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From the 9/3/2021 release of VAERS data:

Found 661,087 cases where Vaccine is COVID19 and Patient Did Not Die



Case Details (Reverse Sorted by Onset Date)

This is page 183 out of 6,611

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VAERS ID: 1510046 (history)  
Form: Version 2.0  
Age: 40.0  
Sex: Female  
Location: California  
Vaccinated:2021-07-27
Onset:2021-07-28
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Diarrhoea, Lethargy, Vomiting
SMQs:, Acute pancreatitis (broad), Pseudomembranous colitis (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Noninfectious diarrhoea (narrow), 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: Lo loestrine
Current Illness: n/a
Preexisting Conditions: n/a
Allergies: n/a
Diagnostic Lab Data:
CDC Split Type:

Write-up: vomiting and diahrea, lethargic


VAERS ID: 1510051 (history)  
Form: Version 2.0  
Age: 20.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 207A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Epistaxis, Headache, Hyperhidrosis, Oxygen saturation decreased, Pain, Presyncope, Vision blurred
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Glaucoma (broad), Lens disorders (broad), Retinal disorders (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (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 got Janssen vaccinc , 5 minutes later his sister told us he was getting head ache ..got him water , headache he stated was getting worse throbbing pain, gave ice pack. as he was drinking bottle water , pt started leaning over as if sick, noticed blood coming from right nasal and he was actually about to pass out.got him sitting up while sister sat with him on phone with mother. Called 911 .pt was soaked with perspiration.He told EMT his vision was blurry but slowly coming back. After EMT assessed him he was starting to feel better and started walking and his oxygen was back up. Mom met with EMT later.


VAERS ID: 1510074 (history)  
Form: Version 2.0  
Age: 31.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 053C21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Chest discomfort, Erythema
SMQs:, Anaphylactic reaction (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: Anaphylactic, Age 13, MMR Vaccination 9/3/19 Merck
Other Medications: Deltasone 10mg, Xopenex HFA, Xopenex Neb 1.25/3mL, Tenex 1mg, Zoloft 100mg, Protonix 40mg EC, Breo-Ellipta 200/25mcg, Flonase, Singulair 10mg, Epi-PEN 0.3mg/0.3mL, Vitamin C 500mg, Zyrtec 10mg, Vitamin D3 25mcg, 1000u
Current Illness: Chronic Asthma, Long Term Benzodiazepine Use, PTSD
Preexisting Conditions: PTSD, Asthma
Allergies: MMR Vaccination, Codeine, Shellfish, Sulfa, Silicone, Wasp Venom
Diagnostic Lab Data: Vital Signs, Nurse respiratory assessment- 7/28/2021
CDC Split Type:

Write-up: Patient complained of chest tightness and was observed to be red in the face arms, chest, and neck.


VAERS ID: 1510085 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-07-22
Onset:2021-07-28
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0196 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Chest discomfort, Chills, Diarrhoea, Dyspnoea, Fatigue, Hypoaesthesia, Illness, Nausea, Pain, Pain in extremity, Paraesthesia, Peripheral coldness, Pyrexia, Rhinorrhoea, Skin discolouration, Skin sensitisation, Throat tightness
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (broad), Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Pseudomembranous colitis (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Noninfectious diarrhoea (narrow), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Sexual dysfunction (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: N/A
Current Illness: none
Preexisting Conditions: none
Allergies: N/A
Diagnostic Lab Data:
CDC Split Type:

Write-up: I developed a pain in my right calf and tingliness after 7 1/2 hours after the shot. Woke up next morning very sick as to be expected after already having covid. achey, very tired, headache, runny nose, chills and fever of 101.3, skin is sensative to the touch, nausea diharea, throat is tight, tightness in chest and shortness of breath. at 6:30pm fever goes to 102.3 and my fingers from the 2nd knuckle up turned white, cold and numb which has NEVER happened before. Next morning my fingers and hands are tingling. loose stools for 3 days and exhausted after 6 days.,


VAERS ID: 1510094 (history)  
Form: Version 2.0  
Age: 39.0  
Sex: Male  
Location: California  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 206A21A / N/A LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Hyperhidrosis, Hypopnoea, Hypotonia, Loss of consciousness, Nausea, Pallor, Respiration abnormal
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (broad), Peripheral neuropathy (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (narrow), Generalised convulsive seizures following immunisation (narrow), Respiratory failure (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: NONE
Current Illness: NONE
Preexisting Conditions: NONE
Allergies: SHRIMP-DERIVED IODINE
Diagnostic Lab Data: PULSE OX 97%, BP 96/64 mmHg, HR 79 bpm, Temp. 97-98 F.
CDC Split Type:

Write-up: PATIENT PASSED OUT MOMENTARILY FOR NO MORE THAN 30 SECONDS WITHIN 5 MINUTES OF RECEIVING VACCINE DOSE. PATIENT SELF-REPORTED FEELING ONSET RIGHT BEFORE SYNCOPE OCCURRED. HE SLUMPED BACK IN HIS CHAIR (DID NOT FALL) AND ARMS DROPPED TO HIS SIDES. DURING SYNCOPE PATIENT HAD SHALLOW AND QUICK BREATHING AND TURNED PALE FOR ABOUT 15-20 SECONDS. BREATHING THEN NORMALIZED FOR 10 SECONDS AND PATIENT REGAINED SOME COLOR TO COMPLEXION. PATIENT FINALLY WOKE UP FEELING SLIGHTLY NAUSEOUS, DIAPHORETIC, AND STILL SLIGHTLY PALE. HE WAS PROVIDED WATER AND A GLUCOSE TABLET AND VITALS WERE TAKEN. HE DECLINED PARAMEDICS OR ANY EMERGENCY ASSISTANCE, AND LEFT THE FACILITY ON HIS OWN.


