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From the 1/21/2022 release of VAERS data:

Found 1,049,249 cases where Vaccine is COVID19 and Patient Did Not Die

Government Disclaimer on use of this data



Case Details (Reverse Sorted by Onset Date)

This is page 117 out of 10,493

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VAERS ID: 1989390 (history)  
Form: Version 2.0  
Age: 32.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1855835 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Emotional disorder, Hyperhidrosis, Pallor
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: none.
Preexisting Conditions: none.
Allergies: none as per patient . no known allergies.
Diagnostic Lab Data: none.
CDC Split Type:

Write-up: Following administration of vaccine to patient today, the patient started feeling light headed and dizzy with sweating and pale color of face noted by pharmacist. The patient was given a cold wet towlette for his forehead and monitored by pharmacist, and patient recovered to his normal self after resting in chair and with controlled breathing. No signs of allergic reaction was noted by pharmacist. Patient was closely monitored by pharmacist until he recovered to his normal self. Patient was found to have experienced an emotional response to "needle" due to anxiety about shots in the past explained patient. Patient never lost consciousness and never fainted. After patient was feeling 100% better and regained his alertness he left with his father.


VAERS ID: 1989396 (history)  
Form: Version 2.0  
Age: 27.0  
Sex: Male  
Location: New York  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 069H21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Underdose
SMQs:, Medication errors (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received 0.25cc of Moderna for dose 1 instead of 0.5cc


VAERS ID: 1989414 (history)  
Form: Version 2.0  
Age: 9.0  
Sex: Female  
Location: New York  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5618 / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Nausea
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Flonase
Current Illness: None
Preexisting Conditions: Intermittent Asthma
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: 9yo F patient accompanied by her mother and father here to receive the first dose of Pfizer COVID vaccine. Approx. 10min after vaccination patient was feeling "nauseous". She denied any other symptom. Mother reports that the patient has a PMH of intermittent asthma which has been well controlled, she also claimed that the child was a little nervous about getting the vaccine. Patient was evaluated by on-site EMS and MD; noted to be AAO x3; Initial VS: HR 82, RR 16, SpO2 100%, BP 100/66. Patient was kept on observation sitting down on the stretcher, she drank water. Approx. 20min after, the patient felt better, repeated set of VS remained within normal limits. Discharged home with complete resolution of symptoms......


VAERS ID: 1989415 (history)  
Form: Version 2.0  
Age: 12.0  
Sex: Male  
Location: Maryland  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 070H21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Product administered to patient of inappropriate age
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Moderna 0.5mg admin to 12 year old male


VAERS ID: 1989416 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Male  
Location: California  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 033H21A / 3 - / IM

Administered by: Other       Purchased by: ?
Symptoms: Expired product administered
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Moderna booster 0.25 mL dose was administered after the 12 hour punctured expiration time. Vial was punctured on 12/28/21 at 13:58 PM and the dose was given to patient on 12/29/21 at 11:06 AM.


VAERS ID: 1989419 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 067H21A / 3 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Dizziness
SMQs:, Anticholinergic syndrome (broad), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Diabetic and Hypertensive medications
Current Illness: Patient with history of DM II, HTN, and TIA
Preexisting Conditions: Patient with history of DM II, HTN, and TIA
Allergies: NKDA
Diagnostic Lab Data: SEE ABOVE..only vital signs taken
CDC Split Type:

Write-up: Patient c/o feeling lightheaded approximately 20 minutes after receiving vaccine. Patient reported that she usually feels like that when her blood sugar is high. I told her that her blood sugar could also be low and offered her peanut butter crackers and water. She ate 1 cracker and drank the water. We kept her an additional 15 minutes from her 30 minute wait to observe her. Her vitals were as follows: 134/77, 71, 18, O2 sat 97% on RA. She reported a blood sugar reading in the 160s this morning. I offered to call EMS, but she refused. Instead, she wanted to call her husband and daughter to come get her. She said that her daughter would drive her car back home and she would ride with her husband. Patient was escorted via wheelchair to the car. She was able to transfer into the car without any difficulties and reported feeling better before leaving. Patient with history of DM II, HTN, and TIA and reported that she saw her Cardiologist today for a routine visit and her workup was negative. I told her that I would follow up with her in a few days to see how she was doing. She was agreeable to the plan and verbalized good understanding.


VAERS ID: 1989420 (history)  
Form: Version 2.0  
Age: 19.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FE3594 / 3 LA / IM

Administered by: Work       Purchased by: ?
Symptoms: Dizziness
SMQs:, Anticholinergic syndrome (broad), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: LEXAPRO 10 MG QDAY
Current Illness: none
Preexisting Conditions: PMHx - asthma - anxiety - seasonal allergies
Allergies: SHELLFISH SEASONAL ALLERGIES
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: PATIENT RECEIVED HER 3RD DOSE OF PFIZER. PATIENT WAS SITTING IN OBSERVATION AND 5 MINUTES INTO OBSERVATION SHE REPORTS FEELING LIGHTHEADED AND DIZZY. RN ADVISED HER TO LAY ON THE FLOOR WITH HER FEET ELEVATED. PATIENT REPORTS DIZZINESS GETTING BETTER WHEN LYING DOWN AND FEET ELEVATED. VITALS WHEN LYING DOWN INITIALLY WAS 108/65, HR 66, 99% O2, 5 MIN LATER VITALS WERE 105/65, HR 65 99% O2. PATIENT REPORTS HER LAST MEAL WAS 2 PM. AFTER ABOUT 10 MINUTES HER DIZZINESS SUBSIDED AND SHE WAS ABLE TO SIT UP SLOWLY. VITALS AT THIS TIME WERE 120/89, HR 75. SHE WAS GIVEN A SNACK TO EAT AND COLD BEVERAGE. PATIENT REPORTS FEELING MUCH BETTER AT THIS TIME. SHE ALSO REPORTS NOT TAKING HER LEXAPRO PRIOR TO COMING IN TO GET HER VACCINE. MOM STATES SHE HAS A PHOBIA OF NEEDLES WHICH WAS NEVER MENTIONED UP UNTIL THIS EVENT. PATIENT COMPLETED HER OBSERVATION PERIOD AND WAS ABLE TO INDEPENDENTLY AMBULATE OUT OF THE FACILITY WITH NO ACUTE ISSUES; SHE WAS STABLE AT THIS TIME.


VAERS ID: 1989427 (history)  
Form: Version 2.0  
Age: 24.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 3 - / SYR

Administered by: Military       Purchased by: ?
Symptoms: Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had a syncopal episode following a Moderna booster shot.


VAERS ID: 1989434 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Female  
Location: California  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 069H21A / 3 LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0180 / 2 - / IM

Administered by: Public       Purchased by: ?
Symptoms: Dysphagia, Dyspnoea, Interchange of vaccine products, Pharyngeal swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (narrow), Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Hypersensitivity (narrow), Medication errors (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: denied medications, stated she often takes benadryl for headaches
Current Illness: denied
Preexisting Conditions: denied
Allergies: Mangoes
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Four hours after receiving second Pfizer COVID vaccine, patient experienced redness and hot flushing to tops of feet that lasted four days. MD approved booster. 20 minutes after receiving the Moderna booster, patient experienced throat swelling described as "difficulty swallowing" and about one hour later, "hard to breathe". She was taken by ambulance to the hospital.


VAERS ID: 1989436 (history)  
Form: Version 2.0  
Age: 5.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 330308D / 2 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Incorrect dose administered
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None known
Preexisting Conditions: Seasonal allergies
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received 0.2 mL of vaccine from the adult (purple top) vial that was appropriately diluted.


