VAERS 2021 Database www.vaers.hhs.gov

Main Page | All 2021 Deaths | Videos
VAERS Updated: 10/01/2021
** VAERS DATABASE Last updated: October 1, 2021**
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Manufacturers

Total Manufacturer
187,133MODERNA
33,878JANSSEN
2,321PFIZER\BIONTECH
1,091GLAXOSMITHKLINE BIOLOGICALS
983UNKNOWN MANUFACTURER
363MERCK & CO. INC.
229SEQIRUS, INC.
45DYNAVAX TECHNOLOGIES CORPORATION
41NOVARTIS VACCINES AND DIAGNOSTICS
29SANOFI PASTEUR
18EMERGENT BIOSOLUTIONS
8PAXVAX
7TEVA PHARMACEUTICALS
4PFIZER\WYETH
3BERNA BIOTECH, LTD.
2SMITHKLINE BEECHAM
2INTERCELL AG
2PROTEIN SCIENCES CORPORATION
1CSL LIMITED

Incidents per State

State Total
77,548
AK1,869
AL5,581
AR3,688
AS47
AZ14,288
CA61,984
CO11,665
CT8,149
DC1,663
DE1,807
FL37,749
FM5
GA15,058
GU120
HI2,453
IA4,625
ID2,692
IL20,334
IN24,007
KS4,615
KY7,696
LA4,887
MA14,654
MD12,514
ME3,129
MH11
MI18,739
MN12,528
MO9,710
MP29
MS2,790
MT2,375
NC16,368
ND1,356
NE2,880
NH3,100
NJ17,634
NM3,916
NV4,239
NY34,355
OH19,081
OK6,195
OR8,636
PA23,083
PR2,370
QM2
RI2,088
SC6,411
SD1,212
TN9,131
TX35,174
UT4,273
VA14,937
VI64
VT1,676
WA14,909
WI11,259
WV2,388
WY861
XB5
XL1
XV2

ID: 1031875
Sex: F
Age: 17
State: OR

Vax Date: 01/24/2021
Onset Date: 01/24/2021
Rec V Date: 02/15/2021
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:

Symptom List: Dysphagia, Epiglottitis

Symptoms: Patient was administered the Moderna vaccine prior to her 18th birthday

Other Meds:

Current Illness:

ID: 1031876
Sex: F
Age: 36
State: OH

Vax Date: 02/11/2021
Onset Date: 02/12/2021
Rec V Date: 02/15/2021
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: Demerol

Symptom List: Anxiety, Dyspnoea

Symptoms: tachycardia, high fever of 104, prolonged fatigue, chills, dizzy, lightheaded, hypertension

Other Meds: multivitamins

Current Illness:

ID: 1031877
Sex: F
Age: 71
State: WI

Vax Date: 02/12/2021
Onset Date: 02/12/2021
Rec V Date: 02/15/2021
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:

Allergies: No KNown

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

Symptoms: No adverse event reported. It was determined that only air was administered at time of vaccination.

Other Meds: No KNown

Current Illness: No Known

ID: 1031878
Sex: F
Age: 44
State: MI

Vax Date: 01/11/2021
Onset Date: 02/03/2021
Rec V Date: 02/15/2021
Hospital:

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

Lab Data:

Allergies: None

Symptom List: Dizziness, Fatigue, Mobility decreased

Symptoms: Had a chicken pox looking rash on back and some on stomach area. Felt like a pimple, did not spread or itch. Went away in about 1 1/2 weeks.

Other Meds: None

Current Illness: None

ID: 1031879
Sex: M
Age: 87
State: MN

Vax Date: 01/29/2021
Onset Date: 01/31/2021
Rec V Date: 02/15/2021
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: Amlodipine, Statins

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

Symptoms: 1/31/2021 03:56 Nursing Note Note Text: Pt. c/o R Abd pain at the waist line. Pt. stated it felt like a muscle being pulled. Not constipated, bowel sounds active. Took VS and they are charted. Writer called on call and spoke to NP and she stated to give him Tylenol and check the above. Bowel sounds and such. So writer did give him Tylenol at 3:45am. 1/31/2021 12:53 Admit/Discharge/Transfer Note Note Text: at 1030 pt stated that he had been having RLQ pain for the past hour. VS retaken. Described pain as constant but "increases suddenly" to an 8 on a 10 point pain scale. worsens with movement, alleviates with rest. RLQ pain radiates to R shoulder and around to his R lower back. bowel sounds x4, tender abd in right lower quadrant and upper right quadrant. follow-up assessment at 1220 found rebound pain. pt states last bm was yesterday and it was brown, formed, easy to pass. Lower posterior R lung sounds diminished and lower posterior L lung fields contain crackles. at 742: temp 98F, 140/68, 02 saturation 96%, respiration 16. denies n&v. ate pancakes, sausage, and fruit for breakfast. gave morning pantoprazole, held morning am medications. Called on call triage nurse and NP. on call NP suggested sending pt to hospital. transferred to hospital via ambulance and paramedics at 1240.