VAERS ID: 1510107 (history)  
Form: Version 2.0  
Age: 21.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-06-22
Onset:2021-07-28
   Days after vaccination:36
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Fatigue, Oropharyngeal pain, Respiratory tract congestion, Rhinorrhoea
SMQs:, Oropharyngeal conditions (excl neoplasms, infections and allergies) (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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: sore throat, congestion, runny nose, fatigue


VAERS ID: 1510108 (history)  
Form: Version 2.0  
Age: 29.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-07-27
Onset:2021-07-28
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / UNK RA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Asthenia, Back pain, Discomfort, Headache, Nausea, Pain, Pain in extremity
SMQs:, Acute pancreatitis (broad), Retroperitoneal fibrosis (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Tendinopathies and ligament 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: none
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Over night and into next day. Body aches, headache, no energy, nausea, sore arm, amplification of lower back pain, discomfort.


VAERS ID: 1510121 (history)  
Form: Version 2.0  
Age: 19.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0187 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Dizziness, Nausea, Sensation of foreign body, Tremor
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Parkinson-like events (broad), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), 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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Lexapro 10 mg Diflucan 150 mg Xulane 150-35mcg/ 24 hours Maxalt - MCT 5mg prn Acetaminophen 500mg prn
Current Illness: Puritis vaginitis
Preexisting Conditions: Major Depression Mild Alcohol Use disorder with Alcohol induced Mood Disorder Adjustment disorder anxiety Tobacco Use
Allergies: Sulfa
Diagnostic Lab Data:
CDC Split Type:

Write-up: At 40 minutes post vaccination the patient experienced lightheadedness, nausea, and shaking. at 60 minutes the patient experienced a slight lump in her throat which did not progress. The patient was taken to the emergency room for observation.


VAERS ID: 1510122 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 - / IM

Administered by: Other       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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: *Client received dose under minimum interval. 1st dose Pfizer received on 07/13/2021


VAERS ID: 1510131 (history)  
Form: Version 2.0  
Age: 17.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FA6780 / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Seizure, Skin discolouration, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Systemic lupus erythematosus (broad), Arrhythmia related investigations, signs and symptoms (broad), Convulsions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (narrow), 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: Patient seemed to faint / look like they had a seizure, no seizure history, color recovered to face once we laid her down and lifted legs up. EMS was called and assessed patient.


VAERS ID: 1510136 (history)  
Form: Version 2.0  
Age: 37.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0175 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Dizziness, Fear, 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: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Pt started to feel diaphoretic at 12:43pm, RN informed. Pt also states that he felt dizzy for a little bit. Pt states that he got scared and started to feel symptoms. RN assessed, took vitals and gave ice pack and orange. After 1 minute, pt feels a lot better. Patient stated for extra 15 minutes. RN monitored, reassessed, and cleared pt. . V/S 140/83,73.


VAERS ID: 1510137 (history)  
Form: Version 2.0  
Age: 31.0  
Sex: Female  
Location: D.C.  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FA7484 / N/A LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Extra dose administered, Interchange of vaccine products
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient came into clinic and requested Pfizer Covid-19 vaccine. She stated that she had discussed it with her PCP, and even though she had received Janssen Covid-19 vaccine 4/2/21 she wanted to get the vaccine.


VAERS ID: 1510138 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-07-26
Onset:2021-07-28
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 048C21A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Injection site erythema, Injection site warmth
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: unknown
Current Illness: none known
Preexisting Conditions: none
Allergies: no known drug allergies
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient noticed today that her arm was red and warm where injection was given, approx 6x6 inch area. It is not swollen or itchy or painful.


VAERS ID: 1510139 (history)  
Form: Version 2.0  
Age: 31.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 206A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Hyperhidrosis, Paraesthesia
SMQs:, Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre 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: Similar reaction as reported here (dizzy, faint feeling, sweating) about 4 or 5 years ago after receiving a meningococcal vaccin
Other Medications: Unaware of any
Current Illness: Unaware of any
Preexisting Conditions: Unaware of any
Allergies: None
Diagnostic Lab Data: Blood pressure and heart rate checked at 1150am on 7/28/21 - blood pressure was 115/68, heart rate was 69
CDC Split Type:

Write-up: The vaccine was administered to the patient at approximately 1135am. A few minutes after the vaccine was administered, the patient started feeling faint, dizzy, and sweaty (patient was sitting in a chair at the time). He also experienced some tingling in his hands and feet (like they were falling asleep). The patient laid down on his back on floor. The patient said he did not want 911 called. The patient started feeling better after laying down. The patient''s blood pressure and heart rate were checked at 1150am (while still lying down) - blood pressure was 115/68, heart rate was 69. The patient said he had something similar happen once before when getting a Meningococcal vaccine. When feeling well enough, we had the patient sit up on the ground. The patient sat on the ground for a few minutes to acclimate, and then stood up and sat in a chair. The patient reported he was feeling better and continued resting in the chair. The patient reaffirmed he did not want us to call 911 or a family member to come be with him. The patient left the pharmacy around 1215pm after reporting that he was feeling better.


VAERS ID: 1510140 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: Louisiana  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038C21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Device connection issue, Syringe issue, 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: Not known
Current Illness: Not known
Preexisting Conditions: Not known
Allergies: Not known
Diagnostic Lab Data:
CDC Split Type:

Write-up: When injecting vaccine the syringe came apart from the needle in the arm. The vaccine spilled on her arm


VAERS ID: 1510142 (history)  
Form: Version 2.0  
Age: 28.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FA6780 / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Cold sweat, Pallor, Pharyngeal swelling
SMQs:, Anaphylactic reaction (broad), Angioedema (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (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: Benadryl, flu vaccine
Diagnostic Lab Data:
CDC Split Type:

Write-up: six minutes after receiving vaccine patient complained of feeling as if his throat was closing up. Pt appeared pale and clammy. Vital signs BP 150/100, Heart rate 142, PO2 99. 2 doses of EPI given, EMS called. Pt was transported to Hospital.


