State of health of vaccinated children/persons (Gesundheitszustand geimpfter Kinder) 
! entirely unvaccinated children questionnaire for unvaccinated children .! 
For statistical evaluation of the state of health of   vaccinated children/persons  we request you to fill out the following form. The data will be published anonymously and handled with utmost confidentiality.  The results help us to acquire accurate information about the health of unvaccinated children compared to the state of health of vaccinated children.
 
 
  Date of birth of the vaccinated child
							 
							
 
  Age group (present)
0-2 years 
3-4 years 
5-6 years 
7-8 years 
9-10 years 
11-12 years 
13-14 years 
15-16 years 
17-18 years 
19- years and older 
 
 
  Country
United States(USA) 
Canada 
United Kingdom 
Australia 
New Zealand 
--- 
Afghanistan 
Aland Islands 
Albania 
Algeria 
American Samoa 
Andorra 
Angola 
Anguilla 
Antarctica 
Antigua And Barbuda 
Argentina 
Armenia 
Aruba 
Australia 
Austria 
Azerbaijan 
Bahamas 
Bahrain 
Bangladesh 
Barbados 
Belarus 
Belgium 
Belize 
Benin 
Bermuda 
Bhutan 
Bolivia 
Bosnia and Herzegovina 
Botswana 
Bouvet Island 
Brazil 
British Indian Ocean Territory 
Brunei Darussalam 
Bulgaria 
Burkina Faso 
Burundi 
Cambodia 
Cameroon 
Canada 
Cape Verde 
Cayman Islands 
Central African Republic 
Chad 
Chile 
China 
Christmas Island 
Cocos (Keeling) Islands 
Colombia 
Comoros 
Congo 
Congo, the Democratic Republic of the 
Cook Islands 
Costa Rica 
Cote d'Ivoire 
Croatia 
Cyprus 
Czech Republic 
Denmark 
Djibouti 
Dominica 
Dominican Republic 
East Timor 
Ecuador 
Egypt 
El Salvador 
Equatorial Guinea 
Eritrea 
Espana 
Estonia 
Ethiopia 
Falkland Islands 
Faroe Islands 
Fiji 
Finland 
France 
French Guiana 
French Polynesia 
French Southern Territories 
Gabon 
Gambia 
Georgia 
Germany 
Ghana 
Gibraltar 
Greece 
Greenland 
Grenada 
Guadeloupe 
Guam 
Guatemala 
Guernsey 
Guinea 
Guinea-Bissau 
Guyana 
Haiti 
Heard and Mc Donald Islands 
Honduras 
Hong Kong 
Hungary 
Iceland 
India 
Indonesia 
Ireland 
Isle Of Man 
Israel 
Italy 
Jamaica 
Japan 
Jersey 
Jordan 
Kazakhstan 
Kenya 
Kiribati 
Korea, Republic of 
Korea (South) 
Kuwait 
Kyrgyzstan 
Lao People's Democratic Republic 
Latvia 
Lebanon 
Lesotho 
Liberia 
Libya 
Liechtenstein 
Lithuania 
Luxembourg 
Macau 
Macedonia 
Madagascar 
Malawi 
Malaysia 
Maldives 
Mali 
Malta 
Marshall Islands 
Martinique 
Mauritania 
Mauritius 
Mayotte 
Mexico 
Micronesia, Federated States of 
Moldova, Republic of 
Monaco 
Mongolia 
Montenegro 
Montserrat 
Morocco 
Mozambique 
Myanmar 
Namibia 
Nauru 
Nepal 
Netherlands 
Netherlands Antilles 
New Caledonia 
New Zealand 
Nicaragua 
Niger 
Nigeria 
Niue 
Norfolk Island 
Northern Ireland 
Northern Mariana Islands 
Norway 
Oman 
Pakistan 
Palau 
Palestinian Territories 
Panama 
Papua New Guinea 
Paraguay 
Peru 
Philippines 
Pitcairn 
Poland 
Portugal 
Puerto Rico 
Qatar 
Reunion 
Romania 
Russia 
Russian Federation 
Rwanda 
Saint Barthelemy 
Saint Kitts and Nevis 
Saint Lucia 
Saint Martin 
Saint Vincent and the Grenadines 
Samoa (Independent) 
San Marino 
Sao Tome and Principe 
Saudi Arabia 
Scotland 
Senegal 
Serbia 
Seychelles 
Sierra Leone 
Singapore 
Slovakia 
Slovenia 
Solomon Islands 
Somalia 
South Africa 
South Georgia and the South Sandwich Islands 
South Korea 
Spain 
Sri Lanka 
St. Helena 
St. Pierre and Miquelon 
Suriname 
Svalbard and Jan Mayen Islands 
Swaziland 
Sweden 
Switzerland 
Taiwan 
Tajikistan 
Tanzania 
Thailand 
Togo 
Tokelau 
Tonga 
Trinidad 
Trinidad and Tobago 
Tunisia 
Turkey 
Turkmenistan 
Turks and Caicos Islands 
Tuvalu 
Uganda 
Ukraine 
United Arab Emirates 
United Kingdom 
United States(USA) 
United States Minor Outlying Islands 
Uruguay 
Uzbekistan 
Vanuatu 
Vatican City State (Holy See) 
Venezuela 
Viet Nam 
Virgin Islands (British) 
Virgin Islands (U.S.) 
Wales 
Wallis and Futuna Islands 
Western Sahara 
Yemen 
Zambia 
Zimbabwe 
 
