PEG) IgE
List other relevant blood level measurements
What medications did the patient take on the day of the reaction?
What medications did the patient take in the day prior to the vaccination dose?
What other exposures (e.g. foods) did the patient have in the 4-6 hours prior to the vaccination dose?
Was the patient evaluated by an allergist following the vaccine reaction?
Yes
No
Unknown
Does the allergist believe this reaction is allergic?
Yes
No
Possibly
Other:
What was the allergist diagnosis?
Confirmed anaphylaxis
Possible anaphylaxis
Not anaphylaxis
If "possible anaphylaxis" or "not anaphylaxis," what was the alternative diagnosis?
Did the patient undergo skin testing following the vaccine reaction?
Yes
No
Unknown
Why was testing performed?
Which of the substances was tested for?
Please describe other substance tested.
Today M-D-Y
Site of skin testing visit
Which of the following was used in the skin testing protocol?
Polyethylene glycol (PEG) Polysorbate (PS) Vaccine Control
Which of the following was used in the skin testing protocol?
Which of the following was used in the skin testing protocol?
Which of the following was used as the controls in the skin testing protocol?
Which of the following was used for skin testing with vaccine?
Miralax Epicutaneous 1:100 test result
Positive
Negative
Indeterminate
Not done
Miralax Epicutaneous 1:10 test result
Positive
Negative
Indeterminate
Not done
Miralax Epicutaneous 1:1 test result
Positive
Negative
Indeterminate
Not done
Methyl-prednisolone Acetate Epicutaneous 40 mg/ml undiluted test result
Positive
Negative
Indeterminate
Not done
Methyl-prednisolone Acetate Intradermal 0.4 mg/ml test result
Positive
Negative
Indeterminate
Not done
Methyl-prednisolone Acetate Intradermal 4 mg/ml test result
Positive
Negative
Indeterminate
Not done
If other, please describe the skin testing protocol used.
Other protocol test result
Positive
Negative
Indeterminate
Not done
Hepatitis A vaccine or Twinrix Epicutaneous 1:1 test result
Positive
Negative
Indeterminate
Not done
Hepatitis A vaccine or Twinrix Intradermal 1:100 test result
Positive
Negative
Indeterminate
Not done
Hepatitis A vaccine or Twinrix Intradermal 1:10 test result
Positive
Negative
Indeterminate
Not done
Triamcinolone Acetonide Epicutaneous 40 mg/ml test result
Positive
Negative
Indeterminate
Not done
Triamcinolone Acetonide Intradermal 0.4 mg/ml test result
Positive
Negative
Indeterminate
Not done
Triamcinolone Acetonide Intradermal 4 mg/ml test result
Positive
Negative
Indeterminate
Not done
Triamcinolone Acetonide Intradermal 40 mg/ml test result
Positive
Negative
Indeterminate
Not done
Refresh sterile eye drops Epicutaneous 1:1 test result
Positive
Negative
Indeterminate
Not done
Referesh sterile eye drops Intradermal 1:100 test result
Positive
Negative
Indeterminate
Not done
Referesh sterile eye drops Intradermal 1:10 test result
Positive
Negative
Indeterminate
Not done
Prevnar 13 Epicutaneous 1:100 test result
Positive
Negative
Indeterminate
Not done
Prevnar 13 Intradermal 1:10 test result
Positive
Negative
Indeterminate
Not done
If other, please describe the skin testing protocol used.
Other protocol test result
Positive
Negative
Indeterminate
Not done
Vaccine - Epicutaneous step 1 dilution
Vaccine - Epicutaneous Step 1 test result
Positive
Negative
Indeterminate
Not done
Epicutaneous Step 2 dilution
Vaccine - Epicutaneous Step 2 test result
Positive
Negative
Indeterminate
Not done
Vaccine - Epicutaneous (other protocol). Please describe the skin testing protocol used.
Vaccine - Epicutaneous (other protocol) test result
Positive
Negative
Indeterminate
Not done
Vaccine - Intradermal Step 1 dilution
Vaccine - Intradermal Step 1 dilution test result
Positive
Negative
Indeterminate
Not done
Vaccine - Intradermal Step 2 dilution
Vaccine - Intradermal Step 2 test result
Positive
Negative
Indeterminate
Not done
Vaccine - Intradermal Step 3 dilution
Vaccine - Intradermal Step 3 test result
Positive
Negative
Indeterminate
Not done
Vaccine - Intradermal, other protocol. Please describe the skin testing protocol used.
