Vaccine Toxic Exposure Survey by Kevin Thomson May 12, 2022 written by Kevin Thomson May 12, 2022 394 Welcome to the Vaccine Toxic Exposure Survey Having a DD-214 and Medical Record ready may help answer some questions but is not required Press Next to get started What is your Name? What is your Gender Man Woman Transgender Non-Binary/Non-Conforming Prefer not to Answer What is your Age Are you Currently Employed? Yes No Are you receiving compensation through the VA for service connected disabilities? Yes No What is your VA disability Rating? Please select your answer 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100% Are you Collecting Social Security Disability Insurance (SSDI)? Yes No At what age did you begin receiving SSDI? What Branch(es) of Military Were you In Army Army Reserves Army National Guard Navy Navy Reserves Marine Corps Marine Corps Reserves Airforce Airforce Reserves Airforce National Guard Coast Guard Coast Guard Reserves Civilian Contractor What was your MOS or Rate (Navy) Were you Medically Discharged? Yes No Did you serve in the Continental U.S. Area? This does NOT include Alaska or Hawaii This DOES include any training or shore duty Yes No What Time and Places did you serve in CONUS? Example: NAS Oceana 97-05, FT. Hood 93-94, etc Did you Deploy to Southwest Asia area (Iraq, Kuwait, Saudi Arabia, Neutral Zone Between Iraq & Saudi Arabia, Bahrain, Qatar, United Arab Emirates, Oman, Gulf of Aden, Gulf of Oman, Waters of the Persian Gulf, the Arabian Sea, and the Red Sea, the Airspace above these locations) Yes No Where in Southwest Asia Theater were you located and years? Did you serve outside the Continental U.S. Area? Other than Southwest Asia Theater of Military Operations Yes No What Time and Places did you serve OCONUS? Example: NAF Atsugi - Japan 93-97, NATO LANDCOM - Turkey-04-05, etc Did you Receive the Anthrax Vaccine? Yes No Which Vaccinations or Treatment Protocols are Recorded on your Medical Records? Yellow Fever Typhoid Oral Typhoid Cholera Hepatitis A Hepatitis B Menigitis Whooping Cough Polio Oral Polio Tetanus Japanese Encephalitis Influenza Influenza Intranasal Measels, Mumps, and Rubella (MMR) Meningococcal (MGC) PPD TB Skin Test Anthrax Botulinum Toxoid Pyridostigmine Bromide Pills Mefloquine (Malaria Drug) Small Pox Adeno Virus I Don't Have My Record Which Vaccinations or Treatment Protocols are NOT Recorded on your Medical Records? Separate each one by a comma please. Have you Received the Following Anthrax Lot Numbers? FAV008 FAV017 FAV020 FAV030 FAV038 FAV041 FAV043 FAV047 FAV048b FAV066 FAV068 FAV069 FAV070 FAV071 FAV073 FAV074 FAV075 FAV078 What dates did you receive the Anthrax Vaccine? If you didn't receive the entire series, leave those dates blankMM/DD/YY, MM/DD/YY, etc. How long after the Anthrax Series did you first notice symptoms? Immediately 2-5 Months 6 Months 1 Year 2Years 3-4 Years 5-10 Years 10+ Years Have you been exposed to any of the following: (Multiple Response) Agent Orange or other herbicides Chemicals (solvents, cleaners, degreaser, etc) JP-4/5/8 Jet fuel (Direct skin exposure) Sand/Dust Storms Smoke from burning trash/feces Smoke from Oil Fires/Wells Depleted Uranium None of the Above In General, would you say your health is? (Select an Answer) Excellent Very Good Good Fair Poor Do you suffer from any of the following: Neurological Issues? Forgetful or Trouble Remembering Things Short Term Memory Loss Cognitive Dysfunction Dizziness Migraines Light Sensitivity Loss of Balance Disorder of Autonomic Nervous System Insomnia Sleep Disturbance Sleep Apnea Night Sweats Tremors Chemical Sensitivity Disorder Passing out and fainting None of the Above Neurological Issues - Page 2 Paralysis Feeling hot or cold regardless of weather Numbness or tingling in any part of the body Troubles with Sensory Processing (site, touch, taste, smell, or hearing) Parkinson's Disease Dementia or Alzheimer's disease Peripheral Neuopathy Lyme's Disease Lou Gehrig's disease Also called: ALS, amyotrophic lateral sclerosis Raynaud's Phenomenon Restless Leg Syndrome Other Neurological Issues None of the Above Do you suffer from any of the following: Psychological Issues? Depression Anxiety PTSD Other Psychological Problems None of the Above Do you suffer from any of the following: Digestive / Gastrointestinal problems? Functional Dyspepsia (recurring signs of indigestion) Functional Abdominal Pain Syndrome Gastrointestinal Problems Irritable Bowel Syndrome (IBS) Intestinal or Stomach Problems Interstitial Cystitis Nausea or Vommiting Poor Appetite None of the Above Do you suffer from any of the following: Excretory System Issues? Overactive Bladder Frequent Need to Urinate at Night Difficulty with Urination Diarrhea None of the Above Do you suffer from any of the following: Musculoskeletal Issues? Fibromyalgia Muscle Spasms Muscle Pain Joint Pain Muscle Weakness Neck ache or pains Arm, hand, foot or leg aches and pains Swelling of arms, hands, legs or feet Degenerative Disc Disease Chronic Back pain, sciatica, or herniated disk Broken bones or joint surgery or back surgery Arthritis Patellofemoral Arthritis (Affects Knees) Temporomandibular (TMJ) Bruxism (unconsciously grind or clench your teeth) Difficulty swallowing Multiple Sclerosis Lupus or Sarcoidosis None of The Above Do you suffer from any of the following: Reproductive System Issues? Burning Semen Male Reproductive Issues Female Reproductive Issues Menstrual Disorders Endometriosis Dyspareunia None of the Above Do you suffer from any of the following: Integumentary (Skin) Issues? Hives Dermatitis Skin Trouble (rashes, boils, itching) Keratitis None of the Above Do you suffer from any of the following: Cardiovascular Issues? Respiratory Disorders Difficulty breathing or shortness of breath Asthma Thrombocytopenia Postural Orthostatic Tachycardia Syndrome Palpitations or Heart Pounding Chest Pains Chronic Cough Cardiovascular Disease Emphysema or Chronic Lung Disease Chronic Bronchitis None of the Above Do you suffer from any of the following: Endocrine Issues? Adrenal Deficiency Fatigue Chronic Fatigue Syndrome Lyhphedema Multinodular Goiter Gout Thyroid Issues Thydroid Disease None of the Above Do you suffer from any OTHER diagnosis? Separate multiple symptoms by a comma Leave Blank if not Have you ever had an Adverse Reaction to Immunization Yes No Have you been diagnosed with Vaccine Immunoglobulin and Antisera Adverse Reaction Yes No If you suffered a Vaccine Injury did you report it to VAERS? Yes No Not Applicable (N/A) Have you (or your partner or spouse) had any problems with infertility, miscarriages, or still births? Yes No Unknown N/A Have any of your biological children been diagnosed with birth defects? Yes No Unknown N/A Have any of your biological children been diagnosed with other disabilities? Yes No Unkown N/A Would you be interested in conducting an interview that will be included in our video documentary? The video documentary will be used to bring awareness of Chronic Multi-Symptom Illness and will be used at our Congressional hearing as personal testimony. If so please include email below. Yes No Would you care to fill out a flyer to highlight your personal experiences? This would be posted on our social media as well as given to Congress for personal testimony? Yes No What is your Email Address? Thank You for taking the time to fill out the survey. If you would like to schedule time for a one on one consultation and learn more about our projects, what you can do to help, or how to participate in our documentary. You may reserve time by visiting our board members page. Please Press Submit to Finish Time is Up! Time's up 0 comment 0 FacebookTwitterLinkedinEmail Kevin Thomson Leave a Comment Cancel ReplyYou must be logged in to post a comment.
