This is a registry for those with PSP or CBD to report adverse effects of their COVID vaccine.  CurePSP will use this information to help researchers and other patients with PSP or CBD understand the potential risks of the vaccines.

First, some instructions:
A.     Please do not report common, expected vaccine side effects such as sore shoulder or mild fever, body aches, sleepiness or general fatigue if they went away after two or three days. 
B.     Do not report immediate effects of stress from the needlestick such as fainting, sweating or feelings of anxiety/panic.
C.     If you are uncomfortable providing any of these items, just leave that space blank.

If you have any further questions or comments, please contact CurePSP at info@curepsp.org.

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* 1. Today's Date:

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* 2. First name:

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* 3. Last name:

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* 4. In what year were you born? (enter 4-digit birth year; for example, 1976)

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* 5. Sex:

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* 6. Neurological diagnosis:

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* 7. Subtype, if known:

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* 8. Was this diagnosis made or confirmed by a neurologist specializing in movement disorders?

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* 9. Have any other vaccines given you adverse effects other than injection site soreness or minor fever and fatigue?

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* 10. Do you have a medical condition that increases the risk of allergic reactions?

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* 11. List of oral or injected medications taken in the past month (do not list dosages or frequency, just the generic or brand names; include over-the-counter medications such as aspirin):

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* 12. Type of COVID vaccine received:

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* 13. Dates of immunization

Date
Date

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* 14. Adverse effect:

[Please enter each additional adverse effect, if any, separated by commas. (If multiple symptoms seem to be part of the same reaction, do not report each symptom separately. For example, if the reaction was hives, report “hives” as a single adverse effect. Do not report “red spots” and “itching” as two separate adverse effects.)]

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* 15. Symptoms you experienced:

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* 16. Medical name of the reaction (if known):

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* 17. Dates of reaction onset and resolvement

Date
Date

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* 18. Did it require attention from a doctor, nurse or physician’s assistant?

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* 19. How long did it last?

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* 20. Did it interfere at all with continuing your previous, normal activities?

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* 21. Did it require hospitalization overnight?

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* 22. May we contact you to ask for more information?

Thank you for your time and effort to help others with your condition.

Lawrence I. Golbe, MD
Director of Clinical Affairs, CurePSP

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