Share your story - Vaccine hesitant

Step 1 of 4

25%

Name(Required)

Email Address(Required)

IG Handle(Required)

Age(Required)

Location(Required)

Occupation(Required)

Describe your family/children.(Required)

Upload Image(Required)

Max. file size: 2 GB.

Upload Second Image (optional)

Max. file size: 2 GB.

List your autoimmune diseases.(Required)

List your chronic or related viruses.(Required)

Describe your diet, physical activity, sleep routine and any other relevant information.(Required)

Do you have any of the following COVID “high risk” factors? Check all that apply(Required)

Comorbidity (the presence of 2 or more diseases in the same person)

Cancer

Chronic Kidney Disease

Heart Disease

Down Syndrome

Pregnancy

Type 2 Diabetes mellitus

Over age 55

Metabolic Syndrome

Obesity

Coagulation/Blood Clotting

Respiratory Issues/Lung Issues

I have no COVID “high risk” factors

Are you under the care of a medical doctor?(Required)

Yes

What kind of doctor(s)/provider(s) do you work with? Explain.(Required)

Did your doctor(s)/provider(s) advise you to get the vaccine?

Yes

Provide the studies/resarch that you're doctor(s)/provider(s) used to support you getting the vaccine or not getting the vaccine.(Required)

What other resources have you read to make you feel vaccine hesitant? Provide links to studies, articles, scientific research, etc.(Required)

Health Related Questions:

Please describe your health along with any autoimmune, chronic or related illness symptoms you are experiencing.(Required)

What kind of prescribed medications do you currently take?(Required)

What kind of vitamins/supplements do you currently take?(Required)

Covid-19 Questions:

Did you already have Covid-19?(Required)

Yes

When did you have Covid-19?(Required)

Please explain your symptoms and experiences while sick with Covid-19.(Required)

Since having Covid-19, have you been tested for Covid-19 antibodies?(Required)

Yes

What were the results of your Covid-19 antibody test?(Required)

What factors are influencing your hesitation to be vaccinated for Covid-19? (For example: religious, scientific, consciousness, cultural)(Required)

In Conclusion – Provide a general summary that we can use to introduce your story to our community.(Required)

In order to submit this form, the following must be completed:

Are you interested in having Aimee contact you to schedule an interview-style session to discuss your submission on a recorded video?(Required)

Yes, I am interested.

No, thank you.

What is the best email address or phone # to contact you at?(Required)

We would like to do a follow up on your health in the coming months. When do you want us to reach out to you again?(Required)

I would like to be contacted in 12 months to complete a follow up questionnaire.

I would like to be contacted in 6 months to complete a follow up questionnaire.

PERMISSION: I give permission for AUTOIMMUNE SISTERS to share this information on the @AutoimmuneSisters instagram feed, in instagram stories and/or on their website www.AutoimmuneSisters.org(Required)

Yes, I agree with the permission statement.

Form Preview

{all_fields}

Share your story – Vaccine hesitant

Health Related Questions:

Covid-19 Questions:

In order to submit this form, the following must be completed:

Form Preview

Free Downloads!

Smoothie eBook

Smoothie Chart

10 Questions to Ask

Anti-Inflammatory Recipes

AUTOIMMUNE SISTERS

Resorces

About