Other Meds: Sennosides Tablet 8.6 MG Nitroglycerin Tablet Sublingual 0.4 MG Tylenol Extra Strength Tablet 500 MG (Acetaminophen) predniSONE Tablet 5 MG predniSONE Tablet 1 MG Pantoprazole Sodium Tablet Delayed Release 20 MG Metoprolol Tartrate Tablet 5

Current Illness: OTHER PULMONARY EMBOLISM WITHOUT ACUTE COR PULMONALE POLYMYOSITIS, ORGAN INVOLVEMENT UNSPECIFIED ACUTE RESPIRATORY FAILURE WITH HYPOXIA PARALYTIC SYNDROME, UNSPECIFIED ACUTE KIDNEY FAILURE, UNSPECIFIED ANEMIA, UNSPECIFIED DYSPHAGIA, OROPHARYNGEAL PHASE VENOUS INSUFFICIENCY (CHRONIC) (PERIPHERAL) THROMBOCYTOPENIA, UNSPECIFIED ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITH UNSPECIFIED ANGINA PECTORIS LOBAR PNEUMONIA, UNSPECIFIED ORGANISM RIGHT LOWER QUADRANT PAIN SEPSIS, UNSPECIFIED ORGANISM CONTUSION OF UNSPECIFIED THIGH, SUBSEQUENT ENCOUNTER ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS ESSENTIAL (PRIMARY) HYPERTENSION PRESENCE OF OTHER VASCULAR IMPLANTS AND GRAFTS PURE HYPERCHOLESTEROLEMIA, UNSPECIFIED HISTORY OF FALLING OLD MYOCARDIAL INFARCTION LOCALIZED EDEMA NONTOXIC SINGLE THYROID NODULE SOLITARY PULMONARY NODULE

ID: 1031880
Sex: M
Age: 52
State: CA

Vax Date: 01/29/2021
Onset Date: 01/29/2021
Rec V Date: 02/15/2021
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:

Allergies: none

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

Symptoms: patient may have received different dose. Patient on the vaccinator list when brought to attention

Other Meds: none

Current Illness: none

ID: 1031881
Sex: F
Age: 60
State: MI

Vax Date: 01/20/2021
Onset Date: 01/20/2021
Rec V Date: 02/15/2021
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: ALLERGIC TO BEES NO KNOW DRUG ALLERGIES

Symptom List: Pyrexia, White blood cell count decreased

Symptoms: AFTER THE VACCINE IT WAS DESCRIBED AS AN ALLERGIC REACTION. ONSITE EMS WAS REQUESTED WITH PHYSICIAN, SHE WAS TREATED AND TRANSPORTED TO THE LOCAL HOSPITAL

Other Meds:

Current Illness:

ID: 1031882
Sex: M
Age: 86
State: WI

Vax Date: 02/12/2021
Onset Date: 02/12/2021
Rec V Date: 02/15/2021
Hospital:

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

Lab Data:

Allergies: No Known

Symptom List: Pharyngeal swelling

Symptoms: No adverse event reported. It was determined that only air was administered at time of vaccination.

Other Meds: No KNown

Current Illness: No Known

ID: 1031883
Sex: F
Age: 29
State: CA

Vax Date: 02/15/2021
Onset Date: 02/15/2021
Rec V Date: 02/15/2021
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: Abdominal pain, Chills, Sleep disorder

Symptoms: Tingly lips and throat. Red eyelids. Self-administered benadryl and all symptoms resolved after monitoring for 1 hour.

Other Meds:

Current Illness:

ID: 1031884
Sex: F
Age: 82
State: HI

Vax Date: 01/25/2021
Onset Date: 01/31/2021
Rec V Date: 02/15/2021
Hospital: Y

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

Lab Data:

Allergies: aspirin

Symptom List: Diarrhoea, Nasal congestion

Symptoms: 7 days post COVID #1 vaccine, onset of bilateral leg claudication (1/31/21). Subsequently dx'd with acute bilateral arterial clots in both legs requiring thrombolysis, bilateral popliteral/artery thromboembolectomy, heparin. Acute clot per vascular surgeon. Surgery performed 2/12/21.

