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

ID: 1783075
Sex: F
Age: 30
State: TX

Vax Date: 10/13/2021
Onset Date: 10/13/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data:

Allergies: Penicillin

Symptom List: Dysphagia, Epiglottitis

Symptoms: Patient felt itchy. BP 118/62; temp 97.9; BPM 62 and oxygen 99% at 3:45 pm. Final update patient BP 112/78; temp 97.7; BPM 65 and oxygen 99%. Patient reported feeling fine was cleared by nurse. Patient directed to go to urgent care if any side effects later on.

Other Meds: None

Current Illness: None

ID: 1783076
Sex: F
Age: 36
State: NJ

Vax Date: 10/12/2021
Onset Date: 10/13/2021
Rec V Date: 10/13/2021
Hospital:

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

Symptom List: Anxiety, Dyspnoea

Symptoms: Severe pain in armpit and both right and left breasts.

Other Meds: Symbicort

Current Illness:

ID: 1783077
Sex: M
Age: 57
State: WA

Vax Date: 04/21/2021
Onset Date: 07/10/2021
Rec V Date: 10/13/2021
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: Dr will have this info

Allergies: none

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

Symptoms: I have slight heart paplatations that last for 3-10 seconds.. I also have had one large blister on both hands, in the same exact location...these large blisters are NOT caused by working with my hands, etc, they just started first on my left hand index finger on TOP of the finger, and then one month later the same exact location on my other hand...I have pictures of both as well and reported to Dr

Other Meds: aleve, claritin

Current Illness: none

ID: 1783078
Sex: F
Age: 71
State: TN

Vax Date: 10/13/2021
Onset Date: 10/13/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data: N/A

Allergies:

Symptom List: Dizziness, Fatigue, Mobility decreased

Symptoms: CLIENT VACCINE CARD INDICATED 2 PREVIOUS DOSES AND ELIGIBLE FOR BOOSTER. BOOSTER ADMINISTERED. DATA ENTRY OF BOOSTER REVEALED 3 PREVIOUS DOSES. THEREFORE THE DOSE ADMINISTERED IS THE 4TH DOSE.

Other Meds:

Current Illness:

ID: 1783079
Sex: M
Age: 47
State: HI

Vax Date: 07/01/2021
Onset Date: 08/27/2021
Rec V Date: 10/13/2021
Hospital: Y

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

Symptoms: Hospitalization for COVID after full vaccination.

Other Meds:

Current Illness:

ID: 1783080
Sex: F
Age: 15
State: CA

Vax Date: 02/25/2021
Onset Date: 02/25/2021
Rec V Date: 10/13/2021
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: none

Allergies: none

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

Symptoms: Moderna vaccine given on at local Health Clinic was given to 15 year old . Moderna FDA approved for 18 and older. no adverse effects.

Other Meds: none

Current Illness: none

ID: 1783081
Sex: M
Age: 74
State: MN

Vax Date: 03/02/2021
Onset Date: 10/11/2021
Rec V Date: 10/13/2021
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: harsh soap: rash - Allergy - Onset Date 2/16/2021 Sulfa: hives, swelling,lips.tongue - Allergy - Onset Date 2/16/2021 Ciprofloxacin: hives, swelling, lips/tongue - Allergy - Onset Date 2/16/2021 Keflex: hives, swelling, lips/tongue - Allergy - Onset Date 2/16/2021 PENICILLIN DRUGS: hives, swelling, lips/tongue - Allergy - Onset Date 2/16/2021 Hydrochlorothiazide: lip and mouth tingling - Allergy - Onset Date 2/16/2021 Torsemide: lip and mouth tingling - Allergy - Onset Date 2/16/2021 Latex: rash - Allergy - Onset Date 09/27/2021 Nickel: dermatitis - Allergy - Onset Date 09/27/2021 Pollen: cough - Allergy - Onset Date 09/27/2021

Symptom List: Pyrexia, White blood cell count decreased

Symptoms: sore throat, cough, productive cough, nonproductive cough, body aches, diarrhea, post nasal drainage. starting on 10/11/21

Other Meds: ALPRAZolam 0.5 MG Tablet 0.5 tablet Orally once a day as needed Atorvastatin Calcium 10 MG Tablet 0.5 tablet Orally Once a day Carvedilol 12.5 MG Tablet 1 tablet with food Orally Twice a day Daily Multiple Vitamins - Tablet 1 table

Current Illness: none

ID: 1783082
Sex: F
Age: 95
State: WI

Vax Date: 03/24/2021
Onset Date: 10/07/2021
Rec V Date: 10/13/2021
Hospital: Y

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

Lab Data:

Allergies: Doxycycline, Epinephrine, Amlodipine, Bactrim

Symptom List: Pharyngeal swelling

Symptoms: Patient was admitted to observation level of care on 10-9 for hyponatremia. Patient is noted to have tested positive for covid on 10-7.

