Did you or your child suffer Serious Injuries or Side Effects from the GARDASIL HPV Vaccine?

Who received the vaccine? Select Self Child Spouse Friend Other

When was the vaccine received? Select 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022

Have you been diagnosed with any of the following?

Premature Ovarian Failure Diagnosed by a Doctor? Select Yes No

Premature Menopause Diagnosed by a Doctor? Select Yes No

The person diagnosed is: Select Under 18 years old 18 years or older