Other Meds: Lisinopiril, atorvastatin, advair, metoprolol, amlodipine

Current Illness:

ID: 1031885
Sex: F
Age: 69
State: OH

Vax Date: 02/04/2021
Onset Date: 02/04/2021
Rec V Date: 02/15/2021
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: The evening of Feb 4th she started feeling tired. Feb 7th still tired, started feeling anxious, heart was beating harder and faster, stomach felt upset, she was burping a lot Feb 8th went to primary care doctor. BP was 175/90. She felt dizzy and lightheaded, ringing in ears was louder than usual She gave another BP med to take, but she didn't take it. Instead took an extra of hr own propranolol. Yesterday was the first day the sxs were better. Other than taking the extra propranolol on Feb 8th, she just rested 2/11/21 is the first day the tiredness has let up

Other Meds: hypertension - HCTZ 25 mg, propranolol 40 mg BID Gout- allopurinol 100 mg BID Diabetes metformin 500 mg QD, Glimepiride 4 mg

Current Illness:

ID: 1031886
Sex: F
Age: 82
State: PA

Vax Date: 02/05/2021
Onset Date: 02/13/2021
Rec V Date: 02/15/2021
Hospital:

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

Lab Data:

Allergies: Bee Venom; Voltaren; Clarithromicin; Fluoxetine Hcl; Erythromycin; Celexa; Rosuvastatin Calcium; Ace Inhibitors; Calcilo Xd

Symptom List: Rash, Urticaria

Symptoms: Redness/rash, itching, soreness

Other Meds: Losartan 50 mg; Levothyroxine .075 mg; Desloratadine 5 mg;Omeprazole 40 mg; Montelukast 10 mg; Simvastatin 40 mg; Escitopram 20 mg; Krill oil omega 3 500 mg; multi vitamin; Fluticasone Propionate nasal spray

Current Illness:

ID: 1031887
Sex: M
Age: 75
State: IN

Vax Date: 02/04/2021
Onset Date: 02/04/2021
Rec V Date: 02/15/2021
Hospital:

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

Lab Data:

Allergies: None

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

Symptoms: Shingles

Other Meds: Metformin 1000 mg, glimepiride 1mg

Current Illness: None

ID: 1031888
Sex: F
Age: 67
State: CA

Vax Date: 02/13/2021
Onset Date: 02/14/2021
Rec V Date: 02/15/2021
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: Sulfa antibiotics

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

Symptoms: I was felling a bit dizzy upon awakening the day after the vaccination. Once in the bathroom I became very dizzy and started sweating profusely. I tried to walk back to the bedroom but fainted. I came to sitting on the floor. My husband brought me some water and stayed with me. It took quite a while for those symptoms to subside enough that I could get up and go back to bed. For the next 7 or 8 hours I felt chilly and somewhat tired. Normal by late afternoon and evening.

Other Meds: 12,000 mg flax seed oil, 1,000 IU vitamin D3, 500 mg L-Lysine, LifeTime Osteo Density Blend, Viactive Calcium plus D

Current Illness: none

ID: 1031889
Sex: M
Age: 77
State: DC

Vax Date: 02/11/2021
Onset Date: 02/12/2021
Rec V Date: 02/15/2021
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: Penicillin in chikdhood

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

Symptoms: Ipsilateral lymphocyl in the left axilla, 5 cm in diameter, about 1 cm in thickness. Tender, painful with movement, mild, without discrete palpable lymph node enlargement.

Other Meds: Levothyroxine Atorvastatin Stool softener ASA 81 Antioxidants Eye Vitamins Probiotic Calcium magnesium zinc Tea extract Melatonin

Current Illness: None active

ID: 1031890
Sex: F
Age: 17
State: OR

Vax Date: 01/24/2021
Onset Date: 01/24/2021
Rec V Date: 02/15/2021
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: Nausea, Pain, Pain in extremity, Paraesthesia oral, Pyrexia

Symptoms: Patient was administered the Moderna vaccine prior to her 18th birthday.

Other Meds:

Current Illness:

ID: 1031891
Sex: F
Age: 47
State: MN

Vax Date: 12/18/2020
Onset Date: 01/04/2021
Rec V Date: 02/15/2021
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: Penicillin, minacyclin,

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

Symptoms: Severe enlarged lymph node, resolved in about a week, large lump in armpit that was super sore and hurt to the touch. Right arm pit.

Other Meds: Over the counter vitamins , polmicourt

Current Illness:

ID: 1031892
Sex: F
Age: 66
State: IN

Vax Date: 02/10/2021
Onset Date: 02/11/2021
Rec V Date: 02/15/2021
Hospital:

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

Lab Data:

Allergies:

Symptom List: Ear pain, Hypoaesthesia

Symptoms: Woke up shaking, headache, hurting all over. Lasted about an hour. Feeling tired still on day 6. Day 4 one cold sore started, Day 5, two more cold sores.

