VAERS 2021 Database www.vaers.hhs.gov

Main Page | All 2021 Deaths | Videos
VAERS Updated: 11/12/2021
** VAERS DATABASE Last updated: November 12, 2021**
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Manufacturers

Total Manufacturer
199,106MODERNA
36,710JANSSEN
5,381PFIZER\BIONTECH
2,555GLAXOSMITHKLINE BIOLOGICALS
1,469UNKNOWN MANUFACTURER
897MERCK & CO. INC.
627SEQIRUS, INC.
112DYNAVAX TECHNOLOGIES CORPORATION
91SANOFI PASTEUR
75NOVARTIS VACCINES AND DIAGNOSTICS
40EMERGENT BIOSOLUTIONS
14PAXVAX
12TEVA PHARMACEUTICALS
12PROTEIN SCIENCES CORPORATION
9PFIZER\WYETH
4BERNA BIOTECH, LTD.
4SMITHKLINE BEECHAM
3INTERCELL AG
1MEDIMMUNE VACCINES, INC.
1CSL LIMITED

COVID19 Lot Number

VAX LOT Total
2S9CL7,949
7,473
2,547
1,506
1,187
1,051
1,049
s0294561,043
866
IMM209861
816
UT7065MA766
657
579
U62828AA563
557
538
U6737AA516
515
S034636506
4F472471
458
P100253275449
444
276563436
429
418
4BH32414
MENVEO404
PP9L5362
UJ446AA337
319
306
290
271
49TM3270
R1B252M253
4F472179
933622147
C5763AA144
CW3116134
3Y7NL126
UNK114
113
ARBA141A105
104
103
96
300057A90
79
1F4EB73
R1B743M62
56
UJ090AA55
51
UH894AB46
45
UNK44
UNK42
42
EJ168638
Unknown36
35
34
32
32
26
el128424
24
A115A22
22
EN620222
21
UNK20
20
19
Z127A19
19
17
JEV18K95E15
12
111798PI12
10
A739088
No batch number8
3333324181078
6
6
TAR356
5
5
U6935AA5
UNK5
4
unknown4
3
2
55RB72
2
2
2
2
2
U7124AA2
JEV18A68E2
2
ABYB05BA1
1
1
1
1
AMVA436A1
1
1
TJ3521
A130A; VIS give1
1
U7140BB1
1
1
SP UP016AA1
1
1808P08802/ESV01
037K20A300,947
EL1284288,578
57,766
1,432

Incidents per State

State Total
82,750
CA62,821
FL38,209
TX36,512
NY34,921
PA23,646
IN23,622
IL20,597
MI19,590
OH19,426
NJ18,413
NC16,769
GA15,932
WA15,351
VA15,234
MA14,876
AZ14,206
MN12,940
MD12,656
CO11,908
WI11,425
MO10,240
TN9,685
OR8,768
KY8,437
CT8,300
SC6,700
OK6,293
AL5,692
LA5,025
IA4,825
KS4,821
UT4,637
NV4,374
NM3,967
AR3,807
ME3,161
NH3,096
NE2,918
MS2,859
ID2,785
WV2,469
HI2,459
PR2,417
MT2,414
RI2,076
DE1,868
AK1,830
VT1,734
DC1,715
ND1,388
SD1,269
WY866
GU118
VI69
AS47
MP29
MH8
XB6
FM4
QM3
XV2
XL1

Date Died: 09/02/2021

ID: 1722728
Sex: F
Age: 65
State: KY

Vax Date: 03/09/2021
Onset Date: 08/28/2021
Rec V Date: 09/22/2021
Hospital: Y

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 037K20A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: 8-23-21 tested positive on a COVID antigen test. 8-24-21 tested positive on a COVID PCR test

Allergies:

Symptom List: Dysphagia, Epiglottitis

Symptoms: Symptoms started on 8-22-21. 101 fever, runny nose, fatigue, cough, and shortness of breath. Was hospitalized on 8-28-21 with pneumonia due to COVID 19 virus and acute respiratory failure with hypoxia. Expired on 9-2-21.

Other Meds:

Current Illness:

ID: 1722729
Sex: M
Age: 54
State: KY

Vax Date: 09/03/2021
Onset Date: 09/20/2021
Rec V Date: 09/22/2021
Hospital: Y

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 025L20A
Dose Series: 1
Vax Route: IM
Vax Site: RA

Lab Data:

Allergies: penicillin, sulfa

Symptom List: Anxiety, Dyspnoea

Symptoms: Admitted for COVID. symptoms started about 1 week prior to admission, received Regeneron day of admission at a different facility. after admission pt started on supplemental O2 and decadron but refused remdesivir.

Other Meds: amlodipine, atorvastatin, vit D

Current Illness:

ID: 1722730
Sex: M
Age: 31
State: AL

Vax Date: 09/20/2021
Onset Date: 09/20/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: PFIZER\BIONTECH
Vax Name: COVID19 (COVID19 (PFIZER-BIONTECH))
Lot: EL1284
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: N/A

Allergies: N/A

Symptom List: Chest discomfort, Dysphagia, Pain in extremity, Visual impairment

Symptoms: Local Site Pain and swelling

Other Meds: N/A

Current Illness: N/A

ID: 1722731
Sex: F
Age: 42
State: VA

Vax Date: 05/05/2021
Onset Date: 05/06/2021
Rec V Date: 09/22/2021
Hospital: Y

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: unknown
Dose Series: UNK
Vax Route:
Vax Site:

Lab Data: Hospital: 6 May 2021 Xrays, ultrasounds, blood test, and CT scan Different Hospital: continued to monitor and perform test 6-9 May. No additional scans ran due to pregnancy.