VAERS ID: 1510149 (history)  
Form: Version 2.0  
Age: 21.0  
Sex: Female  
Location: Arizona  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1808980 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Dizziness, Full blood count, Human chorionic gonadotropin, Loss of consciousness, Metabolic function test, Visual impairment
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), Glaucoma (broad), Optic nerve disorders (broad), Lens disorders (broad), Retinal disorders (broad), Vestibular disorders (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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: None listed
Current Illness: none
Preexisting Conditions: none
Allergies: nkda
Diagnostic Lab Data: HCG/cmp/CBC
CDC Split Type:

Write-up: Pt is a 21-year-old female who presents as a rapid response from the: Vaccination clinic. Patient reports that she received her covid vaccine and then sat in the chair while sitting in the chair waiting out her observation. She started to feel lightheaded, noted stars, noted everything started to go black and then slumped over in her chair. According to the nurse/pharmacist that was there they were able to catch her and slowly side or down so there was no head injury. She was brought immediately to the emergency room. She reports that she still is feeling dizzy and lightheaded. She denies any chest pain or shortness of breath No feeling of chest tightness or throat tightness No feeling of swelling or throat closing No swelling to her lips or face No rash, urticarial or hives


VAERS ID: 1510158 (history)  
Form: Version 2.0  
Age: 15.0  
Sex: Male  
Location: Alabama  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0178 / 1 LA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Loss of consciousness
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), Vestibular disorders (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:
Other Medications: no
Current Illness: no
Preexisting Conditions:
Allergies: no
Diagnostic Lab Data: no
CDC Split Type:

Write-up: Passed out . Was out for maybe a minute . Sat up and was dizzy again . Laid down again.


VAERS ID: 1510170 (history)  
Form: Version 2.0  
Age: 35.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 203A21A / UNK RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Dysgeusia, Erythema, Feeling hot, Flushing, Rash, Rash macular
SMQs:, Anaphylactic reaction (broad), Taste and smell disorders (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? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Plaquenil 200mg QD, Buspar 7.5mg BID, HCTZ 12.5mg QD, Levothyroxine 75mcg QD, Zomig 5mg PRN
Current Illness:
Preexisting Conditions:
Allergies: Topamax, Latex, Sulfa, and high doses of Augmentin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt developed metallic taste in her mouth 1-2 minutes after vaccine was administered. After approximately 10-15 minutes, pt. noticed that her chest felt warm and after approximately 25-30 minutes, pt. was noted to have red flushing of her upper chest, her cheeks were pink, her bilateral arms were red, and pt. developed a fine rash on her upper chest and right arm and her left arm was "splotchy" as well.


VAERS ID: 1510178 (history)  
Form: Version 2.0  
Age: 21.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0181 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Flushing
SMQs:, Anaphylactic reaction (broad), Anticholinergic 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: Unknown
Preexisting Conditions: none
Allergies: Antibiotics including PCN and sulfa
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient was lightheaded and felt flushed following vaccination. Patient recommended to place head between legs and was monitored for 30 minutes following administration without further issues.


VAERS ID: 1510179 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0198 / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Inappropriate schedule of product administration, No adverse event
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: No adverse event. Second shot was administered on 7/28/21, which is beyond 6 week window from first shot (4/30/21). Patient was informed of limited efficacy information beyond 6 week window and patient, with doctor''s approval, decided to proceed with getting it. No issues with administration.


VAERS ID: 1510191 (history)  
Form: Version 2.0  
Age: 15.0  
Sex: Male  
Location: Idaho  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0023C21A / 1 RA / IM

Administered by: Pharmacy       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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient was under 18 years old at the time of administration. He had no adverse effect to the vaccination other than being to young for the Moderna vaccination at the time it was given.


VAERS ID: 1510209 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / UNK RA / IM

Administered by: Unknown       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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Vaccine given a beyond use date of 3:30pm and vaccine administered approximately 30 minutes past the BUD time of 3:30pm


VAERS ID: 1510212 (history)  
Form: Version 2.0  
Age: 29.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1821287 / 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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient received vaccination and approximately 5 minutes later fainted. she was helped to a seated position and remained seated for several minutes until able to be helped into a chair. She then stayed seated in the chair under observation for about 20 minutes and returned to a normal general state and was able to be escorted out of the pharmacy to their ride.


VAERS ID: 1510217 (history)  
Form: Version 2.0  
Age: 42.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / UNK LA / -

Administered by: Unknown       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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: vaccin given a beyond use date of 3:30pm and vaccine administered approximately 30 minutes pas the BUD of 3:30pm


VAERS ID: 1510218 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 048C21A / N/A LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Extra 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: Patient was administered Moderna (a third Covid vaccine) instead of her second Shingrix vaccination, due to a mix up with vaccine to be administered. Patient waited and did not have any adverse events before leaving the pharmacy. She had already had her two Pfizer vaccines earlier this year, so she got a third covid vaccine instead of getting her Shingles vaccine, by our error.


VAERS ID: 1510225 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: California  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 048C21A / 2 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Hyperhidrosis, Hypotension, Pallor
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Vestibular disorders (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: Not known
Current Illness: Not known
Preexisting Conditions: Not Known
Allergies: Penicillin
Diagnostic Lab Data: Not known
CDC Split Type:

Write-up: Patient became sweaty, pale and very dizzy. We measured her BP and it seemed very low but later after 10 minutes it went back up again. We called 911 and medics came to take her to the hospital.