Vaccine - Intradermal, other protocol, test result
Positive
Negative
Indeterminate
Not done
Positive
Negative
Indeterminate
Not done
Positive
Negative
Indeterminate
Not done
Methyl-prednisolone Sodium Succinate Epicutaneous 40 mg/ml
Positive
Negative
Indeterminate
Not done
Methyl-prednisolone Sodium Succinate Intradermal 0.4 mg/ml
Positive
Negative
Indeterminate
Not done
Methyl-prednisolone Sodium Succinate Intradermal 4 mg/ml
Positive
Negative
Indeterminate
Not done
Methyl-prednisolone Acetate Intradermal 4 mg/ml
Positive
Negative
Indeterminate
Not done
Positive
Negative
Indeterminate
Not done
Positive
Negative
Indeterminate
Not done
If other, please describe the skin testing protocol used.
Other protocol, test result
Positive
Negative
Indeterminate
Not done
If patient was tested for other substance, please describe the skin testing protocol used.
Other protocol, test result
Positive
Negative
Indeterminate
Not done
Upload any pictures of the skin testing reactions below.
Please do not upload any full face photographs or photographs that can be used to identify the individual .
Skin Test Photo 1 Skin Test Photo 2 Skin Test Photo 3 Skin Test Photo 4 Skin Test Photo 5
Please upload a photo of the positive reaction
Please upload a photo of the positive reaction
Please upload a photo of the positive reaction
Please upload a photo of the positive reaction
Please upload a photo of the positive reaction
What was the recommendation from the allergist after skin testing?
If the patient can only receive a specific COVID vaccine, please specify:
If other recommendation, please specify:
Did the patient report allergic symptoms for prior COVID-19 vaccinations?
Yes
No
Vaccine name and symptoms of the prior COVID-19 vaccinations
Prior Dose (#1) Prior Dose (#2) Prior Dose (#3) Vaccine name Date Dermatologic or mucosal symptoms Cardiovascular symptoms Respiratory symptoms Gastrointestinal symptoms Other symptoms Pre-medication prior to vaccination
Brand name of prior vaccine dose #1?
Brand name of prior vaccine dose #2?
Brand name of prior vaccine dose #3?
Please add name/s of vaccine #1
Please add name/s of vaccine #2
Please add name/s of vaccine #3
Prior dose #1 vaccination date
M-D-Y
Prior dose #2 vaccination date
M-D-Y
Prior dose #3 vaccination date
M-D-Y
Dermatologic or mucosal (#1)
Describe area of swelling (#1)
Dermatologic or mucosal (#2)
Describe area of swelling (#2)
Dermatologic or mucosal (#3)
Describe area of swelling (#3)
Describe other reactions.
Describe other reactions.
Describe other reactions.
Were any pre-medications taken prior to vaccination?
Yes
No
Unknown
Were any pre-medications taken prior to vaccination?
Yes
No
Unknown
Were any pre-medications taken prior to vaccination?
Yes
No
Unknown
Has the patient previously had a known case of COVID-19?
Yes
No
Unknown
Was the patient tested for COVID-19
Yes
No
Unknown
Today M-D-Y
Positive
Negative
Inconclusive
Unknown
Today M-D-Y
Has the patient received a subsequent dose of vaccine after the reaction you are reporting?
Yes
No
Date of dose administration
Today M-D-Y
Brand name of subsequent dose
Pfizer-BioNTech COVID-19 Vaccine
Moderna COVID-19 Vaccine
COVID-19 Vaccine AstraZeneca
Johnson & Johnson/Ad26.COV2.S Vaccine
Other. Provide name(s) of the vaccine(s):
Unknown
Lot # of vaccine (if known):
Right arm
Left arm
Other, specify area of injection:
Unknown
Specify other area of injection
Length of monitoring after dose administration
Not monitored after the dose
15 minutes
30 minutes
Over 30 minutes
Unknown
Were any pre-medications taken prior to vaccination?
Yes
No
Unknown
List pre-medications taken prior to vaccination.
Site of subsequent dose administration
Hospital
Vaccination Clinic
Health Care Center
Pharmacy
Nursing Home
Other, specify the vaccine clinic:
Specify the other vaccine clinic
Did the patient report allergic symptoms for the subsequent dose?
Yes
No
Unknown
Time between administration and reaction
Immediate symptoms, less than 1 hour
Immediate symptoms, more than 1 hour but less than 4 hours
Non-immediate symptoms, more than 4 hours but less than 24 hours
Delayed symptoms, more than 24 hours
Unknown
Symptoms of reaction (Check all that apply)
Specify the area of swelling
If other symptom, please specify
How long until symptoms resolved?
Less than 1 hour
1-2 hours
2-6 hours
6-12 hours
12-24 hours
1-2 days
2-4 days
5-7 days
More than 1 week
Unknown
Allergist-confirmed anaphylaxis?
Confirmed anaphylaxis
Possible anaphylaxis
Not anaphylaxis
What were the specific symptoms of anaphylaxis?
