| Source | cinc.fhir.ig#current:Care In The Community FHIR API (v4.0.1) |
| resourceType | Questionnaire |
| id | ActiveMonitoringDay7Survey |
| canonical | https://build.fhir.org/ig/tewhatuora/cinc-fhir-ig/Questionnaire/ActiveMonitoringDay7Survey |
| version | 0.2.8 |
| status | draft |
| publisher | Te Whatu Ora |
| name | ActiveMonitoringDay7Survey |
| title | Influenza and COVID-19 Booster Vaccination 7 Day Review Questionnaire |
| date | 2023-09-04T01:21:52+00:00 |
| description | Te Whatu Ora 7-day post Influenza/Covid-19 booster vaccination survey. |
| jurisdictions | nz |
| Usages | (none) |
page 1: This is the first of two surveys about your vaccine experience. This survey will take approximately five minutes to complete. You will be asked for some demographic data and about any symptoms you have experienced. There is a section at the end for you to comment on any other parts of the vaccine experience.
page 2: Vaccine Administration
page 2 question 1: Which vaccine did you receive 7 days ago? *
page 2 question 1.1: Were they both given in the arm? *
page 3: Health Conditions
Do you have any long-term medical conditions?
Please select all the long term conditions that apply.
Please explain any other long term medical conditions you have.
page 4 question 1: Side Effects
Did you have any reactions following your vaccine? This includes any reactions your vaccinator told you to expect AND anything you did not expect that you think might be a reaction, no matter how minor.
page 5 question 12.1: Side Effects Details
Did you experience any injection site reactions (pain, redness, swelling, itching at or near the injection site)?
Please select all in select all the injection site reactions that you experienced.
Did you have swelling of entire arm?
Did you have swelling of lymph nodes under your arm/in the armpit?
Fever (a temperature of 38°C or higher)?
Chills (shivering and feeling cold)?
Did you experience a rash, not near the injection site? *
When did the rash appear? *
How long did the rash last? *
Please indicate the location of the rash.
Please explain where rash occurred.
Did you experience headaches, muscle or body aches, or joint aches or pain? *
Please select all that apply. *
Did you experience any gastrointestinal symptoms? *
Please select all that gastrointestinal symptoms that apply. *
Please specify any other gastrointestinal symptoms you experienced.
Did you experience fatigue or tiredness? *
Did you have any of these Chest Symptoms? - Please select all that apply
Please specify other chest symptoms you experienced. *
Did you experience any of the following heart symptoms? Please select all that apply. *
Please specify any other heart symptoms you experienced? *
Did you experience any difficulty breathing? *
Did you experience any symptoms that were not listed above? *
What other side effects did you experience?
page 6 question 3.1.1: Symptom Relief
Did any of the symptoms you reported cause you to miss work, study, or normal daily activities? *
How many days did you miss? *
Did any of the symptoms cause you to seek advice or care from a healthcare professional? *
Please select the type of advice or care you sought. *
Please explain any other advice or care you sought. *
Did you take any over the counter medications to relive the pain/discomfort? *
Please specify what medication you took. *
Please specify any alternate medications you took. *
page 7 question 2.1: Vaccine Experience
How would you rate your overall experience getting the vaccine? *
Do you have any comments about your vaccine experience? *
Please Explain
page 8: Thank you for completing the Day 7 survey, your answers have been submitted. You will receive your Day 42 survey in 35 days. Your responses will help contribute to the safety monitoring of the Influenza vaccine. The information you provide is protected by the Privacy Act 2020. Please remember this is a survey only and your answers will not result in a medical response. If you have any concerns about your health, ring Healthline at 0800 611 116 or speak to your healthcare professional. If you experience any of these symptoms of myocarditis and pericarditis: tightness, heaviness, discomfort, pressure or pain in your chest or neck; difficulty breathing or catching your breath; feeling faint, dizzy, or light-headed; fluttering, racing, or pounding heart, or feeling like it’s ‘skipping beats,’ seek medical help promptly and mention your vaccination.
Produced 08 Sep 2023