Allergies: contrast dyes and latex

Symptom List: Dizziness, Fatigue, Mobility decreased

Symptoms: Pregnant at the time Estimated Date of Delivery: 17 July 2021 Delivery 34/35 weeks 5 May 2021 had a strange feeling, but ignored because everyone I know complained about the 2d dose causing flu symptoms 6 May 2021: started getting worse with rapid heart rate, hard time breathing, chills and fever (105). Went to Hospital because I was nervous about the temperature while being pregnant. A serious a test were ran and I was initially told I was fine; however, my temperature slightly went down and my heart and breathing continued to get worse. A CT scan showed multiple clots on the lungs and a strain on my heart. Was transported by an ambulance to different Hospital and stayed for about 4 days. Was placed on Lovenox.

Other Meds: Flintstone vitamins, Flonase, Flovent, Albuterol, 81mg aspirin, and magnesium

Current Illness: asthma and gestational diabeties

ID: 1722732
Sex: F
Age: 55
State: OK

Vax Date: 09/21/2021
Onset Date: 09/22/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data:

Allergies: Morphine, vicadin, oxycodone, most narcotic pain killers, tomatoes

Symptom List: Injection site erythema, Injection site pruritus, Injection site swelling, Injection site warmth

Symptoms: Bad h headache, stiff arm, sore arm, sick to my stomach, pain in muscles and joints

Other Meds: Metformin, Lisinopril, gabapentin, Amlodipine, lasix, low dose aspirin, vitamin D3, vitamin c, zinc, cranberry, iron, glipazide, flovent,

Current Illness: Bad reaction to first covid shot

ID: 1722733
Sex: F
Age: 39
State:

Vax Date: 09/12/2021
Onset Date: 09/16/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: FLUC4
Manufacturer: SEQIRUS, INC.
Vax Name: INFLUENZA (SEASONAL) (FLUCELVAX QUADRIVALENT)
Lot: 276563
Dose Series: 1
Vax Route: SYR
Vax Site: LA

Lab Data: WBC 88k, HBG 5.0, HCT 15, PLT 41 (9/21/21)

Allergies:

Symptom List: Chills, Confusional state, Eye inflammation, Headache, Laboratory test

Symptoms: Dizziness and presyncope

Other Meds:

Current Illness:

ID: 1722734
Sex: M
Age: 38
State: FL

Vax Date: 03/03/2021
Onset Date: 03/03/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 011J20A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: None

Allergies: None

Symptom List: Pyrexia, White blood cell count decreased

Symptoms: Severe chills, fever 103, lethargy and headache lasting days

Other Meds: None

Current Illness: None

ID: 1722735
Sex: M
Age: 23
State: CO

Vax Date: 09/20/2021
Onset Date: 09/20/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: UNK
Vax Route: IM
Vax Site: LA

Lab Data: unknown

Allergies: None reported

Symptom List: Pharyngeal swelling

Symptoms: About 5 minutes post-vaccination, patient fainted. He came to within seconds, but reported memory loss between the time that he sat and the time that he fainted. He was sweaty, pale, and shaking. He reported feeling nauseated which he contributed to not eating breakfast yet. About 3 minutes later, he reported tingling in his hands. A few minutes after that, he reported the same tingling in his feet. EMS was called when he fainted. They assessed him and decided to take him to the hospital due to him still feeling poorly. The patient stopped by about 2.5 hours later to report he was ok. I left him a message the next day to check on him, but never heard back.

Other Meds: None reported when asked

Current Illness: Unknown

ID: 1722736
Sex: M
Age: 43
State: IN

Vax Date: 04/14/2021
Onset Date: 09/14/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: Sofia Antigen COVID-19 test with a positive result

Allergies:

Symptom List: Abdominal pain, Chills, Sleep disorder

Symptoms: Patient received the Pfizer vaccine on 3/24/21 and 4/14/21 so was fully vaccinated when they tested positive for COVID-19 on 9/14/21.

Other Meds:

Current Illness:

ID: 1722737
Sex: F
Age: 80
State: MI

Vax Date: 05/20/2021
Onset Date: 09/19/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 011J201A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: SARS: Positive (9/19/2021). Chest X-ray. (9/19/2021).

Allergies: Penicillins

Symptom List: Diarrhoea, Nasal congestion

Symptoms: SOB, cough, saturation < 88%. Treatment: 2-3 L nasal cannula oxygen.

Other Meds: allopurinol atorvastatin bumetanide busPIRone clopidogrel , duloxetine, ezetimibe, gabapentin, hydrocodone-acetaminophen, levetiracetam, LEVOthyroxine, metoprolol, nitroGLYCerin, phenytoin, potassium chloride.

Current Illness: N/A

ID: 1722738
Sex: F
Age: 67
State: MI

Vax Date: 09/22/2021
Onset Date: 09/22/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: 1
Vax Route: SYR
Vax Site: LA

Lab Data:

Allergies: NKDA

Symptom List: Vaccination site erythema, Vaccination site pruritus, Vaccination site swelling

Symptoms: Patient experienced severe back spasms approximately 5 minutes after receiving the vaccine.

