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COVID-19 Vaccine Allergy Patient Case Registry

Returning?

A A A

We have created the COVID-19 Vaccine Allergy Patient Case Registry as an effort to collect reports on COVID-19 vaccine hypersensitivity reactions from patients. We are collecting reports of vaccine hypersensitivity or allergic reactions to any of the COVID-19 vaccines, including any photographic evidence of the reactions.

The case report form will take approximately 5-10 minutes to complete. The case report form allows you to save your work and finish at your own pace. Your information will be kept strictly confidential. Data will be stored on a secure server at Massachusetts General Hospital, a teaching hospital of the Harvard University Medical School. The information is only shared with our research group for managing and improving patient care and to better understand the occurrence and symptoms resulting from COVID-19 vaccine allergy.

Thank you for contributing to this endeavor in expanding the current understanding on COVID-19 vaccine reactions. The success of this collaborative effort depends on your active participation, and the accuracy and reliability of the information provided.

Please share the case report survey link with your family, friends, and colleagues who may be interested in sharing their vaccine hypersensitivity or allergy reactions.

Please be reminded that your participation in this research study is voluntary. Whether or not you participate will have no effect on any healthcare that you receive.

If you’d like to speak to someone not involved in this research about your rights as a research subject, or any concerns or complaints you may have about the research, contact the Mass General Brigham Human Research Committee at 857-282-1900.

Thank you for participating in this community-wide effort to improve our knowledge and understanding of COVID-19 vaccine reactions. Your willingness to return the completed questionnaire will indicate your consent for using the information you provided for research to improve the current knowledge on COVID-19 vaccine allergy.

Kimberly Blumenthal, MD, MSc, Massachusetts General Hospital

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COVID-19 Vaccine Allergy Patient Case Report

To be completed by individuals who wish to report their reaction to a COVID-19 vaccine.

Please skip any question that you are not comfortable answering.

First name

Last name

Would you be willing to be contacted in the future if we need more information from you on your symptoms?

Yes

No

How would you prefer to be contacted?

Phone (Home)

Phone (Cell)

Email

Mail

Phone (Home)

Phone (Mobile)

Email address (official email preferred)

The Mass General Brigham standard is to send email securely. This requires you to initially set up and activate an account with a password. You can then use the password to access secure emails sent to you from Mass General Brigham.

If you prefer, we can send you "unencrypted" email that is not secure and could result in the unauthorized use or disclosure of your information. If you want to receive communications by unencrypted email despite these risks, Mass General Brigham will not be held responsible. Your preference to receive unencrypted email will apply to emails sent to you from research staff in this study ONLY.

Please select one of the following options:
I consent to receive unencrypted emails (please use your initials to indicate your response):

Yes

No

Mailing address

Expand

How did you hear about us?

Facebook - chronic spontaneous urticaria support group

Facebook - other

Website (allergyresearch.massgeneral.org)

News article

Twitter

My doctor

Other: Please specify

Your age (in years)

Age:

Prefer to provide age within an age category

Prefer to not answer

Age category

Below 18 yrs

18-20 yrs

21-30 yrs

31-40 yrs

41-50 yrs

51-60 yrs

61-70 yrs

71-80 yrs

Above 80 yrs

How would you describe your biological sex?

Female

Male

Intersex

Prefer not to answer

How would you describe your race? (Check all that apply)

American Indian/Alaska Native

Asian

Black or African-American

Native Hawaiian/Pacific Islander

White

Other, please specify:

Unknown

Prefer not to answer

How would you describe your ethnicity?

Hispanic/Latino

Not Hispanic/Latino

Unknown

Prefer not to answer

Are you a smoker?

Current smoker

Former smoker

Never smoked

Prefer not to answer

What is the state of current residence? (indicate state or territory of residence)

What is your country of residence (If other than United States of America)

Did you receive at least one dose of a vaccination for COVID-19?

Yes

No

How many doses have you received to date?

1

2

3

4

5

6

Other. Please specify the number of vaccination doses received to date:

What is the brand name of vaccine that was administered? Also specify when you received the vaccine(s)

Vaccine brand

Date vaccinated

Dose 1

Dose 2

Dose 3

Dose 4

Dose 5

Dose 6

Are you reporting a reaction to vaccine dose 1, dose 2, dose 3, dose 4, dose 5, or other?

Dose 1

Dose 2

Dose 3

Dose 4

Dose 5

Dose 6

Other. Please specify:

Where did you get the vaccine?

Hospital

Vaccination Clinic

Health Care Center

Pharmacy

Nursing Home

Other:

What is the name of vaccination site?

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

Novavax COVID-19 Vaccine

Other. Please provide vaccine name :

Do not know

Where was the site of injection for this vaccine?