VAERS ID: 1989440 (history)  
Form: Version 2.0  
Age: 32.0  
Sex: Female  
Location: California  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1855191 / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cold sweat, Dizziness, Feeling abnormal, Feeling cold, Hyperhidrosis, Pallor, Tunnel vision, Vaccine positive rechallenge
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Optic nerve disorders (broad), Retinal disorders (narrow), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ajovy, Imitrex
Current Illness: none
Preexisting Conditions: migraines
Allergies: nka
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: On Wednesday, 12/29/21, Patient came to Covid-19 Vaccination Site for her Janssen Covid-19 booster vaccine. Client received her Janssen Covid-19 booster dose (LOT #: 1855191) at 1:12 PM in her left deltoid. During assessment questions, client stated her medical history included migraines and takes ajovy and imitrex for them and no known allergies. Client was to be a 15 minute observation. At 1:16 PM, while waiting in Observation Area, client stated to EMT right after sitting down she felt "dizzy, cold and sweaty with tunnel vision." Client was brought over to sit in anti gravity chair by EMT. At 1:16 PM vitals started, BP: 112/79, HR: 112, O2 sat: 98%, RR: 16, skin: pale, clammy and cool. Client stated she did eat a grilled cheese and soda before vaccination. At 1:25 PM, BP: 110/79, HR: 96, O2 sat: 99%, RR: 16, skin: warm, pink and dry. Client stated she feels "fine" now and experiencing no dizziness. Client did state she experienced a similar sensation after her first Janssen vaccine. Client was offered water which she drank and reclined in anti gravity chair. At 1:33 PM, BP: 112/74, HR: 110, O2 sat: 97%, RR: 16, skin: pink, warm and dry. Client states she feels "back to normal" and experiencing no other symptoms. No further interventions needed. Client was educated by EMT on signs and symptoms of adverse reactions and when to go to the ED/call MD. Client was also encouraged to sign-up for after vaccination health checker. At 1:40 PM, client left vaccination site with a steady gait.


VAERS ID: 1989442 (history)  
Form: Version 2.0  
Age: 40.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 033H21A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Inappropriate schedule of product administration, Underdose
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Moderna Covid-19 vaccine EUA - Pt received an invalid dose of moderna vaccine. Pts second dose was administered 7 days early . Pt was also given a dose of 0.25ml instead of 0.5ml. Will consider dose invalid and revaccinate at proper scheduled interval with 0.5ml.


VAERS ID: 1989443 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Male  
Location: Utah  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL3194 / 3 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Inappropriate schedule of product administration
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Client received a Pfizer booster dose more than 14 days early.


VAERS ID: 1989450 (history)  
Form: Version 2.0  
Age: 13.0  
Sex: Female  
Location: California  
Vaccinated:2021-12-03
Onset:2021-12-29
   Days after vaccination:26
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FF2590 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Diplopia, Dizziness, Headache, Vision blurred
SMQs:, Anticholinergic syndrome (broad), Glaucoma (broad), Lens disorders (broad), Retinal disorders (broad), Vestibular disorders (broad), Ocular motility disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No OTC or prescribed medications at time of vaccination.
Current Illness: No
Preexisting Conditions: None
Allergies: No allergies
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient had dizziness, headache, blurred vision and double vision after first COVID-19 vaccine. Symptoms lasted 2 days.


VAERS ID: 1989453 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 069H21A / 3 LA / IM
FLUC4: INFLUENZA (SEASONAL) (FLUCELVAX QUADRIVALENT) / SEQIRUS, INC. 308476 / N/A RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Inappropriate schedule of product administration
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Patient received his 1st Moderna COVID on 05/28/2021 and his second Moderna vaaccine on 08/09/2021. I administered a Moderna Booster 0.25 ml approximately one monthe early. there was no adverse events. patient agreed to call the clinic w
Current Illness: none
Preexisting Conditions: Asthma, Hypertension, hyperlipidemia, and hypothyroidism
Allergies: Amitriptalyne and Penicillin
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient received his Moderna Booster 0.25 ml approximately 1 month early. First Moderna given on 05-28-2021, second Moderna given on 08/09/2021 and Moderna Booster given 12/29/2021. Patient notified of the error and has agreed to report to the clinic any adverse reactions.


VAERS ID: 1989454 (history)  
Form: Version 2.0  
Age: 12.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL0007 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: No adverse event
SMQs:

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies: Nka
Diagnostic Lab Data:
CDC Split Type:

Write-up: No adverse reaction


VAERS ID: 1989456 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Male  
Location: New York  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 211D21A / N/A LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Tremor, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Patient reported not being on prescription medications or taking OTC, supplements etc.
Current Illness: None
Preexisting Conditions: Patient reported PMH of hypertension. Patient had brain surgery in the past and also reported history of having a seizure.
Allergies: NKA
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient received janssen booster vaccine at around 1:40pm on 12/29/2021. Shortly after at around 1:50 pm patient was observed having his head tilted back and shaking repeatedly. At that moment patient was not alert and oriented, was not responsive to verbal commands. VS signs taken promptly BP: 156/128 , HR 131, RR: 24, T:97.9, oxygen level 96%. 911 called immediately. While waiting for EMS patient had the same cycle of being in and out and not responding to verbal commands. EMS arrived shortly and took patient to nearest hospital.


VAERS ID: 1989458 (history)  
Form: Version 2.0  
Age: 24.0  
Sex: Female  
Location: New York  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 07H21A / 3 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Rash, Rash pruritic
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: 2nd dose similar appearing rash which started anfew hours after injection and resolved on its own after 1 day
Other Medications: Claritin, Dupixent
Current Illness: None
Preexisting Conditions: Eczema, Allergies
Allergies: Doxycycline, pollen, dust mite, shellfish, cockroaches
Diagnostic Lab Data: Not applicable
CDC Split Type:

Write-up: Patient began experiencing itchy rash on neck and palm of hands at 13:03 , approximately 30 min after her Moderna vaccination. Patient was given water at the time and moved to a private observation area where vital signs were recorded every 5 min3 times. Patient was took Benadryl 25 mg PO one time at 13:22. It 13:45 patient reported rash on hands less itchy and clinician noted rash on back of patient''s neck resolved. Patient educated on worsening signs and symptoms and when to follow up with PCP. Patient left at 13:45 by herself and took a car service home.


VAERS ID: 1989463 (history)  
Form: Version 2.0  
Age: 26.0  
Sex: Male  
Location: New York  
Vaccinated:2021-12-28
Onset:2021-12-29
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL3197 / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Blood urine present, Fatigue, Headache
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Pfizer/BioNTech second dose
Other Medications: lisinopril 20mg
Current Illness: chronic kidney diseases
Preexisting Conditions: chronic kidney diseases
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: I feel tired and headache after around 10h after vaccination and I can see gross blood in my urine after 24h. This also happened after I received my second dose of the Pfizer vaccine.


VAERS ID: 1989465 (history)  
Form: Version 2.0  
Age: 36.0  
Sex: Male  
Location: Oklahoma  
Vaccinated:2021-12-28
Onset:2021-12-29
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / 1 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Chest pain
SMQs:, Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Chest pains progressively getting worse


VAERS ID: 1989470 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: Arizona  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 33130BA / 3 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Abdominal discomfort, Nausea, Vomiting
SMQs:, Acute pancreatitis (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Gabapentin 600 MG Invokana 300 MG Januvia 100 MG Lisinopril 10 MG Metformin 1,000 MG Zyrtec 10 MG
Current Illness: Per Patient none that she is aware of.
Preexisting Conditions: Type 2 diabetes Mellitus Hypertension
Allergies: Lisinopril
Diagnostic Lab Data:
CDC Split Type:

Write-up: When patients 15 minute wait was done, she was advised she was ready to go as her recommended time was finished. Pt felt nauseous as she stood up and Vomited. Pt stated she developed a sudden stomach discomfort when she stood up. Pt Vomited twice within 15 minutes. Provider was immediately called and examined Pt. Vitals were taken and provider prescribed Pt Ondansetron 8 mg and recommended she is examined by ER if not feeling any better.


VAERS ID: 1989481 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FH8030 / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Loss of consciousness, Speech disorder
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: PT HUSBAND REPORTS "COMATOSE-LIKE" STATE - EYES CLOSED, NON-VERBAL


VAERS ID: 1989482 (history)  
Form: Version 2.0  
Age: 16.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 33130BA / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Inappropriate schedule of product administration
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: no known medications
Current Illness: no known illnesses
Preexisting Conditions: no known health conditions
Allergies: no known allergies.
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: patient stated that it had been 6 months since last vaccination, vaccine was given two weeks prior to scheduled booster dose.


VAERS ID: 1989484 (history)  
Form: Version 2.0  
Age: 39.0  
Sex: Male  
Location: South Carolina  
Vaccinated:2021-12-27
Onset:2021-12-29
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 3 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Chills, Dry throat, Pain, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Fever chills bodyaches, dry throat


VAERS ID: 1989485 (history)  
Form: Version 2.0  
Age: 9.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL0007 / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness
SMQs:, Anticholinergic syndrome (broad), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies: NONE
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: DIZZINESS


VAERS ID: 1989488 (history)  
Form: Version 2.0  
Age: 36.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-12-28
Onset:2021-12-29
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 LA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Lymphadenopathy
SMQs:, Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lisinopril, atenolol. Pantoprazole,allegra
Current Illness:
Preexisting Conditions: Pcos, Graves disease, asthma, carpal tunnel, migraines, IBD
Allergies: Penicillin, aspirin, Tramadol, tryptans, Gabapentin, dalaudid
Diagnostic Lab Data:
CDC Split Type:

Write-up: Swollen lymph nodes


VAERS ID: 1989490 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Female  
Location: New York  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FE-3592 / 3 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Nausea, Vaccine positive rechallenge
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Metoprolol, Aspirin
Current Illness:
Preexisting Conditions: HTN
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: 68yo F patient here to receive the Pfizer COVID vaccine booster. Approx. 15min after vaccination she was "nauseous", she had the same reaction with the primary vaccines doses which self-resolved the same day. PMH significant for HTN,. She is on Aspirin and Metoprolol, also taking antibiotics (Ciprofloxacin and metronidazole) for a "stomach infection" (does not recall the diagnosis). Denies any visual changes, abdominal pain, vomiting, paresthesia. Patient was evaluated by onsite EMS and MD. Noted to be AAO x 3; Initial VS: HR 82, RR 20, SpO2 100%, BP 138/80. After 20min observation patient felt better, repeated set of VS within normal limits. Patient was discharged home with complete resolution of symptoms.


VAERS ID: 1989494 (history)  
Form: Version 2.0  
Age: 35.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FD7218 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Cold sweat, Pallor, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: UNKNOWN
Current Illness: UNKNOWN
Preexisting Conditions: UNKNOWN
Allergies: PENICILLINS
Diagnostic Lab Data: EMT''S WE''RE CALLED. BLOOD PRESSURE WAS TAKEN. CUSTOMER WAS COLD, PALE, AND CLAMMY
CDC Split Type:

Write-up: PATIENT FAINTED ABOUT 15 FEET FROM WHERE HE WAS SITTING


VAERS ID: 1989501 (history)  
Form: Version 2.0  
Age: 11.0  
Sex: Male  
Location: New York  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Nausea, Vomiting
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: n/a
Current Illness: n/a
Preexisting Conditions: n/a
Allergies: pollen, cats, dogs
Diagnostic Lab Data: 2:32PM HR:116 R 18 BP 120/70 SAT 98% 2:37 PM HR:117 R 18 BP 110/70 SAT 98% 2:41 PM HR 113 R 18 BP 100/60 SAT 98%
CDC Split Type:

Write-up: patient presented with vomiting, nausea 55 minutes after receiving vaccine. symptoms resolved after the episode.


VAERS ID: 1989512 (history)  
Form: Version 2.0  
Age: 33.0  
Sex: Female  
Location: California  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 330368D / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Chest pain, Ear pain, Headache, Pain in jaw, Throat tightness
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Osteonecrosis (broad), Hypersensitivity (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: N/a
Preexisting Conditions: N/a
Allergies: Unknown. Pt reported hives x3 months after first and second dose of Pfizer. Seeing allergist and being worked up for other allergies. Advised by allergist to get booster and pre-medicate with Allegra.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt reported hives x 3 months on both first and second vaccine. Pt''s allergist recommended booster and to take Allegra before, which she took on arrival. Pt denied any hx of anaphylaxis. Requested pt stay 30 min after shot. Almost immediately pt reported headache and "ear pain". She drank water and rested. Pain got worse. After about 30 min, she reported tightness in throat, jaw pain, and chest pain. Instructed pt to go to ER. We walked her there.


VAERS ID: 1989513 (history)  
Form: Version 2.0  
Age: 47.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL3198 / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Hyperhidrosis
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Vestibular disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: UNKNOWN
Current Illness: UNKNOWN
Preexisting Conditions: UNKNOWN
Allergies: NONE
Diagnostic Lab Data:
CDC Split Type:

Write-up: PATIENT RECEIVED THE VACCINE AT 5:30 PM. PATIENT FELT LIGHT HEADED, SWEATY, AND DIZZY AT 5:35 PM. THE PATIENT SAT DOWN IN A CHAIR AND ELEVATED LEGS. PATIENT CONTINUED TO FEEL DIZZY, SWEATY, AND LIGHT HEADED. THE AMBULANCE WAS CALLED PROMPTLY AT 5:40 PM TO THE PHARMACY FOR FURTHER ASSISSTANCE AND SUPPORT. PATIENT''S STATUS IMPROVED AFTER A FEW MINUTES. PATIENT REFUSED TO BE TAKEN TO THE HOSPITAL FOR FURTHER OBSERVATION/CARE. PATIENT LEFT THE FACILITY AT 6:15 PM.


VAERS ID: 1989523 (history)  
Form: Version 2.0  
Age: 15.0  
Sex: Male  
Location: California  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FD7218 / 3 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: No adverse event, Product administered to patient of inappropriate age
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: unknown
Allergies: NKDA
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: NO reaction, just given a booster dose , patient scheduled without realizing under age for booster. RN noticed age after giving Booster when documenting.


VAERS ID: 1989524 (history)  
Form: Version 2.0  
Age: 8.0  
Sex: Female  
Location: California  
Vaccinated:2021-12-28
Onset:2021-12-29
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -
FLUC4: INFLUENZA (SEASONAL) (FLUCELVAX QUADRIVALENT) / SEQIRUS, INC. 308496 / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Incorrect dose administered, Syringe issue
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: unknown
Diagnostic Lab Data: none
CDC Split Type:

Write-up: presented to health center to receive COVID19 vaccine and flu vaccine. Client received flu vaccine after receiving COVID Pfizer PEDS vaccine, RN injected flu vaccine and as she was injecting some of the fluid leaked outside of syringe. Client and Mother were informed of incident. Incident was elevated to Clinical Lead. Client''s Mother was notified of CDC guidelines. Flu vaccine will have to be administered again. Client''s mother verbalized understanding and stated she would come back to have child revaccinated.


VAERS ID: 1989530 (history)  
Form: Version 2.0  
Age: 44.0  
Sex: Female  
Location: Wyoming  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Headache, Impaired work ability, Migraine, Nausea, Rash, Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: None
Preexisting Conditions:
Allergies: Latex, mushrooms, mango
Diagnostic Lab Data: None done. I was told to use hydrocortisone cream.
CDC Split Type:

Write-up: Day after vaccine migraine all day with nausea and vomiting. Unable to go to work. Headache for about 2 more days. 8/27/2021 went to the Dr with rash on back and along pantline.


VAERS ID: 1989531 (history)  
Form: Version 2.0  
Age: 30.0  
Sex: Male  
Location: California  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 33130BA / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Blindness transient
SMQs:, Anticholinergic syndrome (broad), Embolic and thrombotic events, arterial (narrow), Glaucoma (broad), Optic nerve disorders (broad), Retinal disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: n/a
Current Illness: n/a
Preexisting Conditions: n/a
Allergies: n/a
Diagnostic Lab Data:
CDC Split Type:

Write-up: After pt received first dose, about 5 min later approached pharmacy staff and stated they cannot see, and vision is black. Pharmacy manager walked him to take a seat and rest, was given a cup of water to drink. Vison came back and pt confirmed issues with vison wasn''t immediate and started a few minutes after receiving first dose. Pt sat down and was observed for about 15-20 min and then confirmed vison was returned and left the pharmacy.


VAERS ID: 1989542 (history)  
Form: Version 2.0  
Age: 33.0  
Sex: Female  
Location: Colorado  
Vaccinated:2021-12-27
Onset:2021-12-29
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / SYR

Administered by: Unknown       Purchased by: ?
Symptoms: Chest pain
SMQs:, Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Probiotic
Current Illness: None
Preexisting Conditions: None
Allergies: Milk allergy
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Following a Moderna booster shot, (I had already completed a first round of 1 Pfizer vaccine and 1 Pfizer booster), I experienced chest pain 2 days after receiving this second booster shot.


VAERS ID: 1989546 (history)  
Form: Version 2.0  
Age: 16.0  
Sex: Male  
Location: Maryland  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL3198 / 3 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Blindness, Cold sweat, Deafness, Disorientation, Hyperhidrosis, Mydriasis, Pallor
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Glaucoma (broad), Optic nerve disorders (broad), Retinal disorders (broad), Hearing impairment (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient requested for his pfizer booster on the 12/29/21 and administered as per his request. Pt denies any medical condition or allergies. Accompanied by his older sister, 12:04 pm vaccine administered, 12:18 pm patient lost his vision with dilated eyes, lost of hearing , skin was pale, clammy and profusely sweating . Oxygen stat 97% , 63BPM. Ambulance called and responded around 12:23pm. Patient''s vision and hearing in right ear returned. Left ear still affected. Patient left in ambulance still pale and mildly disoriented. Sister accompanied patient to hospital.


VAERS ID: 1989547 (history)  
Form: Version 2.0  
Age: 12.0  
Sex: Female  
Location: California  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL0007 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Underdose
SMQs:, Medication errors (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Client received the 1st COVID vaccine Pfizer (5 yo - <12 yo Lot #FL007 and exp 03/01/2022) at 12:52PM. RN noted the client was 12 years old after administration of the COVID vaccine 5 yo - <12 yo. RN provided education to the client and her mother regarding the medication the client received and recommended per CDC guidelines the client will receive the Pfizer Vaccine for 12 years of age and older for her second dose.


VAERS ID: 1989550 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-11-02
Onset:2021-12-29
   Days after vaccination:57
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Dysarthria, Facial paralysis
SMQs:, Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad), Hearing impairment (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Staff at pt''s facility today noticed her slurring her words and left facial droop.


VAERS ID: 1989554 (history)  
Form: Version 2.0  
Age: 52.0  
Sex: Female  
Location: Arizona  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030H21B / 3 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Injection site erythema
SMQs:, Extravasation events (injections, infusions and implants) (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Rectiv (nitroglycerin) Prilosec
Current Illness: No
Preexisting Conditions: No
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Redness at injection site


VAERS ID: 1989556 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Maine  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 071F21A / 2 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Abdominal pain lower, Hyperhidrosis, Injection site pain, Somnolence, Speech disorder, Syncope, Tremor
SMQs:, Torsade de pointes/QT prolongation (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Parkinson-like events (broad), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness:
Preexisting Conditions: COPD, Diabetes, Pacemaker
Allergies: Lyrica
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient previously received Janssen lot #1805022 and chose to boost with Moderna. 12/29/2021 at approximately 15:50 RN administered vaccine in left deltoid. Patient complained 3 minutes after receiving Moderna booster in left deltoid that he was experiencing left arm pain at injection site, patient was A&Ox3, patient was in wheelchair and was escorted to observation, no complaints at that time. Approximately 5 minutes later RN heard "I need a nurse" coming from observation. RN went to observation and found patient sitting upright in wheelchair, appeared drowsy and non-verbal. RN instructed the Guard in observation to call 911. RN asked patient''s wife and daughter about patient''s medical HX. Wife stated to RN that her father has diabetes, COPD, and a pacemaker. Patient then became coherent and told RN that his left arm was hurting where he had rotator cuff issues. Patient then had a syncope episode and was tremoring and diaphoretic. Patient again become coherent and told RN he was experiencing lower abdominal pain. Patient then had another syncopal episode. Each episode lasting approximately 5-10 seconds. Patient become coherent again, Fire and Rescue and EMT arrived and assessed patient. Patient was able to converse with EMT''s and was placed on stretcher and left via ambulance from Mall and transported to Hospital.


VAERS ID: 1989695 (history)  
Form: Version 2.0  
Age: 22.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013H21B / 3 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Blindness transient, Cold sweat, Dizziness, Hyperhidrosis, Hypotension, Loss of consciousness, Nausea, Pallor
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Embolic and thrombotic events, arterial (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Glaucoma (broad), Optic nerve disorders (broad), Retinal disorders (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Pt fainted after dose #2 approximately 24 hours after vaccine administration
Other Medications:
Current Illness: None
Preexisting Conditions: None
Allergies: Penicillin
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient lost consciousness almost immediately after receiving immunization. Symptoms: Loss of Consciousness, Low B/P, Paleness, Sweating, Cold/Clammy skin, Nausea, Dizziness, Loss of vision. She regained consciousness very quickly; but low B/P and Loss of vision persisted. 911 was called. Response time was approximately 15 minutes after injection. B/P was monitored and was slowly rising; but never reached a satisfactory level. Initial B/P reading was 40/20, and rose to approximately 90/50. Vision was restored in approximately 10 minutes. Pt refused transport by EMS and was taken home by her mother.


VAERS ID: 1989697 (history)  
Form: Version 2.0  
Age: 49.0  
Sex: Female  
Location: California  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 33036BD / 3 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Condition aggravated, Erythema, Throat irritation
SMQs:, Anaphylactic reaction (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Client states that she had a reaction with her previous Pfizer vaccination. Client states that she had hives and difficulty brea
Other Medications: N/A
Current Illness: N/A
Preexisting Conditions: N/A
Allergies: Unknown but reports allergic reaction to 2nd dose of Covid 19 Pfizer vaccination.
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Client c/o HX of rash and itchy throat post previous vaccination. Client initially requested to monitor for 30 minutes by MD on site. At 15 minute mark, client''s husband approached writer to request assistance for itchy throat. Writer noted redness to clients chest. Writer requested assistance from MD onsite, safety team and immediate supervisor. Client visited EMT and sat in ambulance for monitoring. V/S WNL for client, per client, at B/P 145/81, HR 67, and 98% O2 on RA. MD recommend continue monitoring. Client discharged by MD at 3:35 pm with no further c/o itchy throat or redness to chest.


VAERS ID: 1989701 (history)  
Form: Version 2.0  
Age: 10.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL0007 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Fatigue, Pallor
SMQs:, Hypotonic-hyporesponsive episode (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: na
Current Illness: na
Preexisting Conditions: na
Allergies: na
Diagnostic Lab Data:
CDC Split Type:

Write-up: Administered first dose of Pfizer (5-11) at 12:04pm, at 12:09 was alerted that patient was having a reaction to the vaccine. She looked very pale and tired. EMT was called.


VAERS ID: 1989703 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Oregon  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032F21A / 3 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Chest pain, Dizziness, Palpitations
SMQs:, Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Cortisone shot within the last 24 hours, monoclonal antibody treatment administered 90 days prior to vaccination
Current Illness: N/A
Preexisting Conditions: N/A
Allergies: N/A
Diagnostic Lab Data: This patient per self report had been diagnosed with COVID-19 and was treated with monoclonal antibody treatment in October of 2021. This patient is not an established patient of this clinic therefore no further testing or treatment was able to be provided to her.
CDC Split Type:

Write-up: At approximately 1:45PM this patient was advised she could leave after her 15 minute wait time post vaccination. At that time when the patient attempted to stand she stated she felt extremely dizzy and was having heart palpitations. At this time RN assessed this patient took her vitals signs at approximately 1:50PM and they were as follows: Oxygen-94, Pulse 77, BP 132/84. The patient was given water and observed for 15 minutes longer, then complained of chest pain and continued dizziness, patient was assisted to private car via wheelchair and advised to seek emergency medical attention. She declined an ambulance at the time.


VAERS ID: 1989707 (history)  
Form: Version 2.0  
Age: 7.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FE3594 / 1 LA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Extra dose administered, Incorrect dose administered
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient showed up for an appointment on the wrong date, since this was supposed to be a pediatric dose the patient was nervous and a bit upset. In all of the commotion I grabbed the adult dose and gave that to him. I realized that I had done this after the patient left the store with his grandparents. I called them and spoke to the grandmother about the potential for increased side effects of the adult dose as compared to the pediatric dose. I assured her that she could call me (I gave her my personal phone number for any questions) I will follow up with her in a day or two to check on the patient.


VAERS ID: 1989710 (history)  
Form: Version 2.0  
Age: 37.0  
Sex: Female  
Location: California  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL3157 / 3 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Paraesthesia
SMQs:, Peripheral neuropathy (broad), Guillain-Barre syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none
Allergies: nka
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: On Wednesday, 12/29/21, Patient came to Covid-19 Vaccination Site for her Pfizer Covid-19 booster vaccine. Client received her Pfizer Covid-19 booster dose (LOT #: FL3157) at 3:17 PM in her left deltoid. During assessment questions, client stated her medical history included no known drug allergies and no pertinent medical history. Client was to be a 15 minute observation. At 3:35 PM, while waiting in Observation Area, client stated to EMT she felt "tingling" on the back of her next extending to her left arm. EMT noted no stroke symptoms or pain and this sensation did not occur after first vaccine. At 3:35 PM vitals started, BP: 124/80, HR: 78, O2 sat: 97%, RR: 16, skin: warm and dry. At 3:45 PM, BP: 120/78, HR: 69, O2 sat: 99%, RR: 16, skin: warm and dry. Client stated she felt "less tingliness." EMT brought client to anti gravity chair and offered her a water bottle which she drank. Client stated she had two glasses of wine last night, no water this morning and only had coffee and a muffin. EMT offered client Benadryl for her tingly sensation and client denied. Client also bdenied SOB, throat constriction, dizziness, lightheaded. At 3:50 PM, BP: 118/78, HR: 72, O2 sat: 98%, RR: 16, skin: warm and dry. Client states tingliness is "much better" and feels comfortable to go home to rest. No further interventions needed. Client was educated by EMT on signs and symptoms of adverse reactions and when to go to the ED/call MD. Client was also encouraged to sign-up on v-safe. At 3:56 PM, client left vaccination site with a steady gait. Her friend drove her home.


VAERS ID: 1989712 (history)  
Form: Version 2.0  
Age: 12.0  
Sex: Female  
Location: Nevada  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL3198 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NON
Preexisting Conditions: NON
Allergies: KNA
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: SYNCOPE


VAERS ID: 1989715 (history)  
Form: Version 2.0  
Age: 18.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-12-27
Onset:2021-12-29
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL3197 / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Condition aggravated, Loss of consciousness, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Fainting after all vaccines
Other Medications: None
Current Illness: none
Preexisting Conditions: none
Allergies: No known
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient fainted while sitting next to her mother after vaccine administration. Patient was unconscious for about 5 seconds in her mother''s arm. Patient came to again quickly. No treatment was necessary. Patient stated that she faints after all vaccines before the vaccine was administered so staff and mother were ready to deal with the situation


VAERS ID: 1989718 (history)  
Form: Version 2.0  
Age: 9.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FD0809 / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: No adverse event, Product administered to patient of inappropriate age
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: 9 yr old inadvertently given adult dose of Pfizer covid vaccine. No immediate adverse effects.


VAERS ID: 1989722 (history)  
Form: Version 2.0  
Age: 42.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-12-27
Onset:2021-12-29
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028K21A / 1 LA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Chills, Dizziness, Hyperhidrosis, Induration, Nausea, Pain, Pain in extremity, Peripheral swelling, Post-acute COVID-19 syndrome, Pyrexia, Skin warm
SMQs:, Cardiac failure (broad), Acute pancreatitis (broad), Angioedema (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Vestibular disorders (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Vyvanse
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: This is the booster shot : Within 12 hours I felt nauseous, dizzy, body ache , chills , sweating, arm hurt , light fever (100.4f) . The dizziness went away after 24 hours but everything else stayed the same . It?s been 48 hours and my upper arm is swollen (circle patch), hot and hard . I read it?s called Covid arm


VAERS ID: 1989724 (history)  
Form: Version 2.0  
Age: 12.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-12-28
Onset:2021-12-29
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL0007 / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Product administered to patient of inappropriate age
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient received a second dose of Pfizer bioN Tech for age (5-11) years instead of receiving Pfizer bioN Tech for ages 12 and above. no side effects or allergic reactions happened


VAERS ID: 1989728 (history)  
Form: Version 2.0  
Age: 11.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL0007 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient fainted after vaccine


VAERS ID: 1989730 (history)  
Form: Version 2.0  
Age: 8.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL0007 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Feeling abnormal, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Unknown
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient felt "funny" and collapsed over, when brought to our attention the patient was awake and alert, denied any injury, denied anaphylactic symptoms


VAERS ID: 1989833 (history)  
Form: Version 2.0  
Age: 10.0  
Sex: Female  
Location: California  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL0007 / 1 RA / IM

Administered by: Other       Purchased by: ?
Symptoms: Underdose
SMQs:, Medication errors (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: none reported
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: none reported
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Client presented to Public Health Center to receive Pfizer PEDS dose one. Vaccinator was vaccinating client, when Client moved arm and Vaccinator was unable to give full dose. Vaccinator also stated some of the vaccine had leaked from syringe while vaccinating. Incident was elevated to Operations Lead and Med consult and was submitted. Per CDC guidelines approved for client to be revaccinated on opposite arm


VAERS ID: 1989834 (history)  
Form: Version 2.0  
Age: 9.0  
Sex: Female  
Location: California  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5618 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Presyncope
SMQs:, Anticholinergic syndrome (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies: NKDA
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: Child had a near syncopal episode 20 minutes after vaccination, evaluated by pediatrician, juice provided. Child felt better and went home from Covid Vaccine clinic


VAERS ID: 1989836 (history)  
Form: Version 2.0  
Age: 27.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 060H21A / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Immediate post-injection reaction, Loss of consciousness, Seizure
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Convulsions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), Hypersensitivity (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: PATIENT HAD RECIEVED 2 DOSES OF MODERNA AND HAD ARRIVED FOR THEIR 3RD DOSE OF THE MODERNA VACCINE. THE PATIENT WAS SEATED AT THE TIME. IMMEDIATELTY AFTER THE ADMINISTRATION OF THE BOOSTER DOSE OF THE MODERNA VACCINE, THE PATIENT LOST BRIEF CONSCIOUSNESS AND CONVULSED FOR APPROXIMATELY 3 SECONDS WHILE SEATED. PATIENT REGAINED CONSCIOUSNESS IMMEDIATELY AND REMAINED SEATED WHILE BEING ATTENDED TO. NO MEDICATIONS WERE ADMINSITERED TO AID THE PATIENT. THE BLOOD PRESSURE WAS TAKEN ABOUT 5 MINUTES POST-EVENT, AND READ 123/76. PATEINT WAS GIVEN WATER, AND WAS MONITORED FOR 30 MINUTES. PATIENT DID COME WITH THEIR PARTNER AND WAS TAKEN HOME AFTER OBSERVATION ON SITE AT THE PHARMACY.


VAERS ID: 1989838 (history)  
Form: Version 2.0  
Age: 14.0  
Sex: Female  
Location: California  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FE3594 / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Chills, Fatigue, Myalgia, Product administered to patient of inappropriate age, Pyrexia
SMQs:, Rhabdomyolysis/myopathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Eosinophilic pneumonia (broad), Tendinopathies and ligament disorders (broad), Medication errors (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No
Current Illness: None
Preexisting Conditions: None
Allergies: NKDA
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient''s parent made an appointment online for booster shot for patient. It was missed at screening by pharmacist that the patient is 14 years old. In the vaccine room, I assumed it was already screened by the pharmacist and I administered the vaccine. I contacted the clinic to let him know the situation. I contacted the patient''s pediatrician to inform them and also informed the patient''s parents. The only adverse effects likely to happen is muscle soreness and the common side effects reported from the vaccine (chills, fever, fatigue, etc). facility will take care of any medical bills if there is any.


VAERS ID: 1989839 (history)  
Form: Version 2.0  
Age: 35.0  
Sex: Female  
Location: California  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 070H21A / 3 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Dizziness
SMQs:, Anticholinergic syndrome (broad), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: PATIENT FELT DIZZINESS POST VACCINATION


VAERS ID: 1989840 (history)  
Form: Version 2.0  
Age: 13.0  
Sex: Male  
Location: Oregon  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 30135BA / 3 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Product administered to patient of inappropriate age
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: none known
Preexisting Conditions: none known
Allergies: none known
Diagnostic Lab Data: none
CDC Split Type:

Write-up: I gave a 13 year old a booster of Pfizer. His parents gave consent and I gave vaccine then immediately remembered that a booster cannot be given to patients under the age of 16. I informed parents.


VAERS ID: 1989845 (history)  
Form: Version 2.0  
Age: 31.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 033H21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Feeling cold, Pharyngeal swelling, Swollen tongue, Thirst
SMQs:, Anaphylactic reaction (broad), Angioedema (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Anticholinergic syndrome (broad), Oropharyngeal allergic conditions (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: NA
Preexisting Conditions:
Allergies: NA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Post observation period, patient reported sensation of tongue/throat swelling, in addition to excess thirst and a cold sensation to her chest. Patient requested to wait longer in observation. 5 minutes later patient continues to report sensation of throat swelling. Patient worried about possible exposure at work with a work mate that tested positive today. MD STAT called and team responded to vaccine clinic. VS as follow BP 135/95 HR 87 Oxygen saturation of 100% on RA. Patient speaking in full sentences with a clear speech. Respirations are even and non labored. MD evaluated patient and discussed symptoms with her. After evaluation, MD determines that this is not a vaccine adverse reaction, patient reports that she was feeling "very anxious" about receiving vaccine today and about the news of her co workers COVID + status. MD gives approval for patient to go home and completes teaching with patient for when to call emergency or be seen in ED if she experiences worsening symptoms. At the time of departure from clinic patient reports " feeling much better". Patient ambulated out of the clinic with a strong and steady gait. Respirations are even and non labored. Speaking in full sentences with a clear speech.


VAERS ID: 1989854 (history)  
Form: Version 2.0  
Age: 31.0  
Sex: Male  
Location: South Carolina  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 211D21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Feeling hot
SMQs:, Anticholinergic syndrome (broad), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies: NONE
Diagnostic Lab Data: NONE
CDC Split Type:

Write-up: AFTER VACCNATION, PATIENT BECAME EXTREMELY LIGHTHEADED AND DIZZY. HE DESCRIBED THE SENSATION AS "A RUSH ALL OVER HIS BODY". PATIENT WAS AFRAID HE MAY PASS OUT.


VAERS ID: 1989855 (history)  
Form: Version 2.0  
Age: 21.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 330368D / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Flushing, Paraesthesia
SMQs:, Anaphylactic reaction (broad), Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Vestibular disorders (broad), Hypersensitivity (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: patient became faint and flushed and felt tingling in arms


VAERS ID: 1989857 (history)  
Form: Version 2.0  
Age: 22.0  
Sex: Male  
Location: Alabama  
Vaccinated:2021-12-28
Onset:2021-12-29
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013H21B / 3 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Chills, Pain, Pyrexia, Vomiting
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient received 0.5ml dose of Moderna. He experienced fever, chills, aches/pains and vomiting.


VAERS ID: 1989861 (history)  
Form: Version 2.0  
Age: 13.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL3198 / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: n/a
Current Illness: n/a
Preexisting Conditions: n/a
Allergies: nkda
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient fainted for a few seconds after receiving vaccine. She woke up immediately and took a few minutes to feel normal.


VAERS ID: 1989866 (history)  
Form: Version 2.0  
Age: 23.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FD7218 / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dyspnoea, Rash macular, Urticaria
SMQs:, Anaphylactic reaction (narrow), Angioedema (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: During 15 minute observation period after vaccine, patient presented to pharmacist on duty with severe dyspnea and all-body erythematous blotches/hives. RPh administered epipen while staff called 911. Breathing improved and patient was taken to local emergency department.


VAERS ID: 1989870 (history)  
Form: Version 2.0  
Age: 20.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-12-27
Onset:2021-12-29
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FE3594 / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Erythema, Pain, Skin warm, Swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: red half dollar sized circle painful and warm and raised


VAERS ID: 1989871 (history)  
Form: Version 2.0  
Age: 19.0  
Sex: Female  
Location: Kansas  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 211D21A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Condition aggravated, Fear of injection, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: FAINTING
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: PT FAINTED AFTER RECEIVING VACCINE. SHE DOES HAVE A HISTORY OF FAINTING AFTER SHOTS DUE TO FEAR OF NEEDLES SO THIS WAS NO SURPRISE TO HER OR MOM


VAERS ID: 1989872 (history)  
Form: Version 2.0  
Age: 20.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1855835 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Hyperhidrosis, Pallor, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: N/A
Current Illness: N/A
Preexisting Conditions: N/A
Allergies: N/A
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient fainted after receiving vaccination. Rested for 15 minutes and returned to normal. Was pale and sweating. Had water provided and chair to rest. Was able to depart on own.


VAERS ID: 1989873 (history)  
Form: Version 2.0  
Age: 17.0  
Sex: Male  
Location: California  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032H21A / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Product administered to patient of inappropriate age
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies: NONE
Diagnostic Lab Data:
CDC Split Type:

Write-up: None reported by the patient for 15 minutes of waiting time after Moderna vaccine given. Called patient 6 hours after and the call was not picked up. Left message but haven''t heard back.


VAERS ID: 1989874 (history)  
Form: Version 2.0  
Age: 10.0  
Sex: Male  
Location: Wyoming  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL0007 / 2 LA / IM
FLU4: INFLUENZA (SEASONAL) (FLUZONE QUADRIVALENT) / SANOFI PASTEUR UJ767AB / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Loss of consciousness, Muscle rigidity, Partial seizures
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Convulsions (narrow), Parkinson-like events (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: No illness prior
Preexisting Conditions: No chronic health problems
Allergies: none
Diagnostic Lab Data: N/a
CDC Split Type:

Write-up: Approximately 5 minutes after receiving both vaccinations patient had what father, an MD, described as focal seizure. Patient went rigid and lost consciousness briefly.


VAERS ID: 1989875 (history)  
Form: Version 2.0  
Age: 16.0  
Sex: Male  
Location: Arizona  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL0007 / UNK LA / IM

Administered by: Private       Purchased by: ?
Symptoms: No adverse event, Underdose
SMQs:, Medication errors (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: none/unknown
Preexisting Conditions: None
Allergies: Unknown
Diagnostic Lab Data: None
CDC Split Type:

Write-up: I am a contract RN working with the (Privacy) vaccine program, one of the medics on the team gave the patient a Pediatric dose of the Pfizer vaccine. when I was alerted to the incident I informed the Staff Charge nurse, and called the command center to find out the appropriate action, mean while the Staff Charge nurse contacted her director of nursing and the pharmacy. The Staff Pharmacist advised the correct action was to give an additional 0.4 ml of the pediatric Vaccine to equal the 30 mcg for an adult dose. Unfortunately, i was unable to get a timely answer from those that are there to give me guidance and the patient received the additional dose. Patient was monitored for 15 minute after administration of both doses, with no adverse effects noted. I am still not sure which course of action was correct.


VAERS ID: 1989876 (history)  
Form: Version 2.0  
Age: 12.0  
Sex: Male  
Location: California  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL3197 / 1 LA / -

Administered by: Public       Purchased by: ?
Symptoms: Blindness, Feeling abnormal
SMQs:, Dementia (broad), Glaucoma (broad), Optic nerve disorders (broad), Retinal disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: Vitals, water and observation
CDC Split Type: CA134B1001

Write-up: 1722 pt states to RN that he can?t see, feels weird. 97% SPO2, 67 HR, BP unable to get. Patient states that he did not eat anything today. Eyes appear to be dazed. 1726 states after drinking water that he is feeling better, sitting in chair he begins to drop his head back and front. RN assists patient to lay in Trendelenburg position and removed his sweatshirt. After a few minutes he states he feels better and is able to see. Bp 94/40, 97 % spo2, 81 hr. 1733 patient sitting and drinking lots of water. 100% SPO2, HR 100, 102/56. 1748 102/60, 99%, 90 HR, patient feeling better and left with dad.


VAERS ID: 1990025 (history)  
Form: Version 2.0  
Age: 15.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 331308A / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Product administered to patient of inappropriate age
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received booster before the age of 16. (she is 15 years and 4 months). She is not immunocompromised.


VAERS ID: 1990028 (history)  
Form: Version 2.0  
Age: 17.0  
Sex: Male  
Location: California  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041J21A / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Product administered to patient of inappropriate age
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient is 17 years of age. He requested and received Moderna booster 0.25ml after finished the 2 doses of Pfizer. Inappropriate age for Moderna vaccine.


VAERS ID: 1990030 (history)  
Form: Version 2.0  
Age: 18.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013H21B / 3 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Cold sweat, Dizziness
SMQs:, Anticholinergic syndrome (broad), Vestibular disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: dizziness and light headedness
Other Medications: DENIED
Current Illness: NA
Preexisting Conditions: DENIED
Allergies: DENIED
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient experienced light headedness, cold clammy skin and dizziness after Moderna booster administration. Patient and family member reported she had the exact reaction with the primary series. Patient recovered after 30 minutes.


VAERS ID: 1990032 (history)  
Form: Version 2.0  
Age: 13.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FE3590 / 1 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Throat tightness
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Hypersensitivity (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: PT complained of tightness in throat 13 minutes after receiving 1st dose of Pfizer vaccine. Vitals were taken: BP 120/82, P 88, Resp 20 even unlabored, O2 99% RA all lung fields clear to auscultation. No cyanosis noted to lips. Pt is calm, no distress noted. Skin warm and dry. Vitals retaken BP 120/78, P 97. Pt states no change in feeling of throat. EMS called, arrived at 16:02. Pt transported via stretcher without incident.


VAERS ID: 1990033 (history)  
Form: Version 2.0  
Age: 24.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 070H21A / UNK - / -

Administered by: Work       Purchased by: ?
Symptoms: Rash, Rash pruritic
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Pt reports history of atopic dermatitis
Allergies: Pt reports allergy to doxycycline, pollen, dust mites, shellfish, cockroaches.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Approximately thirty minutes post vaccination, pt reported feeling an itchy rash on the back of her neck and palm of her hands. After approximately 20 minutes, with no resolution in symptoms, the decision was made to administer a 25 mg tablet of PO Benadryl. Approximately 20 minutes later, pt reported relief in itchy rash as well as observation of resolution of rash on the neck.


VAERS ID: 1990036 (history)  
Form: Version 2.0  
Age: 51.0  
Sex: Female  
Location: California  
Vaccinated:2021-12-28
Onset:2021-12-29
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 028K21A / 3 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Chills, Dizziness, Ear pain, Fatigue, Headache, Hyperhidrosis, Musculoskeletal discomfort, Oropharyngeal pain, Pain
SMQs:, Rhabdomyolysis/myopathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Vestibular disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: 2nd Covid Same but less chills
Other Medications:
Current Illness: None
Preexisting Conditions: Anxiety/panic. Overproduce prostaglandins.
Allergies: Bactrim and Cipro, celery, cats, trees, grass, cockroaches
Diagnostic Lab Data:
CDC Split Type:

Write-up: Chills, body pain, headache, sweats, earaches, sore throat, neck pressure, fatigue, dizziness


VAERS ID: 1990037 (history)  
Form: Version 2.0  
Age: 10.0  
Sex: Male  
Location: California  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FH8028 / 2 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Incorrect dose administered
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: No
Current Illness: No
Preexisting Conditions: No
Allergies: No
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pfizer COVID-19 purple cap adult was given to 10 yo patient.


VAERS ID: 1990039 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FJ1620 / 3 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Dyspnoea, Eye swelling, Nausea, Pharyngeal swelling
SMQs:, Anaphylactic reaction (narrow), Acute pancreatitis (broad), Angioedema (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Swelling around eyes and throat starting to swell - about 50mg liquid Benadryl was given and monitored for 20-30 minutes. Pt stated she started feeling nauseous and having a hard time breathing so 0.3mg epipen was given in right thigh and called EMS. EMS showed up and evaluated the patient, her blood pressure, heart rate, and breathing was all normal. Patient refused to go to the ER to be monitored and preferred to go home.


VAERS ID: 1990186 (history)  
Form: Version 2.0  
Age: 9.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FE3594 / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Incorrect dose administered, Wrong product administered
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: On 12/29/21 around 6pm two family member arrived at the pharmacy with their parent for their scheduled 2nd covid-19 vaccines. This day was a very busy day from the very beginning and throughout the whole day, I was doing my very best to manage the flow within the pharmacy given the high volume of patients at drop off, pick-up, counseling, and immunization appointments. When they arrived to the pharmacy for their appointment, we checked both patients in at the drop-off window. They then went through the normal screening procedure before getting the vaccine. Once they were checked-in, they were put in the immunization room with their parent (mother). I then took both patient forms and confirmed all the details on the form with the mother of the two patients. One was 12 years old and the other was 9 years old. Then I proceeded to prepared both vaccines. Once the vaccines were made, I came back into the immunization room with the vaccines ready. Both patients looked very alike in terms of height and body features. When came the time to administer the vaccine, I was under the impression that the mom had told me to go ahead and administered the 12 years old first which led me to get the "adult Pfizer vaccine" and administer it. I proceeded to administer the "adult Pfizer vaccine" to the 9 years old thinking that I was in fact giving the vaccine to the 12 years old patient given the similarities in body features. But then I realized that I had given the wrong vaccine to the wrong patient. Instead of the "pediatric Pfizer vaccine", I had given the "Adult Pfizer vaccine" to the 9 year old. Immediately after administration, I informed the mother. The mother was understanding of the situation. I asked the family to stay around for 15 minutes in the room to make sure that everything was ok before they left. When they were leaving, the 9 years old patient was feeling ok. I then followed up with the mom a couple hours after to make sure everything was ok with the patient. I then also proceeded to contact Pfizer but their medical department was already closed for the day. I will follow-up with Pfizer again and I also plan on following up with the patient''s doctor.


VAERS ID: 1990193 (history)  
Form: Version 2.0  
Age: 29.0  
Sex: Female  
Location: California  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 939906 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Incorrect dose administered
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Nurse administered 0.25ml instead of 0.5ml around 2:30pm for patients first dosage in the series. Patient came back around 5:30pm for another 0.25ml of Moderna


VAERS ID: 1990198 (history)  
Form: Version 2.0  
Age: 9.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-12-27
Onset:2021-12-29
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK 5618 / 1 LA / -

Administered by: Military       Purchased by: ?
Symptoms: Ocular hyperaemia
SMQs:, Anaphylactic reaction (broad), Glaucoma (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Redness on the Right Eye


VAERS ID: 1990204 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Female  
Location: New York  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 3 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Unevaluable event
SMQs:

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Metoprolol ASA
Current Illness: a cold drippy nose
Preexisting Conditions: afib controlled hbp
Allergies: Lots of things- both food and medicine
Diagnostic Lab Data:
CDC Split Type:

Write-up: None stated.


VAERS ID: 1991106 (history)  
Form: Version 2.0  
Age: 9.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL8095 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Product preparation issue
SMQs:, Medication errors (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: N/A
Current Illness: N/A
Preexisting Conditions: N/A
Allergies: N/A
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Pt was given a pediatric pfizer that was not reconstituted with diluent; no SE thus far per mother


VAERS ID: 1991108 (history)  
Form: Version 2.0  
Age: 6.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL8095 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: No adverse event, Product preparation issue
SMQs:, Medication errors (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: n/a
Current Illness: n/a
Preexisting Conditions: n/a
Allergies: n/a
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Pt was given a pediatric pfizer that was not reconstituted with diluent; no SE thus far


VAERS ID: 1991915 (history)  
Form: Version 2.0  
Age: 16.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 33025BD / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Condition aggravated, Disorientation, Eye movement disorder, Fall, Musculoskeletal stiffness, Posture abnormal, Seizure
SMQs:, Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Dementia (broad), Convulsions (narrow), Dystonia (broad), Parkinson-like events (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Ocular motility disorders (narrow), Generalised convulsive seizures following immunisation (narrow), Arthritis (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Patient has history of fainting after HPV vaccine in 8th grade per mom. She does not have date or specifics of vaccine, other th
Other Medications: None
Current Illness: None
Preexisting Conditions: Anxiety
Allergies: Penicillin
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient & mom were discussing history of fainting with HPV vaccine prior to vaccination. COVID-19 (Pfizer (2)) dose 2 was administered to patient-seconds (~20-30) later patients head fell back. Mo thought he was joking. Patient then arched back, tensed up and fell out of his chair. Mom was closest to him and tried to protect his head from the wall/floor. Patients eyes were rolled back. Mom was blocking view, but appeared patient was mildly convulsing. Mom said she felt it. Patient was slightly disoriented but smiled one he was off floor. Whole event was less than 1 minute. Advised patient to stay for at least 20 minutes near pharmacy. They soon appeared fine after event. Patient had "hardly" eaten all day and ate cookies & chocolate milk after event. Mom was advised to call peidiatician in AM & ''''seek emergent help if event occurred again.


VAERS ID: 1991111 (history)  
Form: Version 2.0  
Age: 43.0  
Sex: Female  
Location: Arizona  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 3 RA / SYR

Administered by: Public       Purchased by: ?
Symptoms: Chills, Nausea, Vomiting
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Moderna 2nd dose; fever and body aches
Other Medications: Generic Xyrtec
Current Illness: None
Preexisting Conditions: None
Allergies: Target brand dryer sheets
Diagnostic Lab Data: N/a
CDC Split Type:

Write-up: Nausea, vomiting, chills without running a fever


VAERS ID: 1991112 (history)  
Form: Version 2.0  
Age: 11.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL8095 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: No adverse event, Product preparation issue
SMQs:, Medication errors (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: n/a
Current Illness: n/a
Preexisting Conditions: n/a
Allergies: n/a
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Pt was given a pediatric pfizer that was not reconstituted with diluent; no SE thus far


VAERS ID: 1991113 (history)  
Form: Version 2.0  
Age: 6.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL8095 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Product preparation issue
SMQs:, Medication errors (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: n/a
Current Illness: n/a
Preexisting Conditions: n/a
Allergies: n/a
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Pt was given a pediatric pfizer that was not reconstituted with diluent; no SE thus far


VAERS ID: 1991116 (history)  
Form: Version 2.0  
Age: 17.0  
Sex: Female  
Location: Guam  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 036C21A / 3 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Product administered to patient of inappropriate age
SMQs:, Medication errors (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: none
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: 12/29/21 @ 4:42PM As pt. was being assessed , I was notified by Nurse, RN regarding administering moderna booster 0.25mL IM to 17 y/o pt. I informed the father and pt that I have given moderna to his 17 y/o daughter. I explained to parent that moderna should not be given to 17 y/o. Father and pt acknowledged and is aware. Pt will monitored for 30 minutes from 4:30 pm to 5:00 pm.


VAERS ID: 1991129 (history)  
Form: Version 2.0  
Age: 40.0  
Sex: Male  
Location: New York  
Vaccinated:2021-12-28
Onset:2021-12-29
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 3 LA / -

Administered by: Public       Purchased by: ?
Symptoms: Chills, Headache, Insomnia, Pain
SMQs:

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness:
Preexisting Conditions: Hep b
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Headache, slight chills. Slight body ache. Sleeplessness.


VAERS ID: 1991876 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-12-01
Onset:2021-12-29
   Days after vaccination:28
Submitted: 0000-00-00
Entered: 2021-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041J21A / 3 LA / -

Administered by: Unknown       Purchased by: ?
Symptoms: Lymphadenitis, Lymphadenopathy
SMQs:, Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Crestor 10mg
Current Illness:
Preexisting Conditions:
Allergies: Epinefrine
Diagnostic Lab Data:
CDC Split Type:

Write-up: Inflammation of the axilar and near the breast. Big bump.


VAERS ID: 1991880 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 068H21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Blindness, Visual impairment
SMQs:, Anticholinergic syndrome (broad), Glaucoma (broad), Optic nerve disorders (broad), Lens disorders (broad), Retinal disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Systemic: Visual Changes/Disturbances-Severe, Additional Details: Patient called later that day and said she was losing her eye sight. Told her to go to nearest hospital


VAERS ID: 1991881 (history)  
Form: Version 2.0  
Age: 22.0  
Sex: Female  
Location: California  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FJ8757 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Syncope, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Systemic: Fainting / Unresponsive-Severe, Additional Details: After Admenstring Vaccine, noticed patient is fainting. Held patient to ground and called for hlep and pharmacy staff called EMS. Patient gained consciousness before EMS arrive. When EMS arrived, we relayed info to the EMS responders. They took over


VAERS ID: 1991883 (history)  
Form: Version 2.0  
Age: 18.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FE3594 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Chills, Headache, Hypotension, Nausea, Syncope, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Systemic: Chills-Medium, Systemic: Fainting / Unresponsive-Mild, Systemic: bp 90/70; hypotension-Medium, Systemic: Headache-Mild, Systemic: Nausea-Mild


VAERS ID: 1991885 (history)  
Form: Version 2.0  
Age: 44.0  
Sex: Male  
Location: California  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 33030BD / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Syncope, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Systemic: Fainting / Unresponsive-Mild


VAERS ID: 1991887 (history)  
Form: Version 2.0  
Age: 33.0  
Sex: Female  
Location: Missouri  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FE3594 / 2 LA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Fear of injection, Flushing, Hyperhidrosis, Pallor, Syncope, Tremor, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Systemic: Dizziness / Lightheadness-Mild, Systemic: Fainting / Unresponsive-Mild, Systemic: Flushed / Sweating-Mild, Systemic: Shakiness-Mild, Additional Details: About 2-3 minutes after vaccine went back into vaccine area and pt was diaphoretic and pale and fainted post vaccine. Pt was assisted to a flat postions and she regained consciousness approx 15-30 seconds after she was flat. She was monitored in the pharmacy area for 30 minutes and given water. Pt reports that she is needle phobic.


VAERS ID: 1991890 (history)  
Form: Version 2.0  
Age: 8.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-12-29
Onset:2021-12-29
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-12-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FL5618 / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Asthenia, Fall, Head injury, Syncope, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Systemic: Fainting / Unresponsive-Mild, Additional Details: Patient experienced apparent episode of syncope as he fell while standing up from chair and hit his head on the privacy screens surrounding the vaccination area. Patient did not appear to lose consciousness. Patient was very nervous prior to administration&experienced weakness that likely resulted in fall. Patient helped up my pharmacist, helped to chair to recover, and advised to reach out to PCP about potential head injury from fall. Encounter observed by pharmacist.


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