Other Meds:

Current Illness: N/A

ID: 1722739
Sex: F
Age: 68
State: ID

Vax Date: 03/20/2021
Onset Date: 04/01/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 039k20a
Dose Series: 1
Vax Route: SYR
Vax Site: RA

Lab Data: X-ray

Allergies:

Symptom List: Rash, Urticaria

Symptoms: I had acute artistes flare up in my right foot. My left leg muscle weakness and pain. I have been noticing more and more weakness in my leg. I could not hardly walk on it. I went to the ER. They did x-rays and physical movements. I continue with my leg pain. I went to my doctor about it. She gave me pain medicine and physical therapy for awhile. My pain and weakness are still increasing. I went back to the doctor, and was refer to an ortho specialist. My appointment is Sept 27th for that. I can not walk very far or go up and down the stairs anymore due to my leg.

Other Meds: Metformin; levothyroxine; lisinopril; omeprazole; Wellbutrin; Vectical; multivitamin; aspirin; Zyrtec

Current Illness:

ID: 1722740
Sex: F
Age: 32
State: KY

Vax Date: 02/05/2021
Onset Date: 09/19/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data:

Allergies:

Symptom List: Blood pressure decreased, Chest pain, Chills, Confusional state, Decreased appetite

Symptoms: tested positive for COVID 19 9/19/2021

Other Meds:

Current Illness:

ID: 1722741
Sex: F
Age: 52
State: CO

Vax Date: 09/16/2021
Onset Date: 09/17/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 025J20-2A
Dose Series: 1
Vax Route: SYR
Vax Site: LA

Lab Data: None, I waited it out to pass. I knew there was nothing they could/would do, since that is what happended when I had covid.

Allergies: mild itch with latex gloves, slight swelling with iodine taken orally

Symptom List: Dyspnoea, Fatigue, Feeling abnormal, Head discomfort, Headache

Symptoms: The evening of the vaccine: I had fever, severe headache & chills for approx. 6 hrs.The next day (day 2), arm sore as expected, chills, severe headache (in a different area of my head than my usual migraines), fever again, lethargic, shortness of breath, diarrhea & body aches. I also went in & out of AFB RVR all day (some bouts lasting 4 hrs, others two hrs, some only minutes). Finally being out of Afib RVR in the PM. Next day (3rd) more AFib, but not as aggressive. I have not been in Afib like these episodes since my last Heart Ablation; W/O a doubt, I contribute these episodes to the covid vaccine triggering Afib RVR. Summary: After the vaccine, the best way I can describe how I felt, was exactly like when I had covid 19 this past January. On Sept. 13, 2021, I tested negative for the C19 Antibodies (I had previously tested positive for 2xs), therefore opted for the vaccine. I waited out the side effects, did not see a doctor. As of today, I feel good, except for a headache, some mild confusion and being tired.

Other Meds: No Vitamins or over the counter meds were used for the first 2 days of vaccine. The evening of the vaccine: I had fever, severe headache & chills for approx. 6 hrs. The next day (day 2), arm sore as expected, chills, severe headache, fever

Current Illness: none

ID: 1722742
Sex: F
Age: 60
State:

Vax Date: 01/25/2021
Onset Date: 09/08/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 011J20A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data:

Allergies:

Symptom List: Heart rate decreased, Heart rate increased, Hypertension, Injection site pain, Musculoskeletal chest pain

Symptoms: Breakthrough COVID 19 infection

Other Meds:

Current Illness:

ID: 1722743
Sex: F
Age: 39
State: IN

Vax Date: 01/16/2021
Onset Date: 09/19/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 025J20A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: Sofia Antigen COVID-19 test with a positive result

Allergies:

Symptom List: Nausea, Pain, Pain in extremity, Paraesthesia oral, Pyrexia

Symptoms: Patient received the Pfizer vaccine on 12/26/20 and 1/16/21 so was fully vaccinated when they tested positive for COVID-19 on 9/19/21.

Other Meds:

Current Illness:

ID: 1722744
Sex: M
Age: 41
State: CA

Vax Date: 03/18/2021
Onset Date: 08/18/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: DTAPHEPBIP
Manufacturer: GLAXOSMITHKLINE BIOLOGICALS
Vax Name: DTAP + HEPB + IPV (PEDIARIX)
Lot:
Dose Series: UNK
Vax Route:
Vax Site: LG

Lab Data: COVID test

Allergies: No

Symptom List: SARS-CoV-2 antibody test, SARS-CoV-2 test negative

Symptoms: Contracted COVID virus after being fully vaccinated.

Other Meds: High blood pressure medication

Current Illness: No

Date Died:

ID: 1722745
Sex: F
Age: 49
State: FL

Vax Date: 06/17/2021
Onset Date: 07/14/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: HIBV
Manufacturer: MERCK & CO. INC.
Vax Name: HIB (PEDVAXHIB)
Lot:
Dose Series: UNK
Vax Route:
Vax Site: LG

Lab Data: N/A

Allergies:

Symptom List: Ear pain, Hypoaesthesia

Symptoms: Chest pain which led to being taken by ambulance to the Emergency Room where she died of a heart attack.