Other Meds: albuterol, bumetanide, ELIQUIS,ergocalciferol (VITAMIN D2), losartan, nitroglycerin, pravastatin

Current Illness:

ID: 1783083
Sex: F
Age: 68
State: NC

Vax Date: 10/05/2021
Onset Date: 10/11/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data:

Allergies: no

Symptom List: Abdominal pain, Chills, Sleep disorder

Symptoms: vertigo along with dizziness, nausea, sweating - getting better after 3 days....hope it resolves soon

Other Meds: latanoprost duloxetine albuterol omeprozole biotin and kerotin

Current Illness: none

ID: 1783084
Sex: M
Age: 38
State: KS

Vax Date: 10/13/2021
Onset Date: 10/13/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data:

Allergies:

Symptom List: Diarrhoea, Nasal congestion

Symptoms: This was a vaccine error where I mistakenly gave the patient a pfizer second dose instead of moderna. At this time there are no reported side effects from the patient.

Other Meds:

Current Illness:

ID: 1783085
Sex: F
Age: 29
State: NY

Vax Date: 10/13/2021
Onset Date: 10/13/2021
Rec V Date: 10/13/2021
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: Vaccination site erythema, Vaccination site pruritus, Vaccination site swelling

Symptoms: Pt. received Pfizer Dose 1. At 12:32, after 3 minutes in observation, pt. complained of chest pain, shortness of breath, headache, dizziness, nausea and soreness on the arm. VS were taken and within normal limit. Provided water, cracker and ice packs were applied. Pt. was placed on the floor with legs elevated. Encouraged pt to do deep breathing and emotional support provided. Observation was extended. At 1:10 pm, pt stated that shortness of breath and chest pain were resolved. Pt. was placed in sitting position and stated that chest pain and shortness of breath returned. Chest pain described as sharp pain with 10/10 and pt. also and having abdominal pain with 10/10. At 1:42 pm, 911 was activated. EMS arrived at 1:57 pm. Pt awake and alert, left the building via wheelchair, accompanied by 2 transporters, pt's cousin and 2 children.

Other Meds:

Current Illness:

ID: 1783086
Sex: F
Age: 31
State: TX

Vax Date: 03/06/2021
Onset Date: 07/30/2021
Rec V Date: 10/13/2021
Hospital: Y

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

Lab Data: Initial MRI on head and neck on August 13. While in hospital from August 16-19 I underwent several other tests including CT scans, heart MRI, echocardiograms, and an angiogram, as well as had a lot of blood work done.

Allergies: None

Symptom List: Rash, Urticaria

Symptoms: In late July, had a tingling sensation in my right palm. Over two weeks the sensation spread to other areas on the right side of my body and I saw a few doctors which led to an MRI. The MRI showed three strokes, for which I was hospitalized to obtain a full testing work-up as I am an otherwise healthy 32 year old, so the strokes were unusual. I spent three days in the hospital and no underlying condition was identified. Additionally, after the hospitalization, I got tested for COVID antibodies, which I did not have.

Other Meds: Oral contraceptive pill - Junel - had been on for 10+ years at time of vaccination with no issues

Current Illness: None

ID: 1783087
Sex: M
Age: 74
State: MO

Vax Date: 03/29/2021
Onset Date: 04/01/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data: MRI of head and neck left-side.

Allergies: Contrast, Ambien, Morphine, Demerol, Codeine

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

Symptoms: Swelling left-side of face, steriods for 10 days.

