The following items need a response
Do you have a bleeding disorder?

Do you have a weakened immune system (immunocompromised)?

Have you been sick with a cough, sore throat, fever or are feeling sick in another way?

Have you ever been diagnosed with capillary leak syndrome?

Have you ever had major venous and/or arterial thrombosis in combination with thrombocytopenia, including diagnosed Thrombotic Thrombocytopenic Syndrome (TTS), following a previous dose of a COVID-19 vaccine?

Have you ever had cerebral venous sinus thrombosis? *

Have you ever had heparin-induced thrombocytopenia? *

Have you ever had blood clots in the abdominal veins (splanchnic veins)? *

Have you ever had antiphospholipid syndrome associated with blood clots? *