Other Meds:

Current Illness:

ID: 1722746
Sex: F
Age: 33
State:

Vax Date: 08/31/2021
Onset Date: 09/22/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: PNC13
Manufacturer: PFIZER\WYETH
Vax Name: PNEUMO (PREVNAR13)
Lot:
Dose Series: UNK
Vax Route:
Vax Site: LG

Lab Data:

Allergies:

Symptom List: Abdominal pain upper, Dizziness, Dysgeusia

Symptoms: Pt developed lymphadenitis in L arm, beginning in axillary region . Tenderness spread down pt's arm and L lateral chest area.

Other Meds:

Current Illness:

ID: 1722747
Sex: F
Age: 34
State:

Vax Date: 01/20/2021
Onset Date: 09/18/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: RV1
Manufacturer: GLAXOSMITHKLINE BIOLOGICALS
Vax Name: ROTAVIRUS (ROTARIX)
Lot:
Dose Series: 1
Vax Route: PO
Vax Site: MO

Lab Data: On 9/20 tested PCR positive

Allergies:

Symptom List: Blood pressure increased, Chest discomfort, Heart rate increased

Symptoms: Patient became ill and tested PCR positive for Covid > 14 days after the completion of vaccine series

Other Meds:

Current Illness:

Date Died: 09/20/2021

ID: 1722748
Sex: F
Age: 53
State: MO

Vax Date: 09/17/2021
Onset Date: 09/20/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: PFIZER\BIONTECH
Vax Name: COVID19 (COVID19 (PFIZER-BIONTECH))
Lot: Eh9899
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data:

Allergies: NKDA

Symptom List: Injection site erythema, Injection site pruritus, Injection site swelling, Lymph node pain, Lymphadenopathy

Symptoms: Patient died on 09/20/2021

Other Meds: Omeprazole, Novolog, Basaglar KwikPen Insulin, Chlorthalidone, Gabapentin, Magnesium, Metformin, Vandazole, and Glipizide

Current Illness: Bacterial Vaginitis

ID: 1722749
Sex: F
Age: 36
State: MN

Vax Date: 03/21/2021
Onset Date: 09/16/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: Coronavirus 2 PCR Detect, V symptomatic POSITIVE

Allergies: NKA

Symptom List: Unevaluable event

Symptoms: CHIEF COMPLAINT/REASON FOR VISIT Shortness of Breath HISTORY OF PRESENT ILLNESS Patient is a 36-year-old female with a history of prior PE and recent diagnosis of COVID presenting with worsened shortness of breath, weakness, cough, fevers and chills. Patient was first diagnosed with Covid-19 during ED visit yesterday. She initially presented after developing with shortness of breath while walking to work. Of note, she was diagnosed with DVT on 8/6 after presenting to ED with calf pain. She was unable to take prescribed Xarelto due to cost. She returned to the ED on 8/13 with shortness of breath and was found to have a segmental PE, which progressed on repeat ED visit 8/15. She was then able to take her anticoagulant. She was doing better until 1 week ago when she developed progressive shortness of breath and chest pain. EKG was unchanged, troponins were negative, SARS-CoV-2 was negative, CT demonstrated resolution of pulmonary emboli, and patient was discharged. Due to persistent symptoms, she returned to the ED with chest pain and shortness of breath yesterday. At that time, Covid-19 test resulted positive. She was discharged with outpatient followup

Other Meds:

Current Illness:

ID: 1722750
Sex: M
Age: 68
State: AL

Vax Date: 04/06/2021
Onset Date: 09/15/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: PFIZER\BIONTECH
Vax Name: COVID19 (COVID19 (PFIZER-BIONTECH))
Lot:
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: Positive Covid test

Allergies: No

Symptom List: Chills, Dizziness, Injection site pain, Myalgia, Pyrexia

Symptoms: Contracted Covid after vaccination

Other Meds: Vitoza 1.2mg daily levimere Amplodiphine Hydrochlori lisinopril 10mg daily

Current Illness: No

ID: 1722752
Sex: F
Age: 37
State: MD

Vax Date: 06/09/2021
Onset Date: 07/09/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 011L20A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: CBC blood tests on 8/30, 9/8, 9/15 and 9/22 to monitor the iron levels and a pelvic ultrasound on 9/8.

Allergies: Amoxicillin

Symptom List: Injection site pain, Pain

Symptoms: I began experiencing extremely long (9-12 days) and extremely heavy periods (soaking through an ultra tampon in less than an hour) with large blood clots the size of an adult fist in the 3 months following vaccination. I lost so much blood that it induced severe anemia which was so bad I almost had to have a blood transfusion, and I?ve been going for weekly iron IV infusions for the past few weeks to try to get my iron stores up.

Other Meds: Wellbutrin, Xywav, vitamins B, C, & D, NAC

Current Illness: None

ID: 1722753
Sex: F
Age: 31
State:

Vax Date: 09/22/2021
Onset Date: 09/22/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: 1
Vax Route: SYR
Vax Site: LA

Lab Data:

Allergies:

Symptom List: Injection site pain, Menorrhagia

Symptoms: Patient became diaphoretic and dizzy 2 minutes post vaccine. Patient's legs were immediately elevated, ice pack to back of neck, 2 bottles of water were given and graham crackers. 10 minutes later patient feeling better and stated this happens when she gets her blood drawn. Patient's vitals were T 87.5, P 64 BP 100/70 R 15. Patient stayed an additional 20 minutes post vaccine.

Other Meds:

Current Illness:

ID: 1722754
Sex: F
Age: 37
State: CO

Vax Date: 09/19/2021
Onset Date: 09/20/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 025J20A
Dose Series: 1
Vax Route: SYR
Vax Site: LA

Lab Data: No tests completed. When to urgent care on 9/21/2021. Provided confirmed the swelling and asked that I report this as an adverse reaction.