VAERS ID: 1510228 (history)  
Form: Version 2.0  
Age: 11.0  
Sex: Male  
Location: California  
Vaccinated:2021-07-27
Onset:2021-07-28
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FA7485 / 1 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''s mom wrote that patient was "14" but the DOB written on form makes the patient only 11yo. The patient is underage and therefore the vaccination was not given in accordance to the approved EUA guidelines.


VAERS ID: 1510229 (history)  
Form: Version 2.0  
Age: 33.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 040C21A / 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? 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: Syncopal episode 5 minutes after vaccine administration. Patient was monitored and fully recovered within 10 minutes.


VAERS ID: 1510237 (history)  
Form: Version 2.0  
Age: 63.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0196 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Feeling abnormal, Hypoaesthesia, Lymph node pain, Muscle tightness
SMQs:, Peripheral neuropathy (broad), Dementia (broad), Dystonia (broad), Guillain-Barre syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Sexual dysfunction (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: Losartan 25mg , Goldenseal
Current Illness: Shingles (recovered approximately 1 month prior) Congestion
Preexisting Conditions: Hypertension Herniated disc/disc disorder
Allergies: Tetracycline - reaction is bumps on tongue
Diagnostic Lab Data:
CDC Split Type:

Write-up: Approximately 5 minutes after receiving vaccination patient reported feeling tightness on the left side of her jaw, then it spread to back of neck and up the face to below her eye. Patient reported no difficulty breathing and no movement issues (no drooping in face or arms), reported it felt like her lymph node was swelling when she palpated the area, reported she felt like her face was puffy. Patient declined ice pack, emergency services. Patient waited in pharmacy area and was observed for 30 minutes, then decided she wanted to get up and walk around. Patient reported her left foot felt numb upon standing up but that she has experienced that before with her herniated disc. Patient again declined emergency services. Patient reported pain in lymph node improved but still felt tightness in jaw, face, and neck. Patient chose to walk around store for a little bit, then returned to pharmacy to inform pharmacist she felt okay and wanted to leave.


VAERS ID: 1510247 (history)  
Form: Version 2.0  
Age: 29.0  
Sex: Female  
Location: New Hampshire  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 205A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Asthenia, Chills, Dizziness, Hyperhidrosis, Loss of consciousness, Nausea, Tunnel vision, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic 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), Optic nerve disorders (broad), Retinal disorders (narrow), Vestibular disorders (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: panic disorder
Preexisting Conditions: panic disorder
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Before the shot the patient was very nervous. 5 Minutes later she lost consciousness in her chair but quickly recovered, with dizziness, tunnel vision, sweating, shivering, nausea, weakness. She got better with resting her head down by her knees, had some water, then stood up to go to the bathroom due to nausea, but didn''t make it and vomited 2 times. After resting on the floor with pharmacist supervision for about 20 minutes she began to feel better. I called her boyfriend who came to pick her up. She did not want the ambulance.


VAERS ID: 1510252 (history)  
Form: Version 2.0  
Age: 36.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006C21A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Chest discomfort, Dyspnoea, Hypoaesthesia oral, Palpitations, Paraesthesia oral
SMQs:, Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (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: zoloft, prenatal vit
Current Illness: no
Preexisting Conditions: no
Allergies: bee stings, mushrooms
Diagnostic Lab Data: no
CDC Split Type:

Write-up: lips started feeling tingle and numb and couldn''t catch breath, heart racing and tightness in chest


VAERS ID: 1510255 (history)  
Form: Version 2.0  
Age: 24.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 048C21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Injection site pruritus
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:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Localized itching at injection site for about 5 mins


VAERS ID: 1510257 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: California  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006D21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Contusion, Varicose vein
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Accidents and injuries (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: Losartan 50mg
Current Illness: None
Preexisting Conditions: No
Allergies: Flonase, Maxide
Diagnostic Lab Data: advised to see PCP regarding bruise and varicose veins on 07/28/2021 over the phone. No medical tests completed at this time as event was reported over email and was unable to be reached in person.
CDC Split Type:

Write-up: Per , she has a new bruise on her right shoulder and varicose veins in a small series on her right leg. Patient claims that this bruise and the varicose veins were not there before. She noticed this around 1400 and reported it to me at 1433 over email. I then filled in this form with her over the phone.


VAERS ID: 1510271 (history)  
Form: Version 2.0  
Age: 22.0  
Sex: Male  
Location: Idaho  
Vaccinated:2021-07-26
Onset:2021-07-28
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 009D21A / 2 LA / IM

Administered by: School       Purchased by: ?
Symptoms: Electrocardiogram normal, Fatigue, Headache, Loss of consciousness, Nausea, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (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), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), 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? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: EKG --normal. 07-28-2021
CDC Split Type:

Write-up: The day after the shot, the patient experienced severe headaches, fatigue and nausea. This lasted one day. The 2nd day after the shot patient was feeling better and went to work. While there he had one episode of fainting where he was unconscious just momentarily. Pt slumped and DID NOT hit his head. Followed up with healthcare provider. Provider felt things were good and told pt to return if anything changed.


VAERS ID: 1510442 (history)  
Form: Version 2.0  
Age: 24.0  
Sex: Female  
Location: California  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0198 / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Blood pressure decreased, Discomfort, Dizziness, Pallor, Paraesthesia
SMQs:, Anaphylactic reaction (broad), Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (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: None
Current Illness: No
Preexisting Conditions: None
Allergies: NKA
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Pt. received her first dose of COVID - 19 vaccine Pfizer 0.3 ml IM on her Lt. deltoid at 08:39 am on 07/28/21.Pt c/o Lt upper arm tingling at 8:41 am. Nurse did massage on her Lt. arm site area. Then pt. c/o dizziness at 8:42 am. Pt looked pale & conscious. Nurses assisted pt. lay on the examination bed. BP:97/57,P:47,SPO2:96%.at 8:47 am. Pt said that she did not eat her breakfast & did exercise for 1.5 hrs. before the vaccination. BP: 101/64, P:56, SPO2:96% at 08:50 am & pt. said that she had no more dizziness & no tingling on her Lt. injection site arm. Pt said that she was fine & other discomfort. Pulse:60 at 8:51 am. BP:101/64, P:56 at 8:58 am. Cont. monitor pt. Pt alert & conscious. BP:101/64, P 54, SPO2:97% at 9:02 am. BP:101/64, P:56, SPO2:97% at 9:12 am. Pt was monitor for 30 min., & left the facility at 9:14 am without distress noted & in stable condition.