If "possible anaphylaxis" or "not anaphylaxis," what was the alternative diagnosis?
How was the reaction treated? (Check all that apply)
What is the Epinephrine dose used to treat the reaction?
0.15
0.3
0.5
other
If other treatment, please specify
Where was the patient treated for this reaction? (Check all that apply)
Specify other treatment location
Upload any pictures of the vaccination reaction below.
Please do not upload any full face photographs or photographs that can be used to identify the individual .
Reaction Photo 1 Reaction Photo 2 Reaction Photo 3 Reaction Photo 4 Reaction Photo 5
Upload first picture of reaction
Upload second picture of reaction
Upload third picture of reaction
Upload fourth picture of reaction
Upload fifth picture of reaction
What medications did the patient take in the day prior to this dose?
What other exposures (e.g. foods) did the patient have in the 6 hours prior to this dose?
Did the patient have blood drawn during the reaction?
Yes
No
Unknown
Did the patient have any laboratory tests [e.g. for Tryptase level, Polyethylene Glycol IGE, Complement testing] done ?
Yes
No
Were any of the following laboratory tests carried out?
Polyethylene glycol (PEG) IgE
Yes
No
Tryptase level (baseline)
Complement split products
Positive
Negative
List other relevant blood tests and measurements
Does the allergist believe this reaction is allergic?
Yes
No
Possibly
Other
Has the patient experienced an anaphylaxis episode in their lifetime
Yes
No
Triggers of anaphylaxis (Check all that apply)
Specify the other triggers of anaphylaxis
Has the patient seen an allergist about their anaphylaxis?
Yes
No
Unknown
Has the patient been prescribed an Epi-Pen?
Yes
No
Unknown
Does the patient have a history of allergy to the following? (Check all that apply)
How many vaccine allergies does the patient have?
1
2
3
More than 3
How many injectable medication allergies does the patient have?
1
2
3
More than 3
Has the patient tolerated any of the following non-vaccine exposures to PEG? (Check all that apply)
Specify other non-vaccine exposure to PEG
Has the patient tolerated any of the following non-vaccine exposures to polysorbate? (Check all that apply)
Specify non-vaccine exposure to polysorbate
What vaccine caused the reaction?
Influenza
Haemophilus influenza B (HIB)
Hepatitis B
Human papillomavirus (HPV)
Measles, Mumps, Rubella (MMR)
Pneumococcal
Polio vaccine - inactivated (IPV)
Polio vaccine - oral (OPV)
Rabies
Smallpox
Tetanus (including Tdap/DTaP)
Typhoid vaccine - live, oral
Varicella
Yellow fever
Zoster
Other:
When did this reaction occur?
In the past year
1-4 years ago
5-9 years ago
10-14 years ago
15-19 years ago
20 or more years ago
Unknown
If known, what was the date of this reaction?
Today M-D-Y
Time between exposure and reaction
Immediate symptoms, less than 1 hour
Immediate symptoms, more than 1 hour but less than 4 hours
Non-immediate symptoms, more than 4 hours but less than 24 hours
Delayed symptoms, more than 24 hours
Unknown
Symptoms of reaction (Check all that apply)
Specify the area of the body of the swelling
What were the specific symptoms of anaphylaxis?
How long until symptoms resolved?
Less than 1 hour
1-2 hours
2-6 hours
6-12 hours
12-24 hours
1-2 days
2-4 days
5-7 days
More than 1 week
Unknown
How was the reaction treated? (Check all that apply)
If other treatment, please specify
Has the patient received THIS vaccine since the initial reaction?
Yes
No
Unknown
Did the patient experience a reaction when receiving THIS vaccine again?
Yes
No
Unknown
Has the patient tolerated any OTHER vaccines after this reaction?
Yes
No
Unknown
Which vaccines were tolerated after this reaction?
What vaccine caused the reaction?
Influenza
Haemophilus influenza B (HIB)
Hepatitis B
Human papillomavirus (HPV)
Measles, Mumps, Rubella (MMR)
Pneumococcal
Polio vaccine - inactivated (IPV)
Polio vaccine - oral (OPV)
Rabies
Smallpox
Tetanus (including Tdap/DTaP)
Typhoid vaccine - live, oral
Varicella
Yellow fever
Zoster
Other:
When did THIS reaction occur?
In the past year
1-4 years ago
5-9 years ago
10-14 years ago
15-19 years ago
20 or more years ago
Unknown
If known, what was the date of THIS reaction?
Today M-D-Y
Time between exposure and reaction
Immediate symptoms, less than 1 hour
Immediate symptoms, more than 1 hour but less than 4 hours
Non-immediate symptoms, more than 4 hours but less than 24 hours
Delayed symptoms, more than 24 hours
Unknown
Symptoms of reaction (Check all that apply)
Specify the area of the body of the swelling
What were the specific symptoms of anaphylaxis?