Allergies: Wellbutrin

Symptom List: Arthralgia, Chills, Headache, Mobility decreased, Myalgia

Symptoms: Lymph node swelling in the left armpit where the injection was given.

Other Meds: Yasmin, omeprazole and Lexapro

Current Illness: Seasonal allergies

ID: 1722755
Sex: F
Age: 46
State: MI

Vax Date: 08/24/2021
Onset Date: 08/25/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: PFIZER\BIONTECH
Vax Name: COVID19 (COVID19 (PFIZER-BIONTECH))
Lot:
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data:

Allergies: none

Symptom List: Nausea, Pain in extremity, Pyrexia

Symptoms: syncope--memory loss- heart palpitations

Other Meds: none

Current Illness: none

ID: 1722756
Sex: F
Age: 29
State:

Vax Date: 09/22/2021
Onset Date: 09/22/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: UNK
Vax Route: IM
Vax Site: RA

Lab Data:

Allergies:

Symptom List: Chills, Fatigue, Headache, Myalgia

Symptoms: Patient sat in chair for a few minutes before standing due to syncopal episodes in the past after injections. Patient stood and proceeded to exit room with mother at her side and had a syncopal episode. She was caught and lowered to the floor by her mother. Patient assisted to chair and BP taken. BP 110/79. Patient remained in chair for a few more minutes and then was escorted by staff to car with her mother.

Other Meds:

Current Illness:

ID: 1722757
Sex: F
Age: 21
State: TX

Vax Date: 09/22/2021
Onset Date: 09/22/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: PFIZER\BIONTECH
Vax Name: COVID19 (COVID19 (PFIZER-BIONTECH))
Lot:
Dose Series: 1
Vax Route: IM
Vax Site: RA

Lab Data: 9/22/2021 Administered the wrong drug. Wanted to receive the flu shot and I received the Covid Shot.

Allergies:

Symptom List: Headache, Heart rate increased, Injection site erythema, Injection site pain, Injection site swelling

Symptoms: I have received two COVID Pfizer vaccines. My first dose was on 4/9/21 and my second dose was on 5/7/21. I had mild side effects such as a sore arm and was tired. Today 9/22/21 I went into my clinic for a flu shot. They did not verify my name and did not verify the shot prior to injection. After injection, the clinician filled out my paper work and I noticed that it said COVID. I informed the provider that they had made a mistake. She started worrying saying "you are the patient right?". They were not even aware that I was the wrong patient or that I had been given the wrong drug. They explained to me that they believe I will be fine because some elderly people are getting the COVID vaccine booster dose. I was not given a choice to get the shot.

Other Meds:

Current Illness:

ID: 1722758
Sex: M
Age: 74
State: MN

Vax Date: 03/04/2021
Onset Date: 09/10/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: 1
Vax Route: IM
Vax Site: RA

Lab Data: Coronavirus 2 PCR Detect, V symptomatic POSITIVE

Allergies: NKA

Symptom List: Nausea

Symptoms: CHIEF COMPLAINT/REASON FOR VISIT Weakness - Generalized HISTORY OF PRESENT ILLNESS This is a 74-year-old male who was diagnosed with COVID-19 back on September 10th. He presents the emergency department because of progressive dyspnea with minimal exertion. The patient reports that he has had a dry cough as well. He denies any frank chest pain however. Patient did receive a Johnson and Johnson vaccine several months ago. He denies any new peripheral edema, but does have chronic lower extremity edema. He denies any high fevers or chills. He denies a headache, nausea vomiting, abdominal pain, or diarrhea.

Other Meds:

Current Illness:

ID: 1722759
Sex: F
Age: 44
State: NY

Vax Date: 05/28/2021
Onset Date: 06/14/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: UNK
Vax Route: IM
Vax Site: LA

Lab Data: Ekg echo 24 hour monitor blood work

Allergies: Flu vaccine allergy

Symptom List: Injection site pain

Symptoms: Palpitations started mid June and weren?t bad but by July they were often - sometimes every 3 or four beats. On 7/26 I saw a cardiologist and had ekg echo and wore a 24 hour monitor . By end of August they completely resolved

Other Meds: Magnesium and B6, Advil

Current Illness: None

ID: 1722760
Sex: M
Age: 45
State: MO

Vax Date: 08/31/2021
Onset Date: 09/01/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: EKG ECHO-pending serum studies-results pending

Allergies: PCN, ASA

Symptom List: Injection site induration, Injection site pruritus, Injection site swelling, Injection site warmth

Symptoms: Patient c/o increasing in shortness of breath, and admits to regular use of his rescue inhaler with little symptom improvement. States has stepped-up his asthma management, now reportedly taking flovent for 10 days. Continues to experience little symptom improvement. Patient also c/o a chest "squeezing sensation" on an inconsistent basis. Symptoms last for several seconds to several minutes. symptoms are mostly exacerbated with inspiration. Reports nightly palpitations lasting for 1-2 seconds at time, more likely to occur when lying of left side.

