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Post-Vaccination Experience and Side Effect Tracker

Tracks how patients felt in the days after a vaccination — side effect severity, how well staff set expectations, and overall satisfaction — for clinics, pharmacies, and health systems monitoring vaccine programs. An AI follow-up interview reconstructs what actually happened physically and logistically for patients with rougher experiences, going beyond a checkbox symptom list.

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Sample questions

A preview of what’s in the template. Every question is editable before you launch.

14 questions · ~7 min
Q01
Message

Hi! We'd like to check in on how you're doing after your recent vaccination. This will take about 8 minutes and helps us improve the vaccination experience — your honest answers, including any side effects, are genuinely useful to us.

Q02
Multiple ChoiceRequired

Which vaccine did you receive at your most recent visit? (Template note: replace with your organization's actual vaccine list before launching.)

  • Influenza (flu)
  • COVID-19
  • Shingles
  • RSV
  • Other
Q03
DateRequired

What date did you receive this vaccine?

Q04
Multiple ChoiceRequired

Overall, how would you describe any side effects you experienced?

  • No side effects at all
  • Mild (e.g., sore arm, slight tiredness)
  • Moderate (interfered with some daily activities)
  • Severe (needed medical attention or significant recovery time)
Q05
Matrix

In the days after your vaccination, how severe were each of the following symptoms?

6 rows × 4 columns
  • Soreness at the injection site
  • Fatigue
  • Headache
  • Muscle or joint aches
  • Fever or chills
  • +1 more
Columns: None · Mild · Moderate · Severe
Q06
Multiple Choice

In the days after vaccination, did any of the following happen because of how you felt? (Select all that apply.)

  • Missed work or school
  • Cancelled personal plans
  • Needed to rest more than usual
  • Sought medical care
  • None of the above
Q07
Opinion ScaleRequired

Before your vaccination, how clearly did staff explain what side effects to expect?

Scale: 1 – 5
Min:Not at all clearMax:Extremely clear
Q08
Rating ScaleRequired

How would you rate your overall vaccination visit, from check-in to leaving?

Range: 1 – 5
Min:PoorMax:Excellent
Q09
Opinion ScaleRequired

How likely are you to recommend getting vaccinated at this location to a friend or family member?

Scale: 0 – 10
Min:Not at all likelyMax:Extremely likely
Q10
AI Interview

Reconstruct what actually happened physically and logistically after the respondent's vaccination — when symptoms started, how they compared to what they'd been told to expect, and how they managed them. If they reported moderate or severe side effects, or a low recommendation score, probe specifically for what would have made the experience easier (better warning, medication advice, follow-up contact) and whether it affects their willingness to get future recommended vaccines.

Q11
Multiple ChoiceRequired

Based on this experience, how likely are you to return to this same location for future vaccinations?

  • Definitely will return
  • Probably will return
  • Not sure
  • Probably will not return
  • Definitely will not return
Q12
Multiple Choice

What is your age range?

  • Under 18
  • 18-29
  • 30-44
  • 45-59
  • 60-74
  • 75 or older
  • Prefer not to say
Q13
Multiple Choice

What is your gender?

  • Woman
  • Man
  • Non-binary
  • Prefer to self-describe
  • Prefer not to say
Q14
Message

Thank you for sharing your experience! Your responses help our clinical and patient experience teams catch side effect patterns early and make future vaccination visits smoother.

What’s included

  • AI follow-ups

    Adaptive probes on open-ended answers that pull out detail a static form would miss.

  • Attention checks

    Built-in safeguards against rushed answers and low-quality respondents.

  • AI-drafted copy

    Wording, ordering, and branching written by the AI — tuned to your research goal.

  • Auto report

    Themes, quotes, and a plain-English summary write themselves once responses come in.

How it compares

We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.

Why this template

  • Goes beyond a static symptom checklist with an AI follow-up interview that reconstructs what actually happened physically and logistically for respondents who report rougher side effects
  • Separately measures how clearly staff set expectations before vaccination (via an opinion scale) alongside a symptom severity matrix, so clinics can see whether poor communication correlates with worse-reported experiences
  • Captures downstream behavioral signals — overall visit rating, likelihood to recommend the location, and likelihood to return for future doses — not just symptom presence
  • Uses chat-style framing at open and close to make the check-in feel conversational rather than clinical, which can improve completion and honesty on a sensitive health topic

Jotform

Post-Vaccination Questionnaire Form Template

This is a static, fielding-ready form template built on Jotform's drag-and-drop form builder, likely covering basic symptom checkboxes and demographic fields. It's easy to customize and deploy quickly, but it functions as a fixed questionnaire rather than an adaptive interview.

What it does well

  • Quick to customize and deploy using Jotform's widely-used form builder
  • Likely integrates with Jotform's broader form ecosystem (payments, e-signatures, notifications)
  • Familiar, simple UI for respondents filling out a standard form

Where it falls short

  • No adaptive AI follow-up questioning — respondents with severe or unusual side effects get the same fixed field set as everyone else
  • No voice interview option or guided screen-share tasks
  • No automated per-response quality scoring or transparent prompt methodology

SurveySparrow

Post Vaccination Survey Template

This appears to be a conversational-style survey template (SurveySparrow's signature chat-like UI) covering post-vaccination experience, likely dating back to COVID-19 vaccine rollout messaging. It offers a more engaging respondent experience than a plain form, but the question flow is still pre-scripted rather than dynamically generated based on individual answers.

What it does well

  • Conversational chat-style UI that may feel friendlier than a traditional form
  • Ready-to-use template reduces setup time for basic side-effect tracking
  • Likely supports SurveySparrow's standard reporting dashboards

Where it falls short

  • No AI-driven adaptive follow-up interview — all respondents see the same sequential question set regardless of severity
  • No voice AI interview or guided task/screen-share capability
  • No published transparent prompt methodology or automated quality scoring per response

Ready to launch?

Open this template in the editor. Every part is yours to change before the first respondent sees it.

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