How long until symptoms resolved?
Less than 1 hour
1-2 hours
2-6 hours
6-12 hours
12-24 hours
1-2 days
2-4 days
5-7 days
More than 1 week
Unknown
How was the reaction treated? (Check all that apply)
Specify treatment medication
Has the patient received THIS vaccine since the initial reaction?
Yes
No
Unknown
Did the patient experience a reaction when receiving THIS vaccine again?
Yes
No
Unknown
Has the patient tolerated any OTHER vaccines after this reaction?
Yes
No
Unknown
Which vaccines were tolerated after this reaction?
What vaccine caused the reaction?
Influenza
Haemophilus influenza B (HIB)
Hepatitis B
Human papillomavirus (HPV)
Measles, Mumps, Rubella (MMR)
Pneumococcal
Polio vaccine - inactivated (IPV)
Polio vaccine - oral (OPV)
Rabies
Smallpox
Tetanus (including Tdap/DTaP)
Typhoid vaccine - live, oral
Varicella
Yellow fever
Zoster
Other:
When did this reaction occur?
In the past year
1-4 years ago
5-9 years ago
10-14 years ago
15-19 years ago
20 or more years ago
Unknown
If known, what was the date of this reaction?
Today M-D-Y
Time between exposure and reaction
Immediate symptoms, less than 1 hour
Immediate symptoms, more than 1 hour but less than 4 hours
Non-immediate symptoms, more than 4 hours but less than 24 hours
Delayed symptoms, more than 24 hours
Unknown
Symptoms of reaction (Check all that apply)
Specify the area of the body of the swelling
What were the specific symptoms of anaphylaxis?
If other symptom, please specify
How long until symptoms resolved?
Less than 1 hour
1-2 hours
2-6 hours
6-12 hours
12-24 hours
1-2 days
2-4 days
5-7 days
More than 1 week
Unknown
How was the reaction treated? (Check all that apply)
If other treatment, please specify
Has the patient received THIS vaccine since the initial reaction?
Yes
No
Unknown
Did the patient experience a reaction when receiving THIS vaccine again?
Yes
No
Unknown
Has the patient tolerated any OTHER vaccines after this reaction?
Yes
No
Unknown
Which vaccines were tolerated after this reaction?
List all additional vaccine allergies listed
What injectable medication caused the reaction?
What type of injectable medication caused this reaction?
Iodinated contrast media for CT scans w/ premeds
Iodinated contrast media for CT scans w/o premeds
Gadolinium contrast media for MRI scans w/ premeds
Gadolinium contrast media for MRI scans w/o premeds
Injectable steroid, specify which
Injectable antibiotic, specify which
Other, specify the type
Specify the other type of injectable medication
Specify which injectable steroid
Specify which injectable antibiotic
When did this reaction occur?
In the past year
1-4 years ago
5-9 years ago
10-14 years ago
15-19 years ago
20 or more years ago
Unknown
If known, what was the date of this reaction?
Today M-D-Y
Time between exposure and reaction
Immediate symptoms, less than 1 hour
Immediate symptoms, more than 1 hour but less than 4 hours
Non-immediate symptoms, more than 4 hours but less than 24 hours
Delayed symptoms, more than 24 hours
Unknown
Symptoms of reaction (Check all that apply)
Specify the area of the body of the swelling
What were the specific symptoms of anaphylaxis?
If other symptoms, please specify
How long until symptoms resolved?
Less than 1 hour
1-2 hours
2-6 hours
6-12 hours
12-24 hours
1-2 days
2-4 days
5-7 days
More than 1 week
Unknown
How was the reaction treated? (Check all that apply)
What injectable medication caused the reaction?
What type of injectable medication caused this reaction?
Iodinated contrast media for CT scans w/ premeds
Iodinated contrast media for CT scans w/o premeds
Gadolinium contrast media for MRI scans w/ premeds
Gadolinium contrast media for MRI scans w/o premeds
Injectable steroids:
Injectable antibiotic:
Other:
Specify the other type of injectable medication
Specify which injectable steroid
Specify which injectable antibiotic
When did this reaction occur?
In the past year
1-4 years ago
5-9 years ago
10-14 years ago
15-19 years ago
20 or more years ago
Unknown
If known, what was the date of this reaction?
Today M-D-Y
Time between exposure and reaction
Immediate symptoms, less than 1 hour
Immediate symptoms, more than 1 hour but less than 4 hours
Non-immediate symptoms, more than 4 hours but less than 24 hours
Delayed symptoms, more than 24 hours
Unknown
Symptoms of reaction (Check all that apply)