Other Meds: Losartan, Flovent, albuterol, zyrtec

Current Illness: none

ID: 1722761
Sex: M
Age: 63
State: UT

Vax Date: 07/20/2021
Onset Date: 09/07/2021
Rec V Date: 09/22/2021
Hospital: Y

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 011j20a
Dose Series: 1
Vax Route: IM
Vax Site: RA

Lab Data: Blood work Urine analysis Ct MRI xray

Allergies: None

Symptom List: Chills, Dizziness, Nausea, Pain, Tachycardia

Symptoms: Pulmonary embolisms Elevated liver enzymes Elevated D-dimer Elavated and inflamed pancreas Gallbladder needed ingredients to be removed

Other Meds: Oxycodone 10 mg Morphine 20mg Dexalant Maloxicame Cymbalta Gabapentin Prozac Lisinapril

Current Illness: Lower back problems L5-S1 Rynards Prehypertension Reflux

ID: 1722762
Sex: M
Age: 63
State: TX

Vax Date: 04/14/2021
Onset Date: 08/24/2021
Rec V Date: 09/22/2021
Hospital: Y

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 039K20A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: Multiple Cat Scans and MRI's

Allergies: Use Xyzal 5 mg tablet to control Hives

Symptom List: Tremor

Symptoms: Started as a diagnose of TSI then changed to seizures.

Other Meds: aspirin 81 mg tablet, Vytorin 10/20, levothyroxine 50 mcg tablet, multivitamin tablet, Xyzal 5 mg tablet

Current Illness: Had tested positive Covid 19 on December 24th 2020

ID: 1722763
Sex: F
Age: 29
State: MI

Vax Date: 12/30/2020
Onset Date: 09/21/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 025J20A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: positive binax antigen test 9/21/21

Allergies:

Symptom List: Erythema, Pruritus

Symptoms: tested positive for covid 9/21/2021, done r/t sx congestion, exposure to positive household member

Other Meds:

Current Illness:

ID: 1722764
Sex: M
Age: 44
State: CT

Vax Date: 09/15/2021
Onset Date: 09/16/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: UNK
Manufacturer: UNKNOWN MANUFACTURER
Vax Name: VACCINE NOT SPECIFIED (NO BRAND NAME)
Lot:
Dose Series: UNK
Vax Route: SYR
Vax Site: UN

Lab Data:

Allergies: Nones

Symptom List: Injection site erythema, Injection site induration, Injection site pruritus, Injection site swelling, Myalgia

Symptoms: Short of breath pain constantly on my testicular part?sinus ?.sexual desire down ?

Other Meds: Nones

Current Illness: Nones

ID: 1722765
Sex: F
Age: 31
State: TX

Vax Date: 09/13/2021
Onset Date: 09/21/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 011J20A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: Photos of Shingles outbreak post vaccination and Bells Palsy

Allergies: None

Symptom List: Cough, Limb discomfort, Pain, SARS-CoV-2 test positive

Symptoms: Caused Shingles and Bells Palsy

Other Meds: None

Current Illness: None

ID: 1722766
Sex: F
Age: 80
State: MI

Vax Date: 03/22/2021
Onset Date: 09/18/2021
Rec V Date: 09/22/2021
Hospital: Y

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 039K20A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data:

Allergies: Penicillins Hives Cymbalta [Duloxetine Hcl] Other Doxycycline Nausea and Vomiting

Symptom List: Asthenia, Chills, Headache, Myalgia

Symptoms: Hospitalized (9.18.21); COVID-19 positive (9.18.21); fully vaccinated Discharge Provider: MD Primary Care Provider at Discharge: MD Admission Date: 9/18/2021 Discharge Date: 9/21/2021 DETAILS OF HOSPITAL STAY: Patient is an 80-year-old woman with history of chronic stage IV coccygeal ulcer with chronic osteomyelitis, paroxysmal atrial fibrillation on Xarelto, hypertension, obstructive sleep apnea, hyperlipidemia, hypertension, depression, hypothyroidism and chronic pain who presented with 2 days of fever and generalized weakness along with cough. She follows with Wound clinic who sees her every 6 weeks for chronic sacrococcygeal osteomyelitis and ulcer. Due to concerns for fevers patient presented herself to the emergency department. In the ER patient was hemodynamically stable though had a fever of 38.0 degree centigrade. CT thorax abdomen and pelvis with contrast was done which was consistent with inflammation related to chronic osteomyelitis however concerns for possible epidural abscess. MRI of sacrum showed sacral decubitus ulcer 4 cm in depth located just below the tip of the sacrum. No abscess. Acute on chronic osteomyelitis. Extensive changes of chronic osteomyelitis involving the bilateral iliac bones and sacrum. There is chronic near complete destruction of the coccyx with a few tiny bony fragments noted on comparison CT. Wound was consulted who recommended to continue Dakin's dressing changes follow-up with Wound Clinic as scheduled before. Due to fever, cough she was tested for COVID-19 and she was positive. She did receive Pfizer COVID vaccine in March. She had no indication for remdesivir or Decadron. She declined monoclonal antibody infusion. She did not require any oxygen. For chronic pain she will continue methadone 5 mg 2 times a day and Lyrica 150 mg 2 times a day. For all other: She will continue her previous medication. She was discharged home with her husband who is primary caregiver.

Other Meds: Outpatient Medications acetaminophen (TYLENOL) 500 MG tablet ARIPiprazole (ABILIFY) 5 MG tablet bisacodyl (DULCOLAX) 10 MG suppository Cholecalciferol (VITAMIN D3) 2000 units CAPS dilTIAZem (CARDIZEM CD) 120 MG 24 hr capsule FIBER ADULT GUM

Current Illness: NA

ID: 1722767
Sex: F
Age: 36
State: NY

Vax Date: 09/19/2021
Onset Date: 09/19/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 011J20A
Dose Series: 1
Vax Route: SYR
Vax Site: LA

Lab Data: none

Allergies: bactrim, PNC, vermox, prednisone

Symptom List: Injection site erythema, Injection site pain, Injection site swelling

Symptoms: Almost immediately after the shot the area started to itch. after about 10 minutes more and more of my body started to itch. it has been almost 4 days and my whole body is itching with hives in certain places like the back of my head, neck, breast area. I have been trying to take Benadryl to help but it isn't helping much. as of today (9/22/2021 at 12:45pm) I am still having full body itching. If it continues tomorrow I am going to make a doctors visit.

Other Meds: none

Current Illness: none

ID: 1722768
Sex: F
Age: 72
State: TX

Vax Date: 09/22/2021
Onset Date: 09/22/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: PFIZER\BIONTECH
Vax Name: COVID19 (COVID19 (PFIZER-BIONTECH))
Lot: EK9231
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data:

Allergies: Pravachol and Metformin

Symptom List: Chills, Feeling cold, Feeling hot, Myalgia, Pain

Symptoms: Pt started complaing of headache/SOB about 10mins after the vaccine, VS 157/98, 73 98% 02 on RA, 174/97, 68, 97% on RA 15mins interval, Blood sugar 222 but she had breakfast already. Daughter said she took allergy pills along side BP meds just before coming to the clinic. Even though after 45mins of Post vac Patient verbalise she felt better. Her daughter was educated to take her to her Dr's office due to uncontrolled BP and headache. She verbalize understanding.

Other Meds: Valsartan 80mg 2tabs PO daily Montelukast 10mg 1 tablet PO at night Levocetrizine 5mg 1 tablet PO every evening Tresiba Flextouch U-100 100 #ml SQ-0.25 under the skin daily Insulin aspart 100U/ml 3ml insulin pen-8U under the skin 3 times a

Current Illness:

ID: 1722769
Sex: F
Age: 50
State: CA

Vax Date: 08/11/2021
Onset Date: 08/16/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: 2 medical exams

Allergies: Augmentin

Symptom List: Pain in extremity

Symptoms: Noise in inner ear, plugged sensation, pressure build up in ear canal. Ear examination shows normal results but issue has remained constant for over 2 months now.

Other Meds: none

Current Illness: none

ID: 1722770
Sex: M
Age: 24
State: OR

Vax Date: 01/15/2021
Onset Date: 01/19/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: PFIZER\BIONTECH
Vax Name: COVID19 (COVID19 (PFIZER-BIONTECH))
Lot:
Dose Series: 2
Vax Route:
Vax Site:

Lab Data: Left Lower Extremity Doppler Ultrasound CBC CMP

Allergies: None

Symptom List: Abdominal pain upper, Abnormal behaviour, Adverse reaction, Anger, Asthma

Symptoms: Developed left leg pain beginning the Tuesday following the first Pfizer/BioNTech vaccination. The following Monday, the left leg began swelling which prompted a trip to the urgent care and followed with an ultrasound. Ultrasound showed a deep vein thrombosis in the deep calf vein extending to the popliteal bifurcation but not past. Treatment with Eliquis began in the emergency department on 01/25/2021.

Other Meds: Zyrtec, once daily

Current Illness: None

ID: 1722771
Sex: F
Age: 66
State: IN

Vax Date: 05/13/2021
Onset Date: 09/19/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 039K20A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: Sofia Antigen COVID-19 test with a positive result

Allergies:

Symptom List: Consciousness fluctuating, Crying, Dry skin, Epistaxis, Headache

Symptoms: Patient received the Janssen vaccine on 5/13/21 so was fully vaccinated when they tested positive for COVID-19 on 9/19/21.

Other Meds:

Current Illness:

ID: 1722772
Sex: M
Age: 83
State: WI

Vax Date: 03/10/2021
Onset Date: 09/21/2021
Rec V Date: 09/22/2021
Hospital: Y

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 025J20A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: Coronavirus 2 PCR Detect, V symptomatic POSITIVE

Allergies: NKA

Symptom List: Hypotonia, Lethargy, Respiratory rate decreased, Screaming, Skin warm

Symptoms: Respiratory Distress (cough, low SPO2) and Weakness - Generalized (Fall and was on floor for 16 hours this morning; EMS called and patient refused any treatment ) HISTORY OF PRESENT ILLNESS Patient presents is an 83-year-old male per private auto for shortness of breath and weakness. Patient presents per private auto with progression of weakness or last couple of days including increased shortness of breath. According to family members the patient is experiencing some mild cough and cold symptoms. Apparently the EMS for called presented to his place earlier today after the patient been found on the floor and apparently been on the floor for approximately over half a day. Patient refused EMS transport. Respiratory Distress (cough, low SPO2) and Weakness - Generalized (Fall and was on floor for 16 hours this morning; EMS called and patient refused any treatment ) HISTORY OF PRESENT ILLNESS Patient presents is an 83-year-old male per private auto for shortness of breath and weakness. Patient presents per private auto with progression of weakness or last couple of days including increased shortness of breath. According to family members the patient is experiencing some mild cough and cold symptoms. Apparently the EMS for called presented to his place earlier today after the patient been found on the floor and apparently been on the floor for approximately over half a day. Patient refused EMS transport. However as the day progressed family members were able to get hold his primary care provider who came and did a house call and found it to be quite short of breath, lethargic, extremely weak prompting emergency room visit. Patient denies any known contacts with persons of COVID-19. He is vaccinated. Patient denies any chest pains, palpitations. Patient is a full code.