 
  Was your child breastfed and how long(exclusive breastfeeding)?
0 to 4 weeks 
5 weeks - 3 months 
4 months - 6 months 
7 months and longer 
no 
 
 
  Which vaccines were given?
Anthrax 
BCG 
Diphtheria, Tetanus 
Diphtheria, Tetanus, Polio 
Diphtheria,Tetanus, Pertussis 
Diphtheria,Tetanus, Pertussis, HiB 
Diphtheria,Tetanus, Pertussis , Poliovirus 
Diphtheria, Tetanus , Pertussis, Poliovirus and Haemophilus b 
Diphtheria, Tetanus , Pertussis, Poliovirus, Haemophilus b, Hepatitis B 
Haemophilus b 
Haemophilus b & Hepatitis B 
Hepatitis A 
Hepatitis A  +  B 
Hepatitis B 
Human Papillomavirus, HPV 
Influenza 
Influenza, H1N1 
Japanese Encephalitis 
Measles 
Measles, Mumps 
Measles, Mumps, and Rubella 
Measles, Mumps, Rubella and Varicella 
Meningococcal Vaccine 
Mumps 
Plague 
Pneumococcal Vaccine 
Poliovirus 
Rabies 
Rotavirus 
Rubella 
Smallpox 
TBE 
Tetanus 
Typhoid 
Varicella (Chickenpox) 
Yellow Fever 
Zoster(Shingles) Vaccine 
other 
 
 
Which Vaccines were given? 
Please mark every vaccine your child or you received / Bitte markieren Sie jede Impfung, die gegeben wurde mit Yes=ja. 
 
Does your child suffer from any of the following illnesses or symptoms?  (Please answer every question with yes, no or rarely )Leidet Ihr Kind an den folgenden Erkrankungen (Bitte jede Frage beantworten mit Ja=yes, nein=no oder selten=rarely)? 
 
Please specify when you selected "allergies" (300 chars left)  
 
  Please describe the general state of health of your vaccinated child*  
 
  Additional information you want to give 
Re-Captcha - Please Check the box 
                                                    
                                                     
reset submit  
Thank you very much for your report! 
If you want to be informed about the results of the survey, please  subscribe to our newsletter. As soon as the results are published you  will get a message in our newsletter.
 
Vaccine damage In case you have a vaccine damage/injury  in your family, I would appreciate if you could report that case. It is important to let other people know, what can happen after vaccinations. The data will be published anonymously  and  handled   with utmost confidentiality. Please go to our report form .
 
Thank you
Andreas Bachmair