Other Meds: Amlodipine, Omega-3 450mg, Bisoprolol fumarate, Altace, Pravastatin, Flomax, Aspirin, Vision formula, Cinnamon, Flaxseed oil, Aleve

Current Illness: Repair retinal tear (right eye)

ID: 1783089
Sex: F
Age: 66
State: FL

Vax Date: 02/17/2021
Onset Date: 02/18/2021
Rec V Date: 10/13/2021
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:

Allergies:

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

Symptoms: Body cramped Chills

Other Meds: Zyrtec

Current Illness:

ID: 1783090
Sex: M
Age: 25
State: NC

Vax Date: 08/13/2021
Onset Date: 08/17/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data: AHe was thoroughly examined by an orthopedic-trained PA-C on 1 OCT 2021. This included full strength and sensory evaluation of the upper limb. The provider found no correlation with the symptoms and known effects of the vaccine or intramuscular immunizations. Thoracic outlet syndrome, carpal tunnel, and cubital tunnel were considered but the reported nerve distribution does not apply to them. These findings were reviewed by another PA-C and physician. The same conclusion was found.

Allergies:

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

Symptoms: Patient endorses paraesthesias, pain, and "arm falling asleep" while driving. Pain starts at biceps/deltoid area and travels through triceps area and sometimes his entire hand goes numb with arm extension for prolonged period of time. Patient reports that 3 days after the immunization, he developed these symptoms. It has been ongoing for 2 months. The patient declined the second immunization based on this report.

Other Meds: celebrex, duloxetine

Current Illness:

ID: 1783091
Sex: M
Age: 38
State:

Vax Date: 05/07/2021
Onset Date: 09/27/2021
Rec V Date: 10/13/2021
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:

Allergies:

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

Symptoms: Guillain Barre syndrome

Other Meds:

Current Illness:

Date Died: 10/13/2021

ID: 1783092
Sex: F
Age: 32
State: OR

Vax Date: 09/28/2021
Onset Date: 10/01/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data:

Allergies: NKDA

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

Symptoms: Pt presented to the ED 10/13 with syncope and what appeared to be a pulmonary embolism. Tried to resuscitate patient for 90 minutes but no success.

Other Meds: escitalopram, atomoxetine, norethindrone-ethinyl estradiol, ondansetron, omeprazole

Current Illness:

ID: 1783093
Sex: F
Age: 65
State: OR

Vax Date: 07/13/2021
Onset Date: 07/14/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data: They did blood test and observation. They put an IV at the hospital.

Allergies: I'm allergic to penicillin and seafood

Symptom List: Ear pain, Hypoaesthesia

Symptoms: My skin on my hands started to peel and my pain was really severe. I had body aches and it was painful. I took Tylenol, and my hospital gave me Ibuprofen 600mg. This lasted about two weeks, the pain in my body. The headaches never went away. I have to take pain medication for it.

Other Meds: none.

Current Illness: nothing to report

ID: 1783094
Sex: F
Age: 28
State: AR

Vax Date: 09/04/2021
Onset Date: 09/10/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data: None

Allergies: Ceclor, vancomycin, Tylenol, latex

Symptom List: Abdominal pain upper, Dizziness, Dysgeusia

Symptoms: Almost a week after receiving the shot, my arm started itching and developed a whelp at the injection site on 9/10 at 11:00am. The whelp turned into a larger red blotchy spot by 9:00 pm on 9/10. The spot continued to grow on 9/11 and developed a darker red ring around the red blotchy spot around 2:30pm on 9/11. On 9/12, the spot began to fade and disappeared by end of day on 9/13.

Other Meds: postnatal vitamin, probiotic

Current Illness: None

ID: 1783095
Sex: F
Age: 75
State: NV

Vax Date: 09/27/2021
Onset Date: 10/07/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data: No - except in the ambulance they did an EKG and vitals.