Other Meds:

Current Illness:

ID: 1722773
Sex: F
Age: 46
State: CO

Vax Date: 09/09/2021
Onset Date: 09/11/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 026LZOA
Dose Series: 1
Vax Route: IM
Vax Site: RA

Lab Data: None

Allergies: None

Symptom List: Vomiting

Symptoms: About two day after the vaccine was given, right shoulder and deltoid pain with movement of my arm to the side or behind me. The pain has continued to progress and worsen over 2 weeks, not able to move my arm away from my body if my palm is facing posteriorly. MD appt on Monday 9/27 with employee health

Other Meds: Atorvastatin, multivitamin, coq10, vitamin D, probiotics

Current Illness: None

ID: 1722774
Sex: F
Age: 49
State: FL

Vax Date: 09/01/2021
Onset Date: 09/01/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 037K20A
Dose Series: 1
Vax Route: SYR
Vax Site: LA

Lab Data: none

Allergies: none

Symptom List: Headache, Limb discomfort, Nasal congestion

Symptoms: Patient came for the second shot of pfizer on 09/22/21 and reported that her arm still hurts on and off since her first shot on 09/01/21

Other Meds: none

Current Illness: not known

Date Died: 09/15/2021

ID: 1722775
Sex: M
Age: 79
State: KY

Vax Date: 03/12/2021
Onset Date: 09/13/2021
Rec V Date: 09/22/2021
Hospital: Y

Vax Type: COVID19
Manufacturer: PFIZER\BIONTECH
Vax Name: COVID19 (COVID19 (PFIZER-BIONTECH))
Lot:
Dose Series: 1
Vax Route: IM
Vax Site: RA

Lab Data: 9-13-21 tested positive on COVID 19 PCR

Allergies:

Symptom List: Back pain, Cold sweat, Headache, Nausea, Vomiting

Symptoms: Hospitalized on 9-13-21 for COVID

Other Meds:

Current Illness:

ID: 1722776
Sex: F
Age: 60
State: OH

Vax Date: 09/22/2021
Onset Date: 09/22/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 025j20-2A
Dose Series: 1
Vax Route: IM
Vax Site: LA

Lab Data: NA

Allergies: PCN, Egg Yolk

Symptom List: Injection site swelling, Limb discomfort

Symptoms: Patient experienced a reaction post COVID vaccination Vaccine brand PFIZER Lot # FD0809 Type of reaction TINGLING Symptoms Patient had vaccine and was in the observation area. She experienced tingling of her lips and tongue. Patient felt like her tongue was beginning to feel swollen. Denied trouble breathing or difficulty swallowing. No swelling noted. Vital signs: BP 149/76 | Pulse 71 | Resp 16 | LMP (LMP Unknown) Interventions (Fexofenadine 60 PO given per standing order) Was a code blue called -No How long was patient monitored in observation area -30 minutes after the Fexofenadine was given Final outcome - Tingling subsided. Instructed to call PCP for further instructions and to proceed to nearest ER or call the emergency line for difficulty breathing or swallowing.

Other Meds:

Current Illness: HTN, hyperlipidemia, hypothyroidism

ID: 1722777
Sex: F
Age: 27
State: WI

Vax Date: 09/01/2021
Onset Date: 09/11/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot:
Dose Series: 1
Vax Route: IM
Vax Site: RA

Lab Data: Hgb = 9.6 (9/12/21), 11.1 (9/22/21)

Allergies: NKDA

Symptom List: Chills, Diarrhoea, Fatigue, Feeling abnormal, Headache

Symptoms: Patient experienced significant post-operative GI bleeding after surgery (9/7/21) within two weeks of her vaccination. Patient was using oxycodone and acetaminophen for post-operative pain. Patient did also have ibuprofen on her post-op med list that has since been discontinued. Reporter is unsure if patient was using this medication at the time of event. Patient had additional surgery to repair bleed on 9/12/21.

Other Meds: Unknown

Current Illness: Anal fissure -- repaired via general surgery 9/7/21

ID: 1722778
Sex: M
Age: 22
State: NY

Vax Date: 09/16/2021
Onset Date: 09/16/2021
Rec V Date: 09/22/2021
Hospital:

Vax Type: COVID19
Manufacturer: MODERNA
Vax Name: COVID19 (COVID19 (MODERNA))
Lot: 037K20A
Dose Series: 1
Vax Route: IM
Vax Site: RA

Lab Data: N/A

Allergies: Codeine Fire ant

Symptom List: Hot flush, Myalgia, Nausea, Tension headache

Symptoms: A temperature excursion was discovered in our refrigerator, the high temp. was 48F

Other Meds: albuterol HFA 108 (90 Base) MCG/ACT Aerosol Solution inhaler amphetamine-dextroamphetamine XR 20 MG Capsule Extended Release 24 Hour budesonide-formoterol (SYMBICORT) 160-4.5 MCG/ACT Aerosol inhaler clobetasol propionate 0.05 % Solution fin

Current Illness: N/A

Total 2021 VAERS Injuries: 654,986

Page last modified: 13 November 2021 9:17am