VAERS ID: 1510456 (history)  
Form: Version 2.0  
Age: 31.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FA7485 / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Dyspnoea, Heart rate increased
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Vestibular disorders (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: No.
Current Illness: No
Preexisting Conditions: Hypothyroidism
Allergies: Codeine.
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Fast heartbeat, shortness of breath, dizziness.


VAERS ID: 1510457 (history)  
Form: Version 2.0  
Age: 37.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FA6780 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Hypotension, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), 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: NOT AWARE
Current Illness: NONE
Preexisting Conditions: NOT AWARE
Allergies: NONE
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Patient has needle phobia, but he did not disclosed it at the time of the vaccine. 5 mins after I gave him the shot, other customers shouted that someone is fainting. He had a normal pulse, but upon checking, his blood pressure was low. EMT came to the scene, but the patient denied to be transported to the hospital. He is doing fine and he was able to go home without support.


VAERS ID: 1510459 (history)  
Form: Version 2.0  
Age: 16.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0187 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Cold sweat, Dizziness, Feeling cold, Muscle tightness, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dystonia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Vestibular disorders (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? 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 dizzy, cold and clammy, Starring and not responsive for 1 minute. Jaw was clamped down but upon asking the patient then spoke 2 minutes into episode. Vitals were stable. Rapid response was called. Patient was observed, given fluids and sent home.


VAERS ID: 1510465 (history)  
Form: Version 2.0  
Age: 35.0  
Sex: Male  
Location: Oklahoma  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 048C21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dyspnoea, Hypoaesthesia, Injection site swelling, Paraesthesia
SMQs:, Anaphylactic reaction (broad), Peripheral neuropathy (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Sexual dysfunction (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: Diabetes, smoker
Preexisting Conditions: diabetes
Allergies: nkda
Diagnostic Lab Data:
CDC Split Type:

Write-up: Shortness of breath 15 minutes after giving the vaccine that then went away, then 1 hour later his arm on the injection side swelled up before the elbow and he had numbess and tingling. It went away after taking ibuprofen and benadryl


VAERS ID: 1510472 (history)  
Form: Version 2.0  
Age: 28.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-07-26
Onset:2021-07-28
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 042A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Nasopharyngitis, Swelling face
SMQs:, Anaphylactic reaction (broad), Angioedema (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? 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: Two days after receiving vaccine, patient started to develop cold symptoms and swelling in her face that got progressively worse throughout the day.


VAERS ID: 1510473 (history)  
Form: Version 2.0  
Age: 12.0  
Sex: Female  
Location: California  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FA6780 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Expired product administered, No adverse event
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: Amoxapine
Diagnostic Lab Data:
CDC Split Type:

Write-up: Registered nurse withdrew a pre-filled Pfizer Covid-19 syringe from the refrigerator and administered the vaccine to the patient. Nurse administered 0.3 ml in the right deltoid. Nurse realized after administering that she gave an expired dose. The vaccine was drawn on 7/27/21 @4:42pm. The vaccine was good to be used until 7/27/21 @10:42pm. The nurse administered the vaccine on 7/28/21 @9:49am. Patient was observed for 15 minutes - no adverse reactions noted during observation. The nurse stated she did not look at the label to verify the vaccine was good to use.


VAERS ID: 1510476 (history)  
Form: Version 2.0  
Age: 15.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FA7484 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Feeling abnormal, Hypoaesthesia, Loss of consciousness, Nausea, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (broad), Peripheral neuropathy (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad), Sexual dysfunction (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: No known allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Within 5 minutes of receiving vaccination, the patient began to feel like she was dreaming and passed out while she was seated. We moved the patient to the floor where she regained consciousness . The patient had further complaints of numbness in the arms, light- headedness and was nauseated and vomited. 911 was called and responded, and the patient said she was ok and did not want to go to hospital.


VAERS ID: 1510477 (history)  
Form: Version 2.0  
Age: 32.0  
Sex: Female  
Location: California  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1808982 / 1 UN / SYR

Administered by: Other       Purchased by: ?
Symptoms: Cerebral haemorrhage, Computerised tomogram head abnormal, Generalised tonic-clonic seizure, Subarachnoid haemorrhage
SMQs:, Haemorrhage terms (excl laboratory terms) (narrow), Systemic lupus erythematosus (broad), Haemorrhagic central nervous system vascular conditions (narrow), Convulsions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Generalised convulsive seizures following immunisation (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: IBS, bipolar disorder
Preexisting Conditions:
Allergies: NKDA
Diagnostic Lab Data: CT of head on 7/27/21
CDC Split Type:

Write-up: Had generalized tonic-clonic convulsions. CT scan of the head revealed a subarachnoid hemorrhage in the L cerebral hemisphere.