Allergies: No

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

Symptoms: The first episode - 03:00 am - waking up and the room started going around. Nothing else was going on. I have an apple watch and all the numbers were fine. I felt a little off balance after waking the next morning. I called an Urgent Care that was going to come out 02:15-04:15 - but at 03:45, I was reading a book on the iPad and all of a sudden the whole room was spinning, I started vomiting, I couldn't get out of the chair due to my balance. We called 9/1/1 and all vitals were fine. They took me in though to Hospital - I couldn't walk so that is why I had them take me in. The doctor at ER said there was a bunch of wax in my ear and he thought it was causing the problem. They put some drops in the ear. And after about 10 minutes, my hearing went out and then they took a metal thing and dug the wax out - there was a lot of wax. I was still having some walking problems when they discharged me. Said it was normal, and I threw up once more time when I got home. Next morning, I didn't feel the greatest but by noon time I started feeling normal again. I have never had an issue too much ear wax ever before. I will see an ENT doctor soon (on the 22nd of this month) to see what is going on. I know within the last year, a doctor has looked in my ear and has not said anything. In the ambulance, they gave me something in IV to stop the vomiting. They gave me a pill while in ER but I'm not sure what it was - maybe to stop the vertigo. I brought some ear drops home to use for four days, twice a day - Najar - something to dissolve ear wax. It wasn't a prescription. I can walk my couple of mile walk without getting vertigo. I have had a couple of times when I am lying down and the room starts spinning a little so I'll talk to the ENT doctor about that. I did go to my Primary Care doctor for follow up and she had looked in my ears and said everything was fine - Tuesday, the 12th.

Other Meds: Multivitamin; Lutein; Influenza

Current Illness: No

ID: 1783096
Sex: F
Age: 65
State: CA

Vax Date: 10/12/2021
Onset Date: 10/13/2021
Rec V Date: 10/13/2021
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: None

Allergies: not really - pollen, dust, cats

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

Symptoms: During the night, I had chills. This morning I had a slight fever, aprox 100, chills, and a headache. Symptoms seem to be easing up this afternoon. I called to a clinic and their patient navigator told me these are common side effects. My first Pfizer shot at the Forum on March 3, 2021 EN 6199 got rid of the Vertigo I had been suffering for several weeks! Still a bit chilled today and slight headache but not as bad.

Other Meds: simvastatin 20mg, fish oil 1200 mg, baby aspirin 81 mg, zyrtec 10 mg, calcium 600mg, vit D-3 2000 mg, magnesium 500 mg., woman's 50+ multi-vitamin, eye vitamin (generic Areds 2), glucosomine/chondroitin

Current Illness: Popped a tendon on my rib on 10/7/21

ID: 1783097
Sex: F
Age: 20
State: NY

Vax Date: 10/13/2021
Onset Date: 10/13/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data:

Allergies: unknown

Symptom List: Unevaluable event

Symptoms: Patient stated that she fainted after 1st dose and wanted to let me know. Patient immediately fainted and vomited after second dose. She was given an ice pack, had some water, and rested for 15-20 minutes. Was able to leave on her own per her request. Counseled patient on seeking emergency medical attention if she started showing signs of an allergic reaction. Patient was accompanied by a group of friends who agreed to watch for any symptoms.

Other Meds: unknown

Current Illness: unknown

ID: 1783098
Sex: F
Age: 62
State: IL

Vax Date: 10/08/2021
Onset Date: 10/10/2021
Rec V Date: 10/13/2021
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: NONE

Allergies: none

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

Symptoms: BRUISED ARM RASHES LIKE 2 INCH CIRCLE AROUND INJECTION SITE

Other Meds:

Current Illness: none

ID: 1783100
Sex: M
Age: 86
State: HI

Vax Date: 02/01/2021
Onset Date: 08/30/2021
Rec V Date: 10/13/2021
Hospital: Y

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

Lab Data:

Allergies:

Symptom List: Injection site pain, Pain

Symptoms: COVID hospitalization after full vaccination.

Other Meds:

Current Illness:

ID: 1783101
Sex: F
Age: 43
State: MO

Vax Date: 10/11/2021
Onset Date: 10/12/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data:

Allergies: No known allergies

Symptom List: Injection site pain, Menorrhagia

Symptoms: 1. Large indurated, erythematous area at site of vaccination. Still expanding at time of visit. 2. Headache, dizziness. Resolved at this time.

Other Meds: drospirenone 3 mg-ethinyl estradioL 0.03 mg tablet Flonase Allergy Relief 50 mcg/actuation nasal spray,suspension Vitamin C 1,000 mg tablet Vitamin D3 50 mcg (2,000 unit) capsule

Current Illness:

ID: 1783102
Sex: F
Age: 69
State: NH

Vax Date: 10/13/2021
Onset Date: 10/13/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data:

Allergies: CODEINE

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

Symptoms: patient recieved both vaccines and stood to leave. about two minutes later patient returned to pharmacy and reported "not feeling well". Pharmacist guided patient to a chair to sit down. Once seated, reported feeling dizzy upon being asked what she was experiencing. Shortly after, patient reported severe back pain, began to become flush, and started to perspire. Patient was asked if she wanted to emergency services to check her out to which she agreed. While waiting for their arrival, pharmacist inquired is patient was having any difficultly breathing or if there was any pain originating for injection site which patient denied. Patient was instructed to take slow, deep breaths to help her remain calm. After a few minutes, patient reported that pain was subsiding. Once EMT's had arrived and patient was assessed she was given the option to be transported for further care, which she declined. After patient had spent a few more minutes seated, she decided to leave. She was again asked if she was feeling well and was invited to remain if she needed to more time to recover. Patient declined to remain seated and departed.

Other Meds: XARELTO 20MG, fLUOXETINE 20MG,

Current Illness: uNKNOWN

ID: 1783103
Sex: F
Age: 51
State: AZ

Vax Date: 10/07/2021
Onset Date: 10/07/2021
Rec V Date: 10/13/2021
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: none

Allergies: prochlorperazine - unknown reaction metoclopramide - unknown reaction ergotamine - unknown reaction

Symptom List: Nausea, Pain in extremity, Pyrexia

Symptoms: Pt received Pfizer COVID 19 vax #3 during a vaccine blitz on 10/07/21 on the parking lot. She parked her car for monitoring after the vaccine. She c/o nausea to the staff who then called provider. Pt is alert, oriented x 3. Drinking water. Denies chest pain, shortness of breath, aches, vision changes, headche. BP was wnl 100/80. Pt said she usually runs low BP. HR and O2 saturation were wnl. She left the parking lot after about 30 minutes. Instructed to report to the ER if her symptoms worsen.

Other Meds: unknown

Current Illness: unknown

Date Died: 10/08/2021

ID: 1783104
Sex: F
Age: 56
State: TX

Vax Date: 03/28/2021
Onset Date: 09/13/2021
Rec V Date: 10/13/2021
Hospital: Y

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

Lab Data: Positive COVID test on 9/17/2021 using a PCR based method

Allergies: Penicillin (Rash), Ketorolac (Rash)

Symptom List: Chills, Fatigue, Headache, Myalgia

Symptoms: Pfizer BioNTech COVID-19 Vaccine EUA: COVID-19 case resulting in Hospitalization / Death. Patient received Pfizer Vaccines on 3/7/2021 and 3/28/2021. Presented to the ED on 9/17/2021 with shortness of breath that started yesterday, as well as a 4 day history of nausea and vomiting. Patient was admitted 9/17/21 and initiated on bipap. She was intubated 9/27/21. She was on max mechanical ventilation and epoprostenol and despite proning her saturations were consistently in the 70s-80s. Patient treated with remdesivir, tocilizumab, and methylprednisolone. Her husband elected to make her DNR and then comfort care. Patient passed away on 10/8/2021.

Other Meds: Amlodipine 10 mg QD, Cyclobenzaprine 10 mg TID, Humalog 10, units TID, Hydrochlorothiazide 25 mg QD, Norco 10/325 Q8H Prn, Insulin glargine 42 units BID, Liraglutide 1.8 mg QD, Losartan 100 mg QD, Meloxicam 15 mg QD, Metoprolol 50 mg QD, Ro

Current Illness:

ID: 1783105
Sex: F
Age: 59
State: CA

Vax Date: 03/01/2021
Onset Date: 08/01/2021
Rec V Date: 10/13/2021
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: Blood, 09/25/2021

Allergies:

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

Symptoms: Trembling, shaking, dizziness, excess lung phlegm, fever off and on, no energy, no strength

Other Meds:

Current Illness:

ID: 1783106
Sex: F
Age: 29
State: CA

Vax Date: 10/08/2021
Onset Date: 10/08/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data: Ct, ekg, blood work. Nothing noted

Allergies: N/a

Symptom List: Nausea

Symptoms: Chest pain, dizziness, shortness of breath. Costochondritis.

Other Meds: N/a

Current Illness: N/a

ID: 1783107
Sex: F
Age: 56
State: KY

Vax Date: 10/08/2021
Onset Date: 10/09/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data:

Allergies: bees

Symptom List: Injection site pain

Symptoms: Severe hives throughout body. Patient continues to take benadryl every 8 hours

Other Meds:

Current Illness: rare autoimmune disorder

ID: 1783108
Sex: M
Age: 48
State: HI

Vax Date: 03/01/2021
Onset Date: 08/27/2021
Rec V Date: 10/13/2021
Hospital: Y

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

Symptoms: COVID hospitalization after full vaccination.

Other Meds:

Current Illness:

ID: 1783109
Sex: M
Age: 37
State: NC

Vax Date: 10/12/2021
Onset Date: 10/13/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data: None

Allergies: None

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

Symptoms: Fever, chills, body aches, vomiting.

Other Meds: Insulin, duloxetine,losartan

Current Illness: None

ID: 1783110
Sex: M
Age: 27
State: IL

Vax Date: 10/13/2021
Onset Date: 10/13/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data:

Allergies: NONE

Symptom List: Tremor

Symptoms: 27y/o Male reporting Chest pain s/p COVID19 Vaccine administration. Patient received COVID19 Vaccination Pfizer 2nd Dose on 13OCT21 @1120 and completed a 15min observation period. After leaving the clinic area, patient returned to car and noticed an abrupt onset of Chest pain and returned to the clinic at 1145. Patient evaluation: A&Ox4. Speaking full clear sentences. Chest pain "pressure" like feeling to chest with radiation to flank area. Chest pain aggravated by deep inspiration but otherwise denying sob or difficulty breathing. Pt heart rate regular and strong. Pt lung sounds clear bilaterally. Patient denies any nausea. Vitals Signs BP 145/95, HR 64, RR 18, T 96.6, pain 6/10, po2 100%. EMS notified. EMS arrival @1215 and patient transported to the local Hospital @1225. No emergency medication was given to patient at Vaccination Clinic prior to EMS Arrival.

Other Meds: NONE

Current Illness: Hypothryoidism

ID: 1783111
Sex: F
Age: 33
State: MI

Vax Date: 10/13/2021
Onset Date: 10/13/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data:

Allergies: n/a

Symptom List: Erythema, Pruritus

Symptoms: patient states that she had a "throat congestion" feeling following her first dose in January 2021. Patient at that time received Benadryl IM at vaccine clinic and was transported down to the ER. She stats that she was released after monitoring and to pre-medicate with Benadryl prior to her 2nd dose. She states with her second dose, she did not have any "throat congestion" after pre-medicating. Today she presented for her Pfizer booster. She pre-medicated with Benadryl 25 mg PO at 1208. Patient received her 3rd dose at 1245. at 1300 she reported feeling the same way after her 1st dose with "throat congestion". She was then given 25mg IM in her right arm. VS at 1307 were BP 124/90, 99% on RA and HR 85. EMT hospital team called at 1315. at 1318 she stated that she felt she was clearing her throat more and felt worse. vitals at 1320 were 99% on RA and HR 77. EMT arrived at 1321 and transported patient to ER.

Other Meds: n/a

Current Illness: n/a

ID: 1783112
Sex: F
Age: 13
State: KS

Vax Date: 05/24/2021
Onset Date: 10/13/2021
Rec V Date: 10/13/2021
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: physical exam

Allergies: none

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

Symptoms: brest lump found on physical exam and reported by patient and mother

Other Meds: none

Current Illness: depression, anxiety

ID: 1783113
Sex: F
Age: 74
State: MI

Vax Date: 10/08/2021
Onset Date: 10/09/2021
Rec V Date: 10/13/2021
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: Cough, Limb discomfort, Pain, SARS-CoV-2 test positive

Symptoms: Patient came to the pharmacy on 10/13/21 to show us the reaction she had in the arm she received 2 vaccines in. It was her left arm and she had a bruise the size of a chicken egg that was starting to turn yellow. Additionally she has a faint light pink rash that extended from the bruise down the arm to almost the elbow joint more towards the inside of the arm/bicep area. Patient stated the bruise formed within 24 hours of the vaccination. Then later (unknown time frame) she started to notice the pink rash (and was warm to the touch). She has yet to contact her primary care doctor in regards to the reaction. She did receive an injection in the right arm today 10/13/21 and that is when the nurse stated the patient needed to contact us. I did confirm the injection was in the appropriate site on the arm (deltoid muscle).

Other Meds:

Current Illness:

ID: 1783114
Sex: F
Age: 37
State: TN

Vax Date: 10/07/2021
Onset Date: 10/08/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data: none

Allergies: intolerant to casein (milk protein)

Symptom List: Asthenia, Chills, Headache, Myalgia

Symptoms: Left glute injection site became inflamed with palm-sized area red, indurated, swollen, and exquisitely tender with pain to touch and with movement (painful to put weight on L foot, for example). margins initially clearly defined (pt outlined with sharpie), and redness extended past margins in multiple directions but margins became less clearly demarcated and redness decreased as area spread. Low grade fever (up to 100.3) along with fatigue, headache, myalgia persisted through Monday following vaccine on Thursday. Injection site Redness mostly resolved by Wednesday, but fatigue and induration remains and painful to touch directly. Treatment included rest, acetaminophen, ibuprofen, and ice. Saw walk in provider at PCP clinic on Monday. of note, l arm soreness was mild and resolved within 24 hrs of vaccine; r arm soreness moderate and resolved within 24-48 hrs.

Other Meds: loratadine 10 mg po daily, fluticasone 2 puffs daily, xiidra eye drops BID, spironolactone 25 mg po daily, omega 3 capsules (Prn brand for dry eye) 3 caps daily, probiotic daily

Current Illness: none

ID: 1783115
Sex: M
Age: 60
State: NH

Vax Date: 09/16/2021
Onset Date:
Rec V Date: 10/13/2021
Hospital:

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

Lab Data:

Allergies: None

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

Symptoms: None stated.

Other Meds: BP And Colesterol

Current Illness: None

ID: 1783116
Sex: F
Age: 20
State: ND

Vax Date: 10/13/2021
Onset Date: 10/13/2021
Rec V Date: 10/13/2021
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: None.

Allergies: No severe allergic reactions

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

Symptoms: Gave 2nd dose of COVID-19 as Pfizer. 1st dose was Moderna (9/13/2021). No reaction in 15 minutes.

Other Meds: Unknown

Current Illness: Unknown

ID: 1783117
Sex: M
Age: 67
State: CO

Vax Date: 04/09/2021
Onset Date: 04/09/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data: MRI- Inflamation in the joint not present prior to vaccine

Allergies: Yes: Sulfur and penicillin, codeine most Tetricycline

Symptom List: Pain in extremity

Symptoms: Massive headache, dizziness, nausea, exhausted (3 days), joint pain, severe pain in right knee like prior to having the stem cell work. Symptoms from brain injury came back after vaccine. Didn't have these for 6 mths prior. Hasn't recovered from this yet

Other Meds: B- vitamins and multivitamins, Gabapentin daily 300mg

Current Illness: Herpetic nerve pain

ID: 1783118
Sex: F
Age: 39
State: TX

Vax Date: 10/08/2021
Onset Date: 10/08/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data: She visited Dr's office on Monday 10/11/2021 to be checked. ***** I do not have any physician notes about the visit.******

Allergies: Unknown

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

Symptoms: On 10/8/2021 patient got vaccinated around 10am. She later that afternoon started feeling feverish and tired. During the night she was experiencing fever and frequent urination. Around 6:30am she was taking a shower and felt dizzy and fainted. She woke up in the floor unconscious. Later that morning she fainting again and fell on floor.

Other Meds: Unknown

Current Illness: Unknown

ID: 1783119
Sex: M
Age: 62
State: PA

Vax Date: 08/27/2021
Onset Date: 09/01/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data: 10/1 - blood work, 10/8 insulin training, 10/11 treatment training, 10/12 primary care visit, 10/12 Endocrinology

Allergies: none

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

Symptoms: I'm not sure my issues are related to the covid 19 shot. Had my third shot 8/27/2021 due to compromised immune system. I felt run down and lethargic. In mid September I was having lIght headedness and constant urination. Called the Dr - she ordered blood work. My A!C had jumped from 6.4 to 13.9. I fell during a dizzy spell and broke my wrist, nose and a toe. On 10/8 i was started on Jardiance and insulin. I read an article that the vaccine could raise blood sugar - the way I understood the article that it was short lied. I thought I should share my issues.

Other Meds: Toprol XL, Potassium Chloride, Torsemide, Omeprazole, lipitor, Zetia, aspirin, tylenol, zyrtec, Oxygen, multi Vitamin, advair

Current Illness: none

ID: 1783120
Sex: M
Age: 32
State: CA

Vax Date: 10/12/2021
Onset Date: 10/12/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data:

Allergies:

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

Symptoms: patient was observed to have fainted after receiving the vaccination.

Other Meds: report of patient fainted after receiving vaccination .

Current Illness:

ID: 1783121
Sex: M
Age: 85
State: VA

Vax Date: 10/13/2021
Onset Date: 10/01/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data:

Allergies:

Symptom List: Vomiting

Symptoms: ***VACCINE ERROR *** Patient came in with his daughter for a booster dose of Pfizer. All registration had been completed by the patient prior to arrival and the patient was requesting a Pfizer booster dose. Patients daughter and father verbally confirmed that the previous two doses were Pfizer vaccine to the receptionist and pharmacist. Pt did not provide CDC card. Pt and pt?s daughter dishonestly provided inaccurate information pertaining to the patients vaccine history on multiple occasions to numerous staff members. Upon receiving the Pfizer vaccine pt?s daughter admitted to deceiving staff so that her father would get the Pfizer. Pt did not have any adverse reactions, he waited 15 minutes and left. Staff immediately reached out to the CDC to get a response in regards to follow up or adverse effects. CDC advised there was no need for any follow ups and that there are no potential adverse effects of mixing vaccines.

Other Meds:

Current Illness:

ID: 1783122
Sex: F
Age:
State: CA

Vax Date: 10/11/2021
Onset Date: 10/11/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data:

Allergies:

Symptom List: Headache, Limb discomfort, Nasal congestion

Symptoms: After receiving the shot the patient was fine but 2 minutes later she started shaking like having seizure. After it, she felt dizzy, we gave some water and offer to call 911 but her parents refused. After couple of minutes she was feeling well.

Other Meds:

Current Illness:

ID: 1783123
Sex: F
Age: 32
State: SC

Vax Date: 10/12/2021
Onset Date: 10/12/2021
Rec V Date: 10/13/2021
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: oth source individual and pharmacist went for blood testing. Will hear back in 1-5 business days.

Allergies: PCN allergy

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

Symptoms: Pharmacist administered vaccine to patient , readjusted seating and needle then grazed the inside of thumb. Both source individual and pharmacist went for blood testing. Will hear back in 1-5 business days.

Other Meds: Yaz

Current Illness: NA

Date Died: 09/18/2021

ID: 1783124
Sex: M
Age: 91
State: WI

Vax Date: 02/19/2021
Onset Date: 09/14/2021
Rec V Date: 10/13/2021
Hospital: Y

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

Lab Data: 9/6/2021 Covid positive per antigen 9/14/2021 CT ground glass opacities, likely bronchogenic carcinoma, possible renal cell carcinoma

Allergies: Unknown

Symptom List: Injection site swelling, Limb discomfort

Symptoms: Admitted to hospital on 9/14/2021 with SOB, cough, hypoxia. Had been recommended monoclonal antibiotic therapy, but had not been initiated. DX: acute hypoxic respiratory failure, c-19 pneumonia. on 15 L O2, Decadron, declined intubation. 9/16/2021 awaiting transfer to hospice. Died 9/18/2021. Immunized with Moderna 1/22/2021 and 2/19/2021 - only 2/19 dose available. Copy of vaccination card received where client resided showing both doses.

Other Meds: Unknown

Current Illness: Unknown

ID: 1783125
Sex: M
Age: 11
State: TX

Vax Date: 07/02/2021
Onset Date: 07/02/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data: None

Allergies: NKA

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

Symptoms: Underaged at time of vaccine administration. Age 11 years, 10 months.

Other Meds:

Current Illness:

ID: 1783126
Sex: F
Age: 58
State: WI

Vax Date: 10/13/2021
Onset Date: 10/13/2021
Rec V Date: 10/13/2021
Hospital:

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

Lab Data: None Yet

Allergies: Shellfish, Sulfa-based Medications, Latex, 2012 Flu Vaccine - Anaphylaxis.

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

Symptoms: Trouble Breathing, felt faint - now have pain in upper chest areas. The RN at the clinic monitored my blood pressure and pulse for approx. 40 minutes. I had several "episodes" of shallow, labored breathing when I came home from the clinic, as I write this, it has been 6 hours since I received the vaccine and those breathing symptoms are no longer an issue.

Other Meds: None

Current Illness: None

Total 2021 VAERS Injuries: 654,986

Page last modified: 13 November 2021 9:17am