Your Name:
Child’s Name:
Address:
Telephone:
E-Mail:
1. Which of the following measles-containing vaccines did your child receive? (check one that applies):
2. How old was your child at the time of vaccination with measles-containing or MMR vaccine?
Please Select
6 months or under
12 months or under
15 months or under
18 months or under
24 months or under
36 months or under
4 to 6 years old
7 to 12 years old
Over 12 years old
3. Was your child healthy and developing normally BEFORE receiving measles or MMR vaccine?
4. BEFORE the measles or MMR shot, did your child have reactions or health problems after other vaccinations?
5. Was your child sick with an infection of any kind AT THE TIME OF vaccination with measles or MMR vaccine?
6. Was your child given other vaccines on the SAME DAY that the measles or MMR vaccine was given?
If yes, check other vaccines given that day:
7. After the measles or MMR shot, did your child have (check all that apply):
8. How soon after the measles or MMR shot did your child FIRST show any of the symptoms listed above?
Please Select
24 to 72 hours after vaccination
4 to 7 days
7 to 14 days
3 to 4 weeks
9. Has your child been diagnosed by a doctor as having (check all that apply):
10. Was your child born prematurely?
11. Did your doctor report your child’s change in mental, physical or emotional behavior and other health problems following measles or MMR vaccine to the Vaccine Adverse Event Reporting System
(VAERS)?
12. Does your child have a family history (mother, father, sister, brother, grandparents) of neurological (brain) or immune system disorders? Check all that apply:
