VBF COVID-19 Illness/Vaccination Survey

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* 1. Do you have a vascular birthmark/anomaly/related syndrome, or are you a caregiver or loved one of someone who does?

I have a vascular birthmark/anomaly/related syndrome.

I am a caregiver or loved one of someone with a vascular birthmark/anomaly/related syndrome.

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* 2. What is your COVID-19 virus status?

I had COVID-19

I received a COVID-19 vaccine

I had COVID-19 and then received the vaccine

I have had neither COVID-19 nor a COVID-19 vaccine

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* 3. If you had COVID-19, how severe were your symptoms on a scale of 0-5?

Not Applicable

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* 4. If you received a COVID-19 vaccine, which vaccine did you receive?

Pfizer-BioNTech

Moderna

Johnson & Johnson/Janssen

AstraZeneca-Oxford

Sinovac Biotech's CoronaVac

Not applicable

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* 5. Did you qualify for a COVID-19 vaccine because you/your loved one has a vascular birthmark/anomaly/related syndrome?

Yes

Not applicable

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* 6. Have you noticed any changes to your vascular birthmark/anomaly/related syndrome as a result of having :

COVID-19

COVID-19 Vaccine

Both

Not Applicable

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* 7. Please identify all of the changes you experienced:

New Growth

Crusting

Burning

Oozing

Darkening

Bleeding

Ulcerating

Infection

Arrhythmia

Shrinking

Lightening

Disappeared

Made it better

Decreased infections

Not Applicable

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* 8. What type(s) of vascular birthmark/anomaly/related syndrome have you been told that you have?

Hemangioma

Port Wine Stain Birthmark

Venous Malformation

Arteriovenous Malformation (AVM)

Sturge-Weber Syndrome

Cutis Marmorata Telangiectatica Congenita (CMTC)

Lymphatic Malformation (Lymphangioma)

Klippel-Trenaunay Syndrome (KTS)

P.H.A.C.E. Syndrome

Other

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* 9. If you experienced any complications or positive changes to your vascular birthmark/anomaly/related syndrome due to either COVID-19 or a COVID-19 vaccine, or both, please explain in 30 words or less.

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* 10. What is your gender identity?

Male

Female

Other

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* 11. Which of the following groups do you identify with (Choose all that apply)

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Biracial/Multiracial

Other

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* 12. What is your current country of residence?

United States

Outside of the United States

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* 13. What is your age?

18 - 24

25 - 34

35 - 44

45 - 54

55 - 64

65+

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* 14. What is you annual household income range?

Less than $50,000

Between $50,000 and $74,999

Between $75,000 and $99,999

Between $100,000 and $150,000

Over $150,000

Prefer not to respond

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* 15. What is the location of your vascular birthmark/anomaly/related syndrome?

Nasal Area

Beard (V3) Distribution

Between the eyes

Upper Lip

Lower Lip

Upper or lower eyelid

Involving the eyeball

Forehead

Right side of face

Left side of face

Left or Right Cheek

Oral Cavity (including dental)

Neck

Tongue

Parotid

Ear(s)

Airway

Intracranial (within the brain)

Extracranial (outside on the head)

Visceral

Lower extremities

Upper extremities

Trunk

Lung

Liver

Gastrointestinal Tract

Chin

Spleen

Sacral (lower back)

Perineal (genital area)

Breast Area

Buttocks

Other (Please Specify)

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* 16. Is the birthmark, anomaly, or related syndrome in more than one place?

Yes