Right arm

Left arm

Other, specify area of injection:

Do not know

How long were you monitored after administering the vaccine?

Not monitored after the dose

15 minutes

30 minutes

Over 30 minutes

Other:

Do not know

Did you take any medications prior to vaccination (for example, ibuprofen to prevent or reduce vaccine symptoms) or other medications that you take routinely?

Yes

No

Cannot remember

List medications taken prior to vaccination (i.e., medications taken on the day of vaccination).

Were you seen by an allergist prior to THIS dose of vaccine?

Yes

No

If you are comfortable sharing this information, please tell us the result of the pre-vaccination allergy consultation.

Expand

Please select the type of reaction that you reporting to the COVID-19 vaccine

Allergic or hypersensitivity reaction (not anaphylaxis)

Anaphylaxis

Please select the type of non-anaphylactic reaction that you are reporting to the COVID-19 vaccine?

Immediate large local skin reaction

Delayed large local skin reactions

Hives or red, itchy welts

Swelling

Other reaction

Please describe the reaction.

Expand

Did you experience this reaction immediately (i.e., less than 4 hours after receiving vaccine)?

Yes

No

Do not know

What was the 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

Other. Please specify

Do not know

If symptoms were delayed more than 24 hours, please specify time frame:

Greater than 24 hours but less than or equal to 1 week

More than 1 week but less than or equal to 2 weeks

More than 2 weeks but less than or equal to 4 weeks

Greater than 4 weeks

How many minutes after administration of the vaccine did symptoms begin?

Is there any other information about the reaction timing that you would like to share ?

Expand

What are the reactions that you experienced? (Check all that apply)

Hives at the injection site

Hives at location other than injection site

Flushing

"Skin writing" (redness and/or hives where you scratch your skin, known as dermatographism)

Skin redness

Red and itchy eyes

Swelling (describe area of body):

Swelling in lips-tongue-uvula

Rash (describe}:

Itching

General prickle sensation

Low blood pressure

High blood pressure

Fast heart rate (Tachycardia)

Low heart rate

Abnormal heart rhythm

Chest tightness

Loss of consciousness

Decreased level of consciousness

Collapse

Incontinence

Wheeze (bronchospasm)

Swelling of the airways (tongue, throat, uvula or larynx)

Difficulty breathing (Respiratory distress)

Abnormally rapid breathing (Tachypnea)

Persistent dry cough

Hoarse voice

Sensation of throat closure

Sneezing, rhinorrhea

Shortness of breath

Diarrhea

Abdominal pain

Nausea

Vomiting

Numbness (where):

Tingling (where):

Metallic taste

Change in sensation (where):

Pain (where):

Malaise

Headache

Dizziness

Other:

How much have you suffered from the physical symptoms of the urticaria (itch, hives [welts], and or swelling) in the last four weeks?

Very much

Much

Somewhat

A little

Not at all

How much was your quality of life affected by the urticaria in the last four weeks?

Very much

Much

Somewhat

A little

Not at all

How often was the treatment for your urticaria in the last four weeks not enough to control your urticaria symptoms?

Very much (e.g. treatment was not enough to control my symptoms)

Much

Somewhat

A little

Not at all (e.g. treatment was sufficient to control my symptoms or I didn't need treatment)

Overall, how well have you had your urticaria under control in the last four weeks?

Not at all (e.g my hives are not under control)

A little

Somewhat

Well

Very well (e.g my hives are under good control)

Is there any other information you would like to share about your reaction?

Expand

Symptoms at the site of injection

Redness

Itching

Swelling and heat

Pain at the injection site

Soreness

Rash

Other, describe symptoms below

Describe other symptoms that you experienced at the injection site that you would like to share.

Expand

A local reaction is a reaction that is limited to a specific area on your body. What is your best estimate of the maximum diameter of the local reaction?

If you have any pictures of the reactions, please upload the pictures of the reaction below.

Please do not upload any full face photographs or photographs that can be used to identify you.

Reaction Photo 1	Reaction Photo 2	Reaction Photo 3	Reaction Photo 4	Reaction Photo 5

When did symptoms improve? Give in days.
For example:
Day 0 - On the day of vaccination
Day 1 - 1 day after vaccination
Day 2 - 2 days after vaccination

Did you take any medications (topical or oral) for THIS reaction?

Yes

No

How was the reaction treated? (Check all that apply)

H1 Antihistamines [include medications such as Diphenhydramine (Benadryl), Cetirizine (Zyrtec) Loratadine (Alavert, Claritin), Levocerixine (Xyzal), Clarinex, Allegra, Chlor-Trimeton, Gravol]

Epinephrine shot

Epinephrine drip

Steroids orally

Steroids intravenously

Topical steroids

H2 Blockers [include medications such as cimetidine (Tagamet HB), famotidine (Pepcid Complete or Pepcid AC), nizatidine (Axid AR)]

No treatment needed, symptoms resolved on their own

Other, please specify.

Cannot remember

List any medications you took/used to reduce the reaction symptoms.

Expand

Did symptoms resolve completely?

Yes

No

Please describe details of any lingering symptoms.

Expand

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

Symptoms are ongoing

Other, specify the day the symptoms resolved:

If more than 5 days, please specify total duration of symptoms to date.

<1 week

1 week or more but less than 2 weeks

2 weeks or more but less than 3 weeks

3 weeks or more but less than 4 weeks

4 weeks or more but less than 5 weeks

5 weeks or more but less than 6 weeks

6 weeks or more but less than 8 weeks

2 months or more but less than 4 months

4 months or more but less than 6 months

6 months or more

Did you have any other exposures (e.g. foods) in the 6 hours prior to his dose? If yes, please list exposures (e.g. any foods that you ate).

Expand

Did you undergo an allergy consultation with an allergist following the vaccine reaction?

Yes

No

Did you undergo an allergy consultation with an allergist for skin testing following the vaccine reaction?

Yes

No

Unknown

Why was testing performed?

Expand

Which of the substance was tested for? Check all that apply.

Polyethylene glycol

Polysorbate 20

Polysorbate 80

COVID-19 vaccine

Other. Please describe other substance tested:

If you are comfortable sharing this information, please describe the result of skin test.

Expand

Site of skin testing visit

Name of allergist

Did you have any symptoms for prior COVID-19 vaccination(s)?

Yes

No

Brand name of vaccine dose(s)?

Monovalent Pfizer-BioNTech COVID-19 Vaccine

Bivalent Pfizer-BioNTech COVID-19 Vaccine

Monovalent Moderna COVID-19 Vaccine

Bivalent Moderna COVID-19 Vaccine

COVID-19 Vaccine AstraZeneca

Johnson & Johnson/Ad26.COV2.S Vaccine

Novavax COVID-19 Vaccine

Other. Provide name(s) of the vaccine(s):

Do not know

When did you receive this dose? (Please provide month and year only)

What are the reactions that you experienced? (Check all that apply)

Hives at the injection site

Hives at location other than injection site

Flushing

"Skin writing" (redness and/or hives where you scratch your skin, known as dermatographism)

Skin redness

Red and itchy eyes

Swelling (describe area of body):

Swelling in lips-tongue-uvula

Rash (describe}:

Itching

General prickle sensation

Low blood pressure

High blood pressure

Fast heart rate (Tachycardia)

Low heart rate

Abnormal heart rhythm

Chest tightness

Loss of consciousness

Decreased level of consciousness

Collapse

Incontinence

Wheeze (bronchospasm)

Swelling of the airways (tongue, throat, uvula or larynx)

Difficulty breathing (Respiratory distress)

Abnormally rapid breathing

Persistent dry cough

Hoarse voice

Sensation of throat closure

Sneezing, rhinorrhea

Shortness of breath

Diarrhea

Abdominal pain

Nausea

Vomiting

Numbness (where):

Tingling (where):

Metallic taste

Change in sensation (where):

Pain (where):

Malaise

Headache

Dizziness

Other:

Are there any other symptoms that you experienced to the previous COVID-19 vaccine dose that you would like to share? If yes, please describe here.

Expand

Symptoms at the site of injection

Redness

Itching

Swelling and heat

Pain at the injection site

Soreness

Rash

Other, describe symptoms below

Are there any other symptoms that you experienced at the injection site to the previous COVID-19 vaccine dose that you would like to share? If yes, please describe here.

Expand

If you have any pictures of the reactions, please upload the pictures of the reaction below.

Please do not upload any full face photographs or photographs that can be used to identify you.

Reaction Photo 1	Reaction Photo 2	Reaction Photo 3	Reaction Photo 4	Reaction Photo 5

Did you experience this reaction immediately (i.e., less than 4 hours after receiving vaccine)?

Yes

No

Do not know

What was the 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

Other. Please specify

Do not know

How many minutes after administration of the vaccine did symptoms begin?

If your symptoms were delayed more than 24 hours please specify:

Greater than 24 hours but less than or equal to 1 week

More than 1 week but less than or equal to 2 weeks

More than 2 weeks but less than or equal to 4 weeks

Greater than 4 weeks

Did you take any medications prior to vaccination (for example ibuprofen to prevent or reduce vaccine symptoms) or other medications that you take routinely?

Yes

No

Cannot remember

List medications taken prior to vaccination (i.e., medications taken on the day of vaccination).

Did you have any other exposures (e.g. foods) in the 6 hours prior to his dose? If yes, please list exposures (e.g. any foods that you ate).

Expand

Did you take any medications (topical or oral) for THIS reaction?

Yes

No

How was the reaction treated? (Check all that apply)

H1 Antihistamines [include medications such as Diphenhydramine (Benadryl), Cetirizine (Zyrtec) Loratadine (Alavert, Claritin), Levocerixine (Xyzal), Clarinex, Allegra, Chlor-Trimeton, Gravol]

Epinephrine shot

Epinephrine drip

Steroids orally

Steroids intravenously

Topical steroids

H2 Blockers [include medications such as cimetidine (Tagamet HB), famotidine (Pepcid Complete or Pepcid AC), nizatidine (Axid AR)]

No treatment needed, symptoms resolved on their own

Other, please specify.

Cannot remember

If other, list any medications you took/used to reduce the reaction symptoms.

Expand

Did symptoms resolve completely?

Yes

No

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

If it took over 5 days for reaction to resolve please specify total duration of symptoms.

< 1 week

1 week or more but less than 2 weeks

2 weeks or more but less than 3 weeks

3 weeks or more but less than 4 weeks

4 weeks or more but less than 5 weeks

5 weeks or more but less than 6 weeks

6 weeks or more but less than 8 weeks

2 months or more but less than 4 months

4 months or more but less than 6 months

6 months or more

Please describe details of any lingering symptoms.

Expand

When did symptoms improve? Give in days.
For example:
Day 0 - On the day of vaccination
Day 1 - 1 day after vaccination
Day 2 - 2 days after vaccination

Have you previously had a known case of COVID-19?

Yes

No

Prefer not to answer

Were you tested for COVID-19?

Yes

No

Prefer not to answer

What was the COVID test outcome?

Positive

Negative

Inconclusive

Prefer not to answer

What was the outcome of COVID-19 (i.e., did you recover without treatment or type of treatment you received)?

Recovered at home

Received treatment in the Emergency Department

Received treatment in the hospital

Received treatment in the ICU

I was Intubated

Prefer not to answer

Have you received a subsequent dose of vaccine after the reaction you are reporting?

Yes

No

Did you have any allergic symptoms for this subsequent dose?

Yes

No

Not sure/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

Do not know

If check symptoms were delayed more than 24 hours please specify:

Greater than 24 hours but less than or equal to 1 week

More than 1 week but less than or equal to 2 weeks

More than 2 weeks but less than or equal to 4 weeks

Greater than 4 weeks

What were the symptoms of the reaction to THIS dose (Check all that apply)

Itching

Rash, specify the type of rash:

Hives

"Skin writing" (redness and/or hives where you scratch your skin, known as dermatographism)

Swelling, specify the area of the body:

Shortness of breath

Wheezing

Chest tightness

Fast heart rate (Tachycardia)

GI upset

Diarrhea

Vomiting

Nausea

Headache

Dizziness

Hypotension (low blood pressure)

Anaphylaxis

Large local reaction

Malaise/Fatigue

Fever

Other, specify symptoms:

Unsure/Do not know

Are there any other symptoms that you experienced to this dose of COVID-19 vaccine that you would like to share? If yes, please describe here.

Expand

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

Cannot remember

If symptoms resolved in more than 5 days, please specify total duration of symptoms to date.

< 1 week

1 week or more but less than 2 weeks

2 weeks or more but less than 3 weeks

3 weeks or more but less than 4 weeks

4 weeks or more but less than 5 weeks

5 weeks or more but less than 6 weeks

6 weeks or more but less than 8 weeks

2 months or more but less than 4 months

4 months or more but less than 6 months

6 months or more

Are there any other information on symptom resolution that you experienced to this dose of COVID-19 vaccine that you would like to share? If yes, please describe here.

Expand

Date of dose administration. Please provide month & year.

Brand name of subsequent dose

Monovalent Pfizer-BioNTech COVID-19 Vaccine

Bivalent Pfizer-BioNTech COVID-19 Vaccine

Monovalent Moderna COVID-19 Vaccine

Bivalent Moderna COVID-19 Vaccine

COVID-19 Vaccine AstraZeneca

Johnson & Johnson/Ad26.COV2.S Vaccine

Novavax COVID-19 Vaccine

Other. Provide name(s) of the vaccine(s):

Do not know

Site of injection:

Right arm

Left arm

Other, specify area of injection:

Do not know

Site of subsequent dose administration

Hospital

Vaccination Clinic

Health Care Center

Pharmacy

Nursing Home

Other, specify the vaccine clinic:

Did you take medications prior to vaccination?

Yes

No

Cannot remember

List any medications taken prior to vaccination (i.e., medications taken on the day of vaccination).

Did you have any other exposures (e.g. foods) in the 6 hours prior to his dose? If yes, please list exposures (e.g. any foods that you ate).

Expand

Did you seek treatment for this reaction? (Check all that apply)

No treatment needed, symptoms resolved on their own

Self medicated [e.g. steroids (orally, topical), Ibuprofen]

At the vaccine clinic

Retail pharmacy

Primary care

Allergy clinic

Urgent care

Emergency department

Hospital admission

ICU admission

Other, specify treatment:

How was the reaction treated? (Check all that apply)

H1 Antihistamines [include medications such as Diphenhydramine (Benadryl), Cetirizine (Zyrtec) Loratadine (Alavert, Claritin), Levocerixine (Xyzal), Clarinex, Allegra, Chlor-Trimeton, Gravol]

Epinephrine shot

Epinephrine drip

Steroids orally

Steroids intravenously

Topical steroids

H2 Blockers [include medications such as cimetidine (Tagamet HB), famotidine (Pepcid Complete or Pepcid AC), nizatidine (Axid AR)]

No treatment needed, symptoms resolved on their own

Other, please specify.

Cannot remember

Upload any pictures of the vaccination reaction below.

Please do not upload any full face photographs or photographs that can be used to identify you.

Reaction Photo 1	Reaction Photo 2	Reaction Photo 3	Reaction Photo 4	Reaction Photo 5

Did you take any medications prior to this dose? If yes, please list medications you took.

Expand

Did you have any other exposures (e.g. foods) in the 6 hours prior to his dose? If yes, please list exposures (e.g. any foods that you ate).

Expand

Have you previously experienced an anaphylaxis episode in your lifetime?

Yes

No

Prefer not to say

What caused the episode(s) of anaphylaxis? (Check all that apply)

Food

Medication

Venom

Unknown cause

Other, specify trigger of anaphylaxis:

Have you seen an allergist about the anaphylaxis episode(s)?

Yes

No

Prefer not to say

Has you been prescribed an Epi-Pen?

Yes

No

Prefer not to say

Do you have a history of allergy to any of the following? (Check all that apply)

Vaccine(s) other than COVID-19

Injectable medications

Polyethylene glycol (PEG)

Polysorbate

Food allergies

Drug allergies

Environmental allergic rhinoconjunctivitis

Latex allergy

Hymenoptera venom allergy

Prefer not to say

How many vaccine allergies (other than COVID-19) do you have?

1

2

3

More than 3

Prefer not to say

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

Cannot remember

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

Cannot remember

Symptoms of reaction (Check all that apply)

Itching

Rash. Specify the type of rash:

Hives

Swelling. Specify the area of the body of the swelling:

Shortness of breath

Wheezing

Chest tightness

Fast heart rate (Tachycardia)

Upset stomach (Gastrointestinal upset)

Diarrhea

Vomiting

Nausea

Headache

Dizziness

Low blood pressure

Anaphylaxis

Large local reaction

Malaise/Fatigue

Fever

Other, specify symptoms:

Cannot remember

What were the specific symptoms of anaphylaxis?

Expand

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

Cannot remember

How was the reaction treated? (Check all that apply)

H1 Antihistamines [include medications such as Diphenhydramine (Benadryl), Cetirizine (Zyrtec) Loratadine (Alavert, Claritin), Levocerixine (Xyzal), Clarinex, Allegra, Chlor-Trimeton, Gravol]

Epinephrine shot

Epinephrine drip

Steroids orally

Steroids intravenously

Topical steroids

H2 Blockers [include medications such as cimetidine (Tagamet HB), famotidine (Pepcid Complete or Pepcid AC), nizatidine (Axid AR)]

No treatment needed, symptoms resolved on their own

Other:

Cannot remember

Have you received THIS vaccine since the initial reaction?

Yes

No

Cannot remember

Did you experience a reaction when receiving THIS vaccine again?

Yes

No

Cannot remember

Have you tolerated any OTHER vaccines after this reaction?

Yes

No

Cannot remember

Which vaccines were tolerated after this reaction?

Expand

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

Cannot remember

If known, what was the date of THIS reaction?

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

Cannot remember

Symptoms of reaction (Check all that apply)

Itching

Rash. Specify the area of the body of the swelling:

Hives

Swelling, specify the area of the body of the swelling:

Shortness of breath

Wheezing

Chest tightness

Fast heart rate (Tachycardia)

GI upset

Diarrhea

Vomiting

Nausea

Headache

Dizziness

Hypotension (low blood pressure)

Anaphylaxis

Large local reaction

Malaise/Fatigue

Fever

Other, specify symptoms:

Cannot remember

What were the specific symptoms of anaphylaxis?