VAERS ID: 1510485 (history)  
Form: Version 2.0  
Age: 31.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006D21A / 1 RA / 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: NOT STATED
Current Illness: NONE STATED
Preexisting Conditions: NONE STATED
Allergies: LATEX
Diagnostic Lab Data:
CDC Split Type:

Write-up: ADMINISTERED FIRST DOSE MODERNA VACCINE: APPROX 10 MINUTES POST VACCINATION PATIENT STATED SHE WAS EXPERIENCING LIGHTHEADED, DIZZINESS. I HAD PATIENT LIE DOWN W/ FEET ELEVATED AND PLACED ICE PACK ON BACK OF NECK. SYMPTOMS IMPROVED OVER 10 MINUTES. PATIENT WAS ABLE TO SIT WITHOUT RETURN OF SYMPTOMS. PATIENT KEPT ICE PACK ON BACK OF NECK FOR ADDITIONAL 15 MINUTES. PATIENT REMAINED AT PHARMACY FOR 30 MINUTES SYMPTOM FREE


VAERS ID: 1510674 (history)  
Form: Version 2.0  
Age: 20.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0400C21A / 2 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? 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: 2nd shot received at day 20


VAERS ID: 1510680 (history)  
Form: Version 2.0  
Age: 44.0  
Sex: Female  
Location: Oklahoma  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006D21A / 2 LA / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Inappropriate schedule of product administration, No adverse event
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: HEART BEAT IRREGULARITIES
Allergies: NONE
Diagnostic Lab Data:
CDC Split Type:

Write-up: PATIENT RECEIVED FIRST DOSE AT ANOTHER PHARMCY IN ON 7-12-21. SHE CAME IN FOR HER SECOND DOSE AT PHARMACY IN ON 7-28-21 NOT REALIZING SHE WAS TO WAIT 28 DAYS IN BETWEEN DOSES SHE DIDNT PRESENT HER VACCINATION CARD INITAILLY BUT DID UPON RECEIVING HER VACCINATION THE PHARMACIST IN CHARGE AND TECHNICIAN DIDNT REALIZE THE DOSE WAS 12 DAYS TOO SOON BEFORE GIVING HER THE VACCINATION. HER PRIMARY CARE DR AND CARDIOLOGIST WERE CONSULTED ALONG WITH THE MANUFACTURER. NOT ADVERSE EFFECTS WERE OBSERVED WE ARE CHECKING ON PT DAILY


VAERS ID: 1510682 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-03-10
Onset:2021-07-28
   Days after vaccination:140
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003A21A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (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: lisinopril
Current Illness: none
Preexisting Conditions: HTN
Allergies: bleach
Diagnostic Lab Data:
CDC Split Type:

Write-up: tested positive for covid 19 after completing the vaccine series


VAERS ID: 1510688 (history)  
Form: Version 2.0  
Age: 21.0  
Sex: Male  
Location: California  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0183 / 2 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Feeling abnormal, Feeling cold, Nervousness, Tension, Trismus
SMQs:, Dementia (broad), Dystonia (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: None stated
Current Illness: None Stated
Preexisting Conditions: None Stated
Allergies: None Stated
Diagnostic Lab Data: None
CDC Split Type:

Write-up: At approximately 1106 client approached EMT and asked to have his vitals taken stating he felt, "a little weird". Client received a 2nd dose Pfizer COVID vaccine (LOT EW0183, exp 08/31/2021) at 1050 in the left deltoid and was preparing to leave the observation site when he stated he felt like a cold liquid was running down his left thigh and the left side of jaw was a little tense. Client denied any other symptoms such as shortness of breath, chest pain, numbness or tingling of his mouth, tongue, and throat, dizziness or feeling lightheaded. Client denied any allergies to medications/foods/environment and stated he had no pertinent medical history nor did he take medications regularly. Client reported last oral intake was a cup of coffee in the morning before vaccination with last meal being dinner on 07/27/21. EMT took the client''s vitals at 1106: BP 140/90, HR 70 skin color normal for ethnicity, warm and dry, A&Ox4. Client stated the feeling of cold running down his leg and his tense jaw had resolved. Client stated he had the same feeling after his first dose Pfizer COVID vaccine on 7/7/21. A second set of vitals were taken at 1115: BP 130/90, HR 69 skins normal for ethnicity, warm and dry, A&Ox4. Client stated the vitals were a little higher than his normal but attributed it to having coffee without food and feeling a little nervous. Client stated he felt better and the symptoms had resolved. At 1120 client left the observation site on his own accord with a steady gait.


VAERS ID: 1510693 (history)  
Form: Version 2.0  
Age: 85.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-02-02
Onset:2021-07-28
   Days after vaccination:176
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / UNK LA / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (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: unknown
Current Illness:
Preexisting Conditions: unknown
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: tested positive for covid after completing covid vaccine series


VAERS ID: 1510705 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-02-02
Onset:2021-07-28
   Days after vaccination:176
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL8982 / 2 LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EK9231 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Biopsy skin, Rash
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: Singular, rosuvastin , 2 mg methylpredlisone, alphagan, restasis, baby aspirin, pantoprazole, zolpidem, famvir, prolix injections, pro air if needed Vitamins, b, d, magnesium, biotin, calcium, cow ax, cur cumin
Current Illness: None
Preexisting Conditions: NAION PMR
Allergies: Paleo eye drops, gabapentin, ceftin, codeine, cymbalta, macrodantin, methotrexate, minocycline, ceclor,
Diagnostic Lab Data: Biopsy of rash @ 04/21 Nerve blocks, Botox injections`05 and 06/21 Community hospital,
CDC Split Type:

Write-up: Rash in v shape on neck, then neurological issues Happened both times, different sides


VAERS ID: 1510710 (history)  
Form: Version 2.0  
Age: 17.0  
Sex: Male  
Location: Oregon  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 050C21A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Off label use
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient under the age of 18 was inadvertently administered 1st dose of Modena at pharmacy; per patient and CDC card. 2nd dose of Moderna was given toda as off-label use.


VAERS ID: 1510713 (history)  
Form: Version 2.0  
Age: 22.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 203A21A / N/A 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? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None stated
Current Illness: none indicated
Preexisting Conditions: none indicated
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: About a minute after administering the vaccine,pt said he felt dizzy and and feel like he is goig to faint. so I have pt sit with his head down for several minutes,proceeded to take his Blood pressure and pulse readings every 3 to 5 mins.His Readings were 94/59,pulse 58 at 3:48Pm; 101/72,pulse 72 at 3:55Pm,95/65,pulse 64 at 04:06pm. I observed pt for about 30 more minutes.Pt requested for water and I gave a bottle of Water.Pt said he felt much better and thant he is very okay to go. i advised him to continue to monitor his blood pressure at home and to drink a couple of glasses of gatorade or pedialyte,and to take benadryl if necessary. I advised hime to elevate his legs at home and that if situation deterorates,he can call 911 to go to Er


VAERS ID: 1510730 (history)  
Form: Version 2.0  
Age: 35.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 LA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Headache
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: Lisinopril
Current Illness: Na
Preexisting Conditions: Na
Allergies: Na
Diagnostic Lab Data: Na
CDC Split Type:

Write-up: Mild constant headache


VAERS ID: 1510909 (history)  
Form: Version 2.0  
Age: 15.0  
Sex: Female  
Location: California  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FA7484 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Blindness transient, Chest pain, Deafness, Dizziness, Nausea
SMQs:, Acute pancreatitis (broad), Anticholinergic syndrome (broad), Embolic and thrombotic events, arterial (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Glaucoma (broad), Optic nerve disorders (broad), Cardiomyopathy (broad), Retinal disorders (broad), Hearing impairment (narrow), 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: NKA
Current Illness: NKA
Preexisting Conditions: May have anxiety
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: Dizziness, chest pain, temporary hearing loss, temporary vision loss, nausea.


VAERS ID: 1510910 (history)  
Form: Version 2.0  
Age: 29.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 048C21A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Headache, Heart rate increased
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Vestibular disorders (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? Yes
Hospitalized? No
Previous Vaccinations: mmr,varicalla combo
Other Medications: none at the pharmacy that patient got vaccination at
Current Illness: none
Preexisting Conditions: neurological, heart
Allergies: neomycin, penicillin
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: After vaccination, about 10 min patient complained about her heart pumping very fast and severe headache, after 15-20 min the heart rate felt better however she was very dizzy, called 911 ambulance took the patient to hospital


VAERS ID: 1510912 (history)  
Form: Version 2.0  
Age: 35.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0170 / 1 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? 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: 35 yr old slender man in warm room felt faint 15 minutes after injection, placed supine, iced, hydrated, and self resolved, declined EMS call, departed without assistance with friend.


VAERS ID: 1510913 (history)  
Form: Version 2.0  
Age: 17.0  
Sex: Female  
Location: Nebraska  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FA7485 / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Loss of consciousness, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (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), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), 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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: eggs
Diagnostic Lab Data: patient''s mother called 911 and the rescue squad took patient to the hospital. tried to reach the patient''s parents to see how she was feeling/doing and didn''t get an answer.
CDC Split Type:

Write-up: patient passed out after walking to the waiting area, then threw up when she came to


VAERS ID: 1510917 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Male  
Location: Alabama  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 059E21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Eye movement disorder, Hyperhidrosis, Loss of consciousness, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (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), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Ocular motility disorders (narrow), 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:
Other Medications: None
Current Illness: None indicated.
Preexisting Conditions: None indicated on pt''s VAR
Allergies: None
Diagnostic Lab Data: Not aware of any
CDC Split Type:

Write-up: Patient passed out while waiting until his post injection required 15 minutes. Eyes rolled back and he vomiting all over himself. He was sweating perfusely. Called paramedics and they checked his blood pressure, and remained until he was stable. Patient left sometime later after he had rested .


VAERS ID: 1510923 (history)  
Form: Version 2.0  
Age: 18.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 053C21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Hyperhidrosis, Pallor
SMQs:, Neuroleptic malignant 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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: After patient was given vaccine he sat in waiting area for observation. He started to sweat and turn pale. He was given cool water and ice pack. He said he always has this happen after he sees a needle or gets a shot. He recovered after 5 minutes.


VAERS ID: 1510925 (history)  
Form: Version 2.0  
Age: 18.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FA7484 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Muscle twitching, Syncope, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (broad), Arrhythmia related investigations, signs and symptoms (broad), Dyskinesia (broad), Dystonia (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: n/a
Current Illness: n/a
Preexisting Conditions: n/a
Allergies: n/a
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Patient left to front register to buy an orange juice and fainted at front end, her father sat her on a chair in the photo lab. I wa called to the front end and saw patient twitching and then she started vomiting. I administered an epi pen 0.15 mg on her right leg. She fainted a total of 3 times. EMS checked her blood pressure and it was 91/54 mmhg and her pulse was 103. Second reading on blood pressure was 90/66mmhg and her temperature was 96.7''F. Patient had not eaten before getting her vaccine,


VAERS ID: 1510927 (history)  
Form: Version 2.0  
Age: 31.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0196 / 1 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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: nka
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient reported feeling light headed, dizzy, eyes closed. drank some water. recovered quickly (within 20 minutes). stated that he always feels that way after a vaccine, blood draw, declined emergency support or additional support measures


VAERS ID: 1511078 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: California  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FA6780 / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Extra 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: Pt state that she has never gotten the Pfizer-covid shot; however, after administering the vaccination and while billing her insurance; and then confirming, it was discussed that the patient already gotten both doses of her covid shots in
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient claim that she has never gotten the covid shot; but after giving her the shot, and processing her paper it was discussed by insurance and etc. that she has indeed gotten both doses of her pfizer shots back in Feb.


VAERS ID: 1511082 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: California  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FA6780 / 2 LA / IM

Administered by: Pharmacy       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: UNKNOWN
Current Illness: UNKNOWN
Preexisting Conditions: DEMENTIA - TOLD BY PATIENT''S DAUGHTER AFTER THE FACT
Allergies: UNKNOWN
Diagnostic Lab Data:
CDC Split Type:

Write-up: PATIENT CAME IN TO GET COVID VACCINE - SAID IT WAS HER FIRST SHOT AND HER FORM ALSO SAID THE SAME. ASKED PT WHICH VACCINE SHE WANTED AND SHE REQUESTED PFIZER. WHEN TYPING THE VACCINE LATER IN THE EVENING, GOT A REJECTION FROM THE INSURANCE SAYING PT GOT 1ST DOSE 02/26/21. CALLED PT # AND SPOKE TO HER DAUGHTER, WHO SAID SHE RECEIVED A MODERNA DOSE ON THAT DATE. TOLD DAUGHTER TO MAKE SURE HER MOTHER KNOWS NOT TO COME IN FOR ANOTHER DOSE OF PFIZER.


VAERS ID: 1511089 (history)  
Form: Version 2.0  
Age: 34.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-07-07
Onset:2021-07-28
   Days after vaccination:21
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0181 / 1 - / IM

Administered by: Pharmacy       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: no
Current Illness: no
Preexisting Conditions: no
Allergies: no
Diagnostic Lab Data: no
CDC Split Type:

Write-up: no treatment needed


VAERS ID: 1511259 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 206A21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Dizziness, Urticaria
SMQs:, Anaphylactic reaction (broad), Angioedema (narrow), Anticholinergic syndrome (broad), Vestibular disorders (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:
Other Medications: 81mg of aspirin, naproxen, 400mg ibuprofen, "medicine to prevent anaphylaxis daily"
Current Illness:
Preexisting Conditions:
Allergies: latex- hives, throat swelling, topamax- body stiffness, reglan- body stiffness, morphine- itching, bee sting- hives, eggs- itching,
Diagnostic Lab Data:
CDC Split Type:

Write-up: 24 minutes after vaccine administration, patient experienced hives on nose, arms, chest, thighs, back and buttocks. Also experienced dizziness. 12.5 benadryl tablet was administered at 8:03pm. Patient only wanted half of the pill due to drowsiness affects. Patient was able to leave at 8:09 and denied HA. at 8:35pm, patient asked for the other half of the pill which was 12.5mg of benadryl for a total of 25mg of benadryl given for hives. Patient was instructed to inform PCP about reaction. At 9:20, patient said the hives were disappearing.


VAERS ID: 1511268 (history)  
Form: Version 2.0  
Age: 26.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 091D21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Condition aggravated, Seizure
SMQs:, Systemic lupus erythematosus (broad), Convulsions (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Generalised convulsive seizures following immunisation (narrow), 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: N/A
Current Illness: N/A
Preexisting Conditions: KNOWN HISTORY OF SEIZURES
Allergies: PENICILLIN
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: PATIENT HAD 2 SEIZURES IMMEDIATELY AFTER ADMINISTRATION WITHIN 5 MINUTES. PATIENT WAS OFFERED 911/EMERGENCY MEDICAL SERVICES, BUT REFUSED. PHARMACIST STAYED WITH PATIENT FOR APPROXIMATELY 15 MINUTES AND THEY LEFT WITH A FRIEND. ENCOURAGED EMERGENCY MEDICAL SERVICES, UNKNOWN IF PATIENT WENT.


VAERS ID: 1511270 (history)  
Form: Version 2.0  
Age: 33.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FA7484 / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Inappropriate schedule of product administration, No adverse event
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Dose was given 13 days after first dose. No adverse events noted.


VAERS ID: 1511271 (history)  
Form: Version 2.0  
Age: 12.0  
Sex: Unknown  
Location: Virginia  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FA7484 / 2 RA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: No adverse event, Product administration error
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 WAS ADMINISTERED A SHOT WITH AN EMPTY SYRINGE (NO VACCINE OR DILUENT WAS PRESENT) IN THE LEFT ARM. THE PATIENT WAS INFORMED OF THE MISTAKE AND WAS GIVEN THE CORRECT VACCINE IN THE OPPOSITE ARM. NO ADVERSE EFFECTS WERE NOTICED OR REPORTED BY THE PATIENT BEFORE LEAVING THE PHARMACY.


VAERS ID: 1511272 (history)  
Form: Version 2.0  
Age: 32.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FA7484 / 2 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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Second dose given 13 days after first dose


VAERS ID: 1511275 (history)  
Form: Version 2.0  
Age: 33.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FA7484 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Anxiety, Dehydration, Electrocardiogram normal, Loss of consciousness, Nausea
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (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), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad), Dehydration (narrow)

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: none
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data: EKG by EMT''s Normal
CDC Split Type:

Write-up: Patient received the vaccination and was sitting in counseling room when he passed out. Called for Assistance 88 and 911 EMT. BP 100/60, EKG WNL; Patient states he had worked out, had protein drinks, was dehydrated and anxious about getting the vaccination. Recommended patient go to urgent care to get rehydrated and take care of nausea.


VAERS ID: 1511282 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Female  
Location: California  
Vaccinated:2021-07-27
Onset:2021-07-28
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FA7485 / 2 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Chills, Erythema, Headache, Injection site pruritus, Injection site warmth, Nausea, Pain, Rash
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? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies: Penicillins
Diagnostic Lab Data:
CDC Split Type:

Write-up: All day and night body aches, head ache, nausea, and chills. "Covid arm," with redness/rash, hardness, heat and itching at the injection site.


VAERS ID: 1511285 (history)  
Form: Version 2.0  
Age: 14.0  
Sex: Female  
Location: Arizona  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FA7484 / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Asthenia, Balance disorder, Dizziness, Dry mouth, Incontinence, Loss of consciousness, Pallor
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), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Tretinoin 0.025% gel
Current Illness: None
Preexisting Conditions: Acne
Allergies: None
Diagnