This document details the questions COVERSE asked its users in the vaccine injury profile.
It is important for us to collect data on COVID-19 vaccine injures in Australia so that we have independent data to support our advocacy efforts.
Record your injury in as much detail as possible below. You do not need to complete it all at once — you can save it as a draft and return later when you are able to finish it. Note, if you want to ask us a question or need specific help regarding your injury then send us an email).
We estimate the form will take 20–60 minutes to complete, depending on your circumstances and how much information you wish to provide. This information is held in confidence and individual response details will never be published.
If you had a COVID-19 vaccination after you’d already had an adverse reaction, what was your later experience?
How bad were the following symptoms when they were at their worst?
Note that this list is long. You may wish to complete part of it now, then scroll to the very bottom to save a draft, and return another day to complete it.
| minimal | mild | moderate | moderately severe | severe | N/A | |
|---|---|---|---|---|---|---|
| fatigue | ||||||
| exercise intolerance | ||||||
| brain fog | ||||||
| dizziness | ||||||
| insomnia | ||||||
| sleep disturbances | ||||||
| excessive sleep | ||||||
| paralysis | ||||||
| seizures | ||||||
| head pressure | ||||||
| new headaches | ||||||
| memory loss | ||||||
| new severe anxiety | ||||||
| feeling off-balance, or in motion while at rest | ||||||
| tinnitus | ||||||
| sensitivity to sound | ||||||
| sensitivity to light | ||||||
| visual disturbances | ||||||
| temporary blindness | ||||||
| glaucoma | ||||||
| dry eyes | ||||||
| nerve pain | ||||||
| tremors | ||||||
| muscle twitching | ||||||
| internal vibrations | ||||||
| tingling / numbness in extremities | ||||||
| burning sensation on skin | ||||||
| joint pain / arthritis | ||||||
| muscle aches | ||||||
| muscle weakness | ||||||
| unstable joints | ||||||
| muscle loss | ||||||
| heaviness in legs | ||||||
| adrenaline surges | ||||||
| chest pain | ||||||
| myocarditis | ||||||
| pericarditis | ||||||
| heart palpitations | ||||||
| shortness of breath | ||||||
| high heart rate | ||||||
| low blood pressure | ||||||
| high blood pressure | ||||||
| persistent cough | ||||||
| heartburn / indigestion | ||||||
| dry mouth | ||||||
| abdominal / stomach pain | ||||||
| nausea | ||||||
| diarrhoea | ||||||
| loss of bowel control | ||||||
| constipation | ||||||
| bloody or black tar-like stool | ||||||
| excessive gas | ||||||
| increased thirst | ||||||
| frequent urination | ||||||
| loss of bladder control | ||||||
| abnormal glucose levels | ||||||
| discolouring of skin / eyes | ||||||
| discolouration in fingertips / toes | ||||||
| bulging veins | ||||||
| poor circulation | ||||||
| swelling of extremities | ||||||
| swollen lymph nodes | ||||||
| persistent sore throat | ||||||
| heat intolerance | ||||||
| skin redness, hives, petechia or rashes | ||||||
| new food allergies / intolerances | ||||||
| anaphylaxis | ||||||
| hair loss | ||||||
| chills | ||||||
| irregular menstrual cycle | ||||||
| resurgence of latent disease (e.g. shingles, EBV, cancer, autoimmune disease, etc.) |
Are your symptoms more often on one side of your body? *
i.e. how many months until you began to notice any improvement?
Have you received a diagnosis that later proved to be incorrect?
Order from most helpful to least helpful
Order from least helpful
If you qualify for workers’ compensation, have you had issues with your claim? *