Expand

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

Cannot remember

How was the reaction treated? (Check all that apply)

H1 Antihistamines [include medications such as Diphenhydramine (Benadryl), Cetirizine (Zyrtec) Loratadine (Alavert, Claritin), Levocerixine (Xyzal), Clarinex, Allegra, Chlor-Trimeton, Gravol]

Epinephrine shot

Epinephrine drip

Steroids orally

Steroids intravenously

Topical steroids

H2 Blockers [include medications such as cimetidine (Tagamet HB), famotidine (Pepcid Complete or Pepcid AC), nizatidine (Axid AR)]

No treatment needed, symptoms resolved on their own

Other:

Cannot remember

Have you received THIS vaccine since the initial reaction?

Yes

No

Cannot remember

Did you experience a reaction when receiving THIS vaccine again?

Yes

No

Cannot remember

Have you tolerated any OTHER vaccines after this reaction?

Yes

No

Cannot remember

Which vaccines were tolerated after this reaction?

Expand

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

Cannot remember

If known, what was the date of this reaction?

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

Cannot remember

Symptoms of reaction (Check all that apply)

Itching

Rash, specify the area of the body of the swelling:

Hives

Swelling, specify area of the body:

Shortness of breath

Wheezing

Chest tightness

Fast heart rate (Tachycardia)

GI upset

Diarrhea

Vomiting

Nausea

Headache

Dizziness

Hypotension (low blood pressure)

Anaphylaxis

Large local reaction

Malaise/Fatigue

Fever

Other, specify symptoms:

Cannot remember

What were the specific symptoms of anaphylaxis?

Expand

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

Cannot remember

How was the reaction treated? (Check all that apply)

H1 Antihistamines [include medications such as Diphenhydramine (Benadryl), Cetirizine (Zyrtec) Loratadine (Alavert, Claritin), Levocerixine (Xyzal), Clarinex, Allegra, Chlor-Trimeton, Gravol]

Epinephrine shot

Epinephrine drip

Steroids orally

Steroids intravenously

Topical steroids

H2 Blockers [include medications such as cimetidine (Tagamet HB), famotidine (Pepcid Complete or Pepcid AC), nizatidine (Axid AR)]

No treatment needed, symptoms resolved on their own

Other:

Cannot remember

Has you received THIS vaccine since the initial reaction?

Yes

No

Cannot remember

Did you experienced a reaction when receiving THIS vaccine again?

Yes

No

Cannot remember

Has you tolerated any OTHER vaccines after this reaction?

Yes

No

Cannot remember

Which vaccines were tolerated after this reaction?

Expand

List all additional vaccine allergies other than those mentioned above.

Expand

How many injectable medication allergies do you have?

1

2

3

More than 3

Prefer not to say

In your lifetime have you been exposed to any of the following? (Check all that apply)

Colonoscopy preparations (Golytely)/Constipation treatment (Miralax)

Ultrasound gel

Injectable steroid injections

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:

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

Cannot remember

If known, what was the date of this reaction?

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

Cannot remember

Symptoms of reaction (Check all that apply)

Itching

Rash, specify the type of rash:

Hives

Swelling, specify area of the body:

Shortness of breath

Wheezing

Chest tightness

Fast heart rate (Tachycardia)

GI upset

Diarrhea

Vomiting

Nausea

Headache

Dizziness

Hypotension (low blood pressure)

Anaphylaxis. What were the specific symptoms of anaphylaxis?

Large local reaction

Malaise/Fatigue

Fever

Other, specify symptoms:

Cannot remember

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

Cannot remember

How was the reaction treated? (Check all that apply)

H1 Antihistamines [include medications such as Diphenhydramine (Benadryl), Cetirizine (Zyrtec) Loratadine (Alavert, Claritin), Levocerixine (Xyzal), Clarinex, Allegra, Chlor-Trimeton, Gravol]

Epinephrine shot

Epinephrine drip

Steroids orally

Steroids intravenously

Topical steroids

H2 Blockers [include medications such as cimetidine (Tagamet HB), famotidine (Pepcid Complete or Pepcid AC), nizatidine (Axid AR)]

No treatment needed, symptoms resolved on their own

Other:

Cannot remember

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:

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

Cannot remember

If known, what was the date of this reaction?

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

Cannot remember

Symptoms of reaction (Check all that apply)

Itching

Rash, specify the type of rash:

Hives

Swelling, specify the area of the body of the swelling:

Shortness of breath

Wheezing

Chest tightness

Fast heart rate (Tachycardia)

GI upset

Diarrhea

Vomiting

Nausea

Headache

Dizziness

Hypotension (low blood pressure)

Anaphylaxis. What were the specific symptoms of anaphylaxis?

Large local reaction

Malaise/Fatigue

Fever

Other, specify symptoms:

Cannot remember

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

Cannot remember

How was the reaction treated? (Check all that apply)

H1 Antihistamines [include medications such as Diphenhydramine (Benadryl), Cetirizine (Zyrtec) Loratadine (Alavert, Claritin), Levocerixine (Xyzal), Clarinex, Allegra, Chlor-Trimeton, Gravol]

Epinephrine shot

Epinephrine drip

Steroids orally

Steroids intravenously

Topical steroids

H2 Blockers [include medications such as cimetidine (Tagamet HB), famotidine (Pepcid Complete or Pepcid AC), nizatidine (Axid AR)]

No treatment needed, symptoms resolved on their own

Other:

Cannot remember

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, specify which:

Injectable antibiotic, specify which:

Other, specify the type:

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

Cannot remember

If known, what was the date of this reaction?

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

Cannot remember

Symptoms of reaction (Check all that apply)

Itching

Rash, specify the type of rash:

Hives

Swelling, specify the area of the body of the swelling:

Shortness of breath

Wheezing

Chest tightness

Fast heart rate (Tachycardia)

GI upset

Diarrhea

Vomiting

Nausea

Headache

Dizziness

Hypotension (low blood pressure)

Anaphylaxis. What were the specific symptoms of anaphylaxis?:

Large local reaction

Malaise/Fatigue

Fever

Other, specify symptoms:

Cannot remember

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

Cannot remember

How was the reaction treated? (Check all that apply)

H1 Antihistamines [include medications such as Diphenhydramine (Benadryl), Cetirizine (Zyrtec) Loratadine (Alavert, Claritin), Levocerixine (Xyzal), Clarinex, Allegra, Chlor-Trimeton, Gravol]

Epinephrine shot

Epinephrine drip

Steroids orally

Steroids intravenously

Topical steroids

H2 Blockers [include medications such as cimetidine (Tagamet HB), famotidine (Pepcid Complete or Pepcid AC), nizatidine (Axid AR)]

No treatment needed, symptoms resolved on their own

Other:

Cannot remember

List all additional injectable medication allergies other than those mentioned above.

Expand

What PEG-containing substance(s) caused the reaction?

Expand

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

Cannot remember

If known, what was the date of this reaction?

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

Cannot remember

Symptoms of reaction (Check all that apply)

Itching

Rash, specify the type of rash:

Hives

Swelling, specify the area of the body of the swelling:

Shortness of breath

Wheezing

Chest tightness

Fast heart rate (Tachycardia)

GI upset

Diarrhea

Vomiting

Nausea

Headache

Dizziness

Hypotension (low blood pressure)

Anaphylaxis. What were the specific symptoms of anaphylaxis?:

Large local reaction

Malaise/Fatigue

Fever

Other, specify other symptoms:

Cannot remember

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

Cannot remember

How was the reaction treated? (Check all that apply)

H1 Antihistamines [include medications such as Diphenhydramine (Benadryl), Cetirizine (Zyrtec) Loratadine (Alavert, Claritin), Levocerixine (Xyzal), Clarinex, Allegra, Chlor-Trimeton, Gravol]

Epinephrine shot

Epinephrine drip

Steroids orally

Steroids intravenously

Topical steroids

H2 Blockers [include medications such as cimetidine (Tagamet HB), famotidine (Pepcid Complete or Pepcid AC), nizatidine (Axid AR)]

No treatment needed, symptoms resolved on their own

Other:

Cannot remember

Are you currently avoiding PEG?

Yes

No

Prefer not to say

What polysorbate-containing substance(s) caused the reaction?

Expand

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

Cannot remember

If known, what was the date of this reaction?

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

Cannot remember

Symptoms of reaction (Check all that apply)

Itching

Rash, specify the type of rash:

Hives

Swelling, specify the area of the body of the swelling:

Shortness of breath

Wheezing

Chest tightness

Fast heart rate (Tachycardia)

GI upset

Diarrhea

Vomiting

Nausea

Headache

Dizziness

Hypotension (low blood pressure)

Anaphylaxis. What were the specific symptoms of anaphylaxis?

Large local reaction

Malaise/Fatigue

Fever

Other, specify symptoms:

Cannot remember

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

Cannot remember

How was the reaction treated? (Check all that apply)

H1 Antihistamines [include medications such as Diphenhydramine (Benadryl), Cetirizine (Zyrtec) Loratadine (Alavert, Claritin), Levocerixine (Xyzal), Clarinex, Allegra, Chlor-Trimeton, Gravol]

Epinephrine shot

Epinephrine drip

Steroids orally

Steroids intravenously

Topical steroids

H2 Blockers [include medications such as cimetidine (Tagamet HB), famotidine (Pepcid Complete or Pepcid AC), nizatidine (Axid AR)]

No treatment needed, symptoms resolved on their own

Other:

Cannot remember

Are you currently avoiding polysorbate?

Yes

No

Prefer not to say

How many food allergies do you have?

1

2

3

More than 3

None

Prefer not to say

What food caused this reaction?

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

Cannot remember

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

Cannot remember

Symptoms of reaction (Check all that apply)

Itching

Rash, specify the type of rash:

Hives

Swelling, specify the area of the body of the swelling:

Shortness of breath

Wheezing

Chest tightness

Fast heart rate (Tachycardia)

GI upset

Diarrhea

Vomiting

Nausea

Headache

Dizziness

Hypotension (low blood pressure)

Anaphylaxis What were the specific symptoms of anaphylaxis?

Large local reaction

Malaise/Fatigue

Fever

Other, specify symptoms:

Cannot remember

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

Cannot remember

How was the reaction treated? (Check all that apply)

H1 Antihistamines [include medications such as Diphenhydramine (Benadryl), Cetirizine (Zyrtec) Loratadine (Alavert, Claritin), Levocerixine (Xyzal), Clarinex, Allegra, Chlor-Trimeton, Gravol]

Epinephrine shot

Epinephrine drip

Steroids orally

Steroids intravenously

Topical steroids

H2 Blockers [include medications such as cimetidine (Tagamet HB), famotidine (Pepcid Complete or Pepcid AC), nizatidine (Axid AR)]

No treatment needed, symptoms resolved on their own

Other:

Cannot remember

What food caused this reaction?

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

Cannot remember

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

Cannot remember

Symptoms of reaction (Check all that apply)

Itching

Rash, specify the type of rash:

Hives

Swelling, Specify the area of the body of the swelling:

Shortness of breath

Wheezing

Chest tightness

Fast heart rate (Tachycardia)

GI upset

Diarrhea

Vomiting

Nausea

Headache

Dizziness

Hypotension (low blood pressure)

Anaphylaxis. What were the specific symptoms of anaphylaxis?

Large local reaction

Malaise/Fatigue

Fever

Other, specify symptoms:

Cannot remember

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

Cannot remember

How was the reaction treated? (Check all that apply)

H1 Antihistamines [include medications such as Diphenhydramine (Benadryl), Cetirizine (Zyrtec) Loratadine (Alavert, Claritin), Levocerixine (Xyzal), Clarinex, Allegra, Chlor-Trimeton, Gravol]

Epinephrine shot

Epinephrine drip

Steroids orally

Steroids intravenously

Topical steroids

H2 Blockers [include medications such as cimetidine (Tagamet HB), famotidine (Pepcid Complete or Pepcid AC), nizatidine (Axid AR)]

No treatment needed, symptoms resolved on their own

Other:

Cannot remember

What food caused this reaction?

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

Cannot remember

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

Cannot remember

Symptoms of reaction (Check all that apply)

Itching

Rash, specify the type of rash:

Hives

Swelling, specify the area of the body of the swelling:

Shortness of breath

Wheezing

Chest tightness

Fast heart rate (Tachycardia)

GI upset

Diarrhea

Vomiting

Nausea

Headache

Dizziness

Hypotension (low blood pressure)

Anaphylaxis. What were the specific symptoms of anaphylaxis?:

Large local reaction

Malaise/Fatigue

Fever

Other, specify symptoms:

Cannot remember

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

Cannot remember

How was the reaction treated? (Check all that apply)

H1 Antihistamines [include medications such as Diphenhydramine (Benadryl), Cetirizine (Zyrtec) Loratadine (Alavert, Claritin), Levocerixine (Xyzal), Clarinex, Allegra, Chlor-Trimeton, Gravol]

Epinephrine shot

Epinephrine drip

Steroids orally

Steroids intravenously

Topical steroids

H2 Blockers [include medications such as cimetidine (Tagamet HB), famotidine (Pepcid Complete or Pepcid AC), nizatidine (Axid AR)]

No treatment needed, symptoms resolved on their own

Other:

Cannot remember

List all additional food allergies other than those mentioned above.

Expand

How many drug allergies do you have?

1

2

3

More than 3

None

Prefer not to say

What drug caused this reaction?

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

Cannot remember

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

Cannot remember

Symptoms of reaction (Check all that apply)

Itching

Rash, specify the type of rash:

Hives

Swelling: specify the area of the body of the swelling

Shortness of breath

Wheezing

Chest tightness

Fast heart rate (Tachycardia)

GI upset