Other Meds:

Current Illness:

ID: 1031893
Sex: F
Age: 71
State: FL

Vax Date: 02/11/2021
Onset Date: 02/12/2021
Rec V Date: 02/15/2021
Hospital:

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

Lab Data:

Allergies: Codeine

Symptom List: Abdominal pain upper, Dizziness, Dysgeusia

Symptoms: Welts, rashes, severe itching and pain

Other Meds: Multi vitamin, Glusosamine Chond, Metamucil, C, E, Fish Oil, Aspirin, Zinc, Calc/Mag/Zinc, Potassium , Motrin and Elavil

Current Illness: None

ID: 1031894
Sex: M
Age: 24
State: CA

Vax Date: 01/29/2021
Onset Date: 01/29/2021
Rec V Date: 02/15/2021
Hospital:

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

Lab Data:

Allergies:

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

Symptoms: patient may have been given different dose. Patient on the list of the vaccinator when brought to attention

Other Meds:

Current Illness:

ID: 1031895
Sex: F
Age: 81
State: LA

Vax Date: 02/03/2021
Onset Date: 02/04/2021
Rec V Date: 02/15/2021
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: codeine

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

Symptoms: pt stated that she has had difficulty breathing at night, congestion, thickness in her throat, chills, nausea, constant dizziness, has a rash around her neck, has fatigue and weakness. Pt also has had pain in her right knee the night of the vax. Pt just feels bad, raised blood pressure, has numbness in both hands and is very uncomfortable. Pt called her PCP and was told to her to take an extra HBP pill. Since pt is still having most of these symptoms she will call her PCP back for more medical advice.

Other Meds: Furosemide 20mg, ezetimibe 10mg, losartan potassium 100mg, hydralazine 50 mg, diltiazem 120mg, Multivitamin, aspirin 81mg,

Current Illness: blood pressure running higher than normal

ID: 1031896
Sex: F
Age: 73
State: KS

Vax Date: 02/11/2021
Onset Date: 02/12/2021
Rec V Date: 02/15/2021
Hospital:

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

Lab Data:

Allergies: Naproxine

Symptom List: Unevaluable event

Symptoms: fever, diarrhea, headache, sore arm, sore underarm, mouth sores (cheeks, tongue, under tongue, gums)

Other Meds: Levothyroxine allopurinol fluoxetine simvastatin omprazole fish oil probiotic apple cider vinegar

Current Illness: none

ID: 1031897
Sex: F
Age: 56
State: IL

Vax Date: 01/13/2021
Onset Date: 01/13/2021
Rec V Date: 02/15/2021
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: Compazine; Sulphur; tomatoes

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

Symptoms: After getting vaccine, I got burning in my chest and after a few seconds that went away. After 15 minutes, I noticed a headache and after an hour it became more intense and I had to take something for it. No other symptoms except a headache until the next day. I had chills; general body aches; real bad joint point - couldn't work from home because I couldn't type on computer. Chills and headache continued - at midnight - the right side of my neck was really stiff and painful to touch. My lymph nodes on right side were enlarged. The next morning, at 11:00 - general fatigue; body aches and headache and chills and couldn't drive yourself. Went to my provider and got a COVID screening; mumps titer screen; Epstein Barr Virus titer; Nurse practitioner gave me doxycycline and Dr. told me stay off work until they got COVID test back. Went back to work that following Monday. On Monday test results were back and were negative for everything. Have had the same reaction to flu reaction about seven years ago. I had the same reaction to the Hepatitis Vaccine and the Hepatitis B vaccine - is what triggered my IGG numbers to be higher. Symptoms have lessened with flu vaccines over the years. This COVID vaccine was an intense response for the first dose. I took Ibuprofen and then Tylenol (alternating with Ibuprofen six hours later) for second dose of the vaccine and my response for that does wasn't as intense - it was there but not enough of a reaction where I couldn't work.

Other Meds: I was getting a weekly B12 injection; Vit D injection 50,000 IUD orally- a week

Current Illness: no

ID: 1031898
Sex: F
Age: 81
State: MO

Vax Date: 02/04/2021
Onset Date: 02/15/2021
Rec V Date: 02/15/2021
Hospital:

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

Lab Data:

Allergies: Bactrim

Symptom List: Injection site pain, Pain

Symptoms: Dose 2 given 14 days after dose 1

Other Meds: unknown

Current Illness: unknown

ID: 1031899
Sex: M
Age: 32
State: CA

Vax Date: 01/16/2021
Onset Date: 01/19/2021
Rec V Date: 02/15/2021
Hospital:

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

Lab Data:

Allergies: Only known allergy is Penicillin.

Symptom List: Injection site pain, Menorrhagia

Symptoms: Severe hives and swelling in face/lips appx 3.5 days after getting 1st dose of Covid-19 Moderna Vaccine. Blood test showed that I am suddenly highly allergic to 19 different food groups. I have no known food allergies prior to C19 Moderna Vaccine. I have had hives every single day since they 1st appeared (3.5 days after vaccine). I have had multiple days of facial swelling as well and have been to the hospital multiple times. To this date (date of this report) I still have hives and facial swelling. Facial swelling is intermittent. I have stayed away from the list of foods that I am apparently suddenly allergic to and I still have hives and swelling. I occasionally have a irritated throat which makes it difficult to breathe in. I have a specialist appointment with an allergy/immunology doctor this coming Thursday to see what thier diagnosis is. My family doctor believes my potential angioedema diagnosis is directly related to my 1st dose of C19 Moderna Vaccine.

Other Meds: None.

Current Illness: None.

ID: 1031900
Sex: F
Age: 29
State: PA

Vax Date: 01/18/2021
Onset Date: 01/30/2021
Rec V Date: 02/15/2021
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: Shellfish, pollen/seasonal allergies

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

Symptoms: Left second toe became discolored and stinging/painful, then left 4th toe. Exam c/w pernio/chillblains

Other Meds: none

Current Illness: None other than lymphadenopathy also associated with vaccine

ID: 1031901
Sex: M
Age: 77
State: MN

Vax Date: 01/29/2021
Onset Date: 01/30/2021
Rec V Date: 02/15/2021
Hospital: Y

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: No Known Allergies

Symptom List: Nausea, Pain in extremity, Pyrexia

Symptoms: 1/30/2021 23:08 Nursing Note Note Text: Patient refused to use incentive spirometer at bedtime. Writer administered prn Mucinex at 1600 and 2130 for upper chest congestion. 02 at 1 liter per NC during thru the night for comfort. 02 sats at 95%. Writer encouraged fluids at bedside. Patient was compliant in taking a shower earlier this afternoon but refused supper. Patient has been mildly confused to place and time, reoriented easily. Will continue monitor vital signs and encourage incentive spirometer. 1/31/2021 00:15 Nursing Note Note Text: Patient had very large incontinent fowl smelling bloody stools at mid noc. Writer called Nurse supervisor also to assess stool. MD was called new order to send patient to hospital for evaluation. Wife was called and updated, bedhold obtained.

Other Meds: Pantoprazole Sodium Tablet Delayed Release 40 MG Multivitamin Tablet (Multiple Vitamin) guaiFENesin ER Tablet Extended Release 12 Hour 600 MG Atorvastatin Calcium Tablet 40 MG Aspirin EC Tablet Delayed Release 81 MG (Aspirin) Apixaban

Current Illness: ENCOUNTER FOR SURGICAL AFTERCARE FOLLOWING SURGERY ON THE CIRCULATORY SYSTEM PRESENCE OF OTHER VASCULAR IMPLANTS AND GRAFTS PRESENCE OF PROSTHETIC HEART VALVE OTHER SPECIFIED DISORDERS OF ARTERIES AND ARTERIOLES NONRHEUMATIC AORTIC (VALVE) STENOSIS CEREBRAL INFARCTION DUE TO UNSPECIFIED OCCLUSION OR STENOSIS OF LEFT MIDDLE CEREBRAL ARTERY APHASIA FOLLOWING CEREBRAL INFARCTION ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS THORACIC AORTIC ANEURYSM, WITHOUT RUPTURE UNSPECIFIED ATRIAL FIBRILLATION GASTROINTESTINAL HEMORRHAGE, UNSPECIFIED ACUTE DUODENAL ULCER WITHOUT HEMORRHAGE OR PERFORATION POLYP OF COLON ABNORMAL ELECTROCARDIOGRAM [ECG] [EKG] LONG TERM (CURRENT) USE OF ANTICOAGULANTS ESSENTIAL (PRIMARY) HYPERTENSION HYPERLIPIDEMIA, UNSPECIFIED RETENTION OF URINE, UNSPECIFIED ACUTE POSTHEMORRHAGIC ANEMIA ALCOHOL ABUSE, UNCOMPLICATED DIAPHRAGMATIC HERNIA WITHOUT OBSTRUCTION OR GANGRENE OTHER POSTPROCEDURAL COMPLICATIONS AND DISORDERS OF THE CIRCULATORY SYSTEM, NOT ELSEWHERE CLASSIFIED

ID: 1031902
Sex: F
Age: 66
State: NY

Vax Date: 02/14/2021
Onset Date: 02/15/2021
Rec V Date: 02/15/2021
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: Significant discomfort when raising arm above a certain height and redness/inflammation at injection site

Other Meds:

Current Illness:

ID: 1031903
Sex: F
Age: 56
State: AL

Vax Date: 02/09/2021
Onset Date: 02/12/2021
Rec V Date: 02/15/2021
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:

Allergies: NKA

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

Symptoms: Rash on right buttock after first vaccine and went away. Came back after 2nd vaccine with burning and itching and more places. No pus just red and angry

Other Meds: Estradiol

Current Illness: None

ID: 1031904
Sex: F
Age: 66
State: MO

Vax Date: 02/11/2021
Onset Date: 02/12/2021
Rec V Date: 02/15/2021
Hospital:

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

Lab Data:

Allergies: None known

Symptom List: Nausea

Symptoms: Moderna COVID-19 Vaccine EUA Vaccine administered at 8:30 am on 2/11/2021. Left arm started becoming sore about 8 PM that night. Patient took 325 mg aspirin po to relieve inflammation. Chills began at 1:30 and persisted for 3-4 hours. Patient collapsed about 6:30 PM on 2/12/2021 and EMS responded to home within minutes. Vitals were WNL. EKG showed no significant problems. Blood glucose was 144 mg/dl.

Other Meds: Krill oil, aspirin, Vitamin C, Vitamin D, alpha lipoic acid

Current Illness: None

ID: 1031905
Sex: F
Age: 72
State: NH

Vax Date: 02/05/2021
Onset Date: 02/09/2021
Rec V Date: 02/15/2021
Hospital:

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

Lab Data:

Allergies: vicodin tetracycline bactrim

Symptom List: Injection site pain

Symptoms: 2/5 vaccination 2/6 arm a little sore when moved, very fatigued- 2/7-2/8-2/9 very fatigued 2/9 nausea, vomited once, diarrhea several times, aches, fever of 101.5, sleeping 2/10 totally recovered

Other Meds: metformin probiotics losartan lovastatin lantus solostar insulin

Current Illness: none

ID: 1031906
Sex: F
Age: 70
State: NY

Vax Date: 01/30/2021
Onset Date: 02/07/2021
Rec V Date: 02/15/2021
Hospital:

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

Lab Data:

Allergies: Tegaderm tape

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

Symptoms: Arm where shot was given became hot, swollen, covering 75% of area between shoulder & elbow. Presented on day 8 after injection, lasted eight days. Took thuja for five days.

Other Meds: Tacrolimus,Clobatsel, Protopic, Vit. D3,Vit. E, Fish Oil , S.A.T. , L-Glutamine, Citrus Pectin, Probiotic, Melotonin

Current Illness: Post chemo & Radiation 5 months out

ID: 1031907
Sex: F
Age: 40
State: FL

Vax Date: 02/10/2021
Onset Date: 02/11/2021
Rec V Date: 02/15/2021
Hospital:

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

Lab Data:

Allergies: None

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

Symptoms: Fever over 102, body aches, headache, redness and swelling and knotting 10-15 cm in diameter at injection site.

Other Meds: None

Current Illness: None

ID: 1031908
Sex: M
Age: 75
State: CA

Vax Date: 02/05/2021
Onset Date: 02/05/2021
Rec V Date: 02/15/2021
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: Acute sudden hearing loss in right ear 4 hours after being vaccinated with Pfizer Covid vaccine

Other Meds: Klonipin Synthroid

Current Illness: Sleep apnea Hypothyroidism Perioidic limb movement disorder

Date Died: 02/14/2021

ID: 1031909
Sex: F
Age: 56
State: FL

Vax Date: 01/08/2021
Onset Date: 01/30/2021
Rec V Date: 02/15/2021
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: amoxicillin (swelling), sulfur (swelling), loratadine (rash)

Symptom List: Erythema, Pruritus

Symptoms: Pt received dose #1 of COVID-19 vaccine (Pfizer-BioNTech) on 12/18/20 and dose #2 ( Pfizer-BioNTech) on 1/8/21. On 1/30, patient was evaluated at urgent care due to back pain. No bloodwork done; metronidazole prescribed for 7 days. On 2/8, patient was admitted to outside hospital due to ongoing symptom progression. At time of admission, hgb 5 g/dL and plt 9k. Per Dr. (hematology/oncology), pt with schistocytes, LDH 1500, and elevated reticulocyte count consistent with thrombotic thrombocytopenic purpura (TTP). SCr >2 mg/dL. Patient immediately treated with plasma exchange and steroids, however continued to decline. Patient expired on 2/14/21.

Other Meds: Acetaminophen 650 mg PO q4h PRN for pain, amlodipine 10 mg PO daily, atenolol 100 mg PO daily, calcium carbonate/cholecalciferol 600 mg/200 mg PO BID, fluticasone 50 mcg per nare daily, HCTZ 25 mg PO daily, phentermine 37.5 mg PO AC breakfa

Current Illness: None known

ID: 1031910
Sex: F
Age: 33
State: CA

Vax Date: 02/12/2021
Onset Date: 02/14/2021
Rec V Date: 02/15/2021
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: None

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

Symptoms: Malaise & hypersomnolence around 20 hours post-injection. "COVID arm" around 36 hours post-injection: redness and slightly raised bump all around injection site, ~1" diameter. Sensitive , tender, painful to touch, pain is about 2/10 without movement, 6/10 with palpation. Feels like a very bad mosquito or bug bite.

Other Meds: Prenatal

Current Illness: None

ID: 1031911
Sex: F
Age: 55
State: CA

Vax Date: 02/04/2021
Onset Date: 02/14/2021
Rec V Date: 02/15/2021
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: Seasonal allergies, pollen , etc

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

Symptoms: Small red rash on cheeks and diarrhea for 2 days

Other Meds: None

Current Illness: None

ID: 1031912
Sex: F
Age: 39
State: CA

Vax Date: 02/15/2021
Onset Date: 02/15/2021
Rec V Date: 02/15/2021
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: NKA

Symptom List: Asthenia, Chills, Headache, Myalgia

Symptoms: 12:36: Vaccine administered 0.5 ml Moderna. 12:46: Patient became, light headed and flushed. Assessed by RN on site. Vitals taken,Vitals :139/80 P:125 02:100%. Patient alert oriented and verbally reported feeling flushed. Pt given 50mg oral Benadryl and water, elevated legs. Symptoms relieved within 10 minutes of admin. Monitored patient for an aditional 30 mins, family onsite and availabe to drive patient home for safety. Advised patient to go home and rest for the the day, provided education to take Acetaminophen for any additional mild symptoms and to call emerency service or any unexpected adverse. V/S after 30 mins BP127/81 P92 02:99% and patient reported feeling back to baseline prior to vaccine administration. Supervisor on site currnetly in vaccination room and aware.

Other Meds: Unknown

Current Illness: Unknown

ID: 1031913
Sex: F
Age: 31
State: IN

Vax Date: 01/09/2021
Onset Date: 01/10/2021
Rec V Date: 02/15/2021
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:

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

Symptoms: Severe Chills, body aches. Fatigue

Other Meds:

Current Illness:

ID: 1031914
Sex: F
Age: 30
State: OK

Vax Date: 02/12/2021
Onset Date: 02/13/2021
Rec V Date: 02/15/2021
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: None

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

Symptoms: Besides the usual body aches and body chills, I also developed sinus pressure, chest pressure, and a very mild cough.

Other Meds: Balcoltra (birth control) Spironalactone

Current Illness: None

ID: 1031915
Sex: F
Age: 67
State: GA

Vax Date: 02/07/2021
Onset Date: 02/07/2021
Rec V Date: 02/15/2021
Hospital:

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

Lab Data:

Allergies: Augmentin Clarithromycin Doxycycline Sulfa Class Avelox

Symptom List: Pain in extremity

Symptoms: 8 hours post the vaccine the pt experienced severe nausea, vomiting, diarrhea, fever , chills and aches

Other Meds: None

Current Illness: None

ID: 1031916
Sex: F
Age: 67
State: ME

Vax Date: 02/03/2021
Onset Date: 02/03/2021
Rec V Date: 02/15/2021
Hospital:

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

Lab Data:

Allergies:

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

Symptoms: Increased Temp and lethargy after second dose resolved after 24 hours

Other Meds:

Current Illness:

ID: 1031918
Sex: F
Age: 55
State: MI

Vax Date: 02/15/2021
Onset Date: 02/15/2021
Rec V Date: 02/15/2021
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: LIDOCAINE,BACTRIM DS, CODEINE

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

Symptoms: AFTER RECEIVING VACCINE SHE COMPLAINED OF HEADACHE AND LIGHT HEADEDNESS. GLUCOSE 69, BP 156/96 HR 68 100% O2 ON ROOM AIR SHE WAS TREATED WITH ORAL GLUCOSE WAITED 15 MINUTES RECHECKED GLUCOSE WAS 75MG/DL AND SHE FELT BETTER. SHE WAS RELEASED TO HOME, WITH A RECOMENDATION TO GET SOMETHING TO EAT.

Other Meds:

Current Illness:

ID: 1031919
Sex: F
Age: 68
State: MO

Vax Date: 02/09/2021
Onset Date: 02/10/2021
Rec V Date: 02/15/2021
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: Penicillin, Adhesive

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

Symptoms: Chills, Fever, Body aches

Other Meds: Escitalopram 10 mg, Dutasteride 0.5mg , Cranberry supplement, Hydrocodone 10-325 mb

Current Illness: N/A

ID: 1031920
Sex: F
Age: 67
State: MD

Vax Date: 02/12/2021
Onset Date: 02/13/2021
Rec V Date: 02/15/2021
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: none

Symptom List: Vomiting

Symptoms: received the 2nd vaccination of Moderna on 2/12 930a on 2/13 at 11a started to feeol diczzy - try to make it the bed but able to do so ended up part on bed and part on floor - unable to move - could hear things around me - the tv was on - I could feel the sweat drops coming off my face - (it felt like I was "locked in" - term used when coma pts can hear but able to move - I could feel the chills down my back - this lasted about 1/2 hr then started to be able to feel myself coming around - the whole time I kept telling myself to take slow deep breaths- the entire episode lasted about 1 1/2 -2hr - felt low energy after that - following morning felt back to normal

Other Meds: Hydroxurea 500mg qday HCTZ 25 mg /day ASA 81 mg

Current Illness: received 2nd Shingle shot Decemember 30

ID: 1031921
Sex: F
Age: 74
State: TX

Vax Date: 02/05/2021
Onset Date: 02/07/2021
Rec V Date: 02/15/2021
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: Demerol

Symptom List: Headache, Limb discomfort, Nasal congestion

Symptoms: skin redness , irritation and itching. In arms, midsection and groaning areas. Mostly on the right side. Moderna Vaccine

Other Meds: Allergy medication

Current Illness: small area skin poison ivy infection

ID: 1031922
Sex: F
Age: 52
State: ID

Vax Date: 02/15/2021
Onset Date: 02/15/2021
Rec V Date: 02/15/2021
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:

Allergies: Sulfa

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

Symptoms: Patient was waiting the 15 minutes for observation after vaccine was administered and after about 5 minutes patient slid out of chair and had a syncopal episode with extreme redness around throat area, elevated heart rate and blood pressure, extreme shakiness. And could not clearly describe her symptoms. Patient stated she just wanted to go to sleep. Patient was monitored and epi pen was administered to patient by provider. EMS was called and patient transported to ER.

Other Meds:

Current Illness:

ID: 1031923
Sex: F
Age: 17
State: OR

Vax Date: 01/24/2021
Onset Date: 01/24/2021
Rec V Date: 02/15/2021
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:

Allergies:

Symptom List: Injection site swelling, Limb discomfort

Symptoms: Patient was administered the Moderna vaccine prior to her 18th birthday

Other Meds:

Current Illness:

ID: 1031924
Sex: F
Age: 75
State:

Vax Date: 02/06/2021
Onset Date: 02/06/2021
Rec V Date: 02/15/2021
Hospital:

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

Lab Data:

Allergies:

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

Symptoms: Patient is a 75 year old female who has completed a 2 hours observation period with the following signs and symptoms of an adverse reaction; hypotension and loss of consciousness. Moderna COVID-19 vaccine #1 in series administered. 1318- pt. reported blurred vision to RN. Pt immediately assessed, during assessment pt. temporarily lost consciousness. Vitals- O2 sat-96%, HR-55, B/P-55/27, resp-16; 1320-DOD called, recommendation was to send to the ER via 911; 1324- Paramedics arrived and assessed pts. blood sugar (167), vitals O2 sat-98%, HR-71, resp 16, BP-91/40. Paramedics stated transfer to hospital was not necessary, but offered, Pt. declined ambulance transfer to ER. 1330- Continued to monitor pt. while giving oral fluids. Pt. reports she has fully regained consciousness, and blurry vision has resolved. Vitals, BP-102/42, HR-73, O2sat-96%, resp-16; 1335- Vitals, BP-110/50, HR-82, O2sat-96%, resp-16; 1400- Vitals, BP-121/45, HR-66, O2sat-97%, resp-18; 1420- Vitals, BP-125/31, HR-66, O2sat-96%, resp-16, DOD advised pt. should be assessed by MD. Pt. continues to refuse transfer via ambulance, no family members present. 1440- Pt discharged. o Action(s) taken: Recommended transfer to higher level of care, risk and benefits explained to patient, patient declined ride from ambulance to ER and was discharged. o Patient advised to discuss second dose considerations with a clinician

Other Meds:

Current Illness:

ID: 1031925
Sex: M
Age: 71
State: OH

Vax Date: 02/09/2021
Onset Date: 02/11/2021
Rec V Date: 02/15/2021
Hospital:

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

Lab Data:

Allergies: none

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

Symptoms: On 2/9/2021 experienced headache, chills, and sore arm 0n 2/10/2021 still experiencing similar side effects but know light headed On 2/11/2-12: 930AM experienced a TIA . I totally believed it was a by product of the Covid shot - 1st dose. Had to go to ER and go through series of tests. Now on blood thinner. Since this occurred i know of 2 people that had similar results and experienced a stroke with 2 of them experiencing major stroke and died. people had similar results Now I don't think I will take second dose - very scared NOTE: I was in great shape prior to this vaccine

Other Meds: metformin simvastatin vitamin D3

Current Illness: none good health

Total 2021 VAERS Injuries: 636,615

Page last modified: 03 October 2021 5:28pm