COVID-19 Vaccine Follow-Up Survey for DRESS, SJS/TEN and AGEP Patients

Information gathered from this survey will help us better understand how patients and survivors of severe adverse hypersensitivity drug reactions are reacting to the COVID-19 vaccines.

Although responses may be shared with the public, personal identifying information will be kept confidential.

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* 1. Patient Information

Name

Email Address

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* 2. Please confirm that you have taken the COVID-19 vaccine before completing this survey.

Yes, I've had the first dose.

Yes, I've had the first and second doses.

Maybe — I'm in a clinical trial.

No, but I plan to get the vaccine as soon as I am able. Please send me a reminder in one month. (stop here and submit survey).

No, I do not plan to get the vaccine (you may specify a reason below and answer through question #11 then submit survey).

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* 3. In what country do you live?

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* 4. In what state or U.S. territory do you live?

Other (state or province outside of US)

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* 5. What is your age?

Under 18

18-24

25-34

35-44

45-54

55-64

65-74

75+

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* 6. Please describe your gender.

Female

Male

Other Description (please specify)

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* 7. Please describe your ethnicity.

White or Caucasian

Hispanic or Latino

Black or African American

Native Hawaiian or other Pacific Islander

American Indian or Alaska Native

Asian or Asian American

Other (please specify)

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* 8. Was your severe adverse drug reaction diagnosed by a physician?

Yes

No, but it is suspected that I had a severe adverse drug reaction.

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* 9. What year were you diagnosed with or suspected of having a severe adverse drug reaction?

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* 10. Which drug reaction did you have?

DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms) also known as
DIHS (Drug Induced Hypersensitivity Syndrome)

SJS (Stevens-Johnson Syndrome)

TEN (Toxic Epidermal Necrolysis)

Both SJS and TEN

AGEP (Acute Generalized Exanthematous Pustulosis)

Other (please specify)

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* 11. Was a known medication associated with your adverse reaction?

Yes

No (skip to question #11)

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* 12. Which medication is believed to have caused your adverse reaction?

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* 13. If not a medication, what was thought to be the cause of your adverse reaction?

Unknown

Mycoplasma (confirmed by testing)

Herpes virus (confirmed by testing)

Mycoplasma, Herpes, or other virus was suspected but I tested negative.

N/A

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* 14. Which vaccine did you receive?

Pfizer-BioNTech COVID-19 vaccine

Moderna's COVID-19 vaccine

AstraZeneca's COVID-19 vaccine

Janssen's COVID-19 vaccine

Novavax's COVID-19 vaccine

I Don't Know

Other (please specify)

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* 15. How would you describe your reaction to the 1st dose of vaccine?

Mild

Severe

None

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* 16. Did you experience any of the following symptoms after being vaccinated with the 1st dose?

Fatigue

Hives

Swelling

Wheezing (respiratory distress)

Fever (<101F/38.3C)

Fever (>102F/38.8C)

Tenderness, swelling, or bruising at injection site

Anaphylaxis

Fainting (syncope, vasovagal)

Other immediate reaction (within 4 hours of vaccine)

Other delayed reaction (later than 4 hours of vaccine)

N/A

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* 17. How would you describe your reaction to the 2nd dose of vaccine?

Mild

Severe

None

N/A

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* 18. Did you experience any of the following symptoms after being vaccinated with the 2nd dose?

Fatigue

Hives

Swelling

Wheezing (respiratory distress)

Fever (<101F/38.3C)

Fever (>102F/38.8C)

Tenderness, swelling, or bruising at injection site

Anaphylaxis

Fainting (syncope, vasovagal)

Other immediate reaction (within 4 hours of vaccine)

Other delayed reaction (later than 4 hours of vaccine)

N/A

COVID-19 Vaccine Follow-Up Survey for DRESS, SJS/TEN and AGEP Patients

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* 1. Patient Information

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* 2. Please confirm that you have taken the COVID-19 vaccine before completing this survey.

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* 3. In what country do you live?

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* 4. In what state or U.S. territory do you live?

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* 5. What is your age?

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* 6. Please describe your gender.

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* 7. Please describe your ethnicity.

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* 8. Was your severe adverse drug reaction diagnosed by a physician?

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* 9. What year were you diagnosed with or suspected of having a severe adverse drug reaction?

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* 10. Which drug reaction did you have?

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* 11. Was a known medication associated with your adverse reaction?

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* 12. Which medication is believed to have caused your adverse reaction?

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* 13. If not a medication, what was thought to be the cause of your adverse reaction?

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* 14. Which vaccine did you receive?

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* 15. How would you describe your reaction to the 1st dose of vaccine?

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* 16. Did you experience any of the following symptoms after being vaccinated with the 1st dose?

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* 17. How would you describe your reaction to the 2nd dose of vaccine?

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* 18. Did you experience any of the following symptoms after being vaccinated with the 2nd dose?

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* 19. What else would you like to share about your experience with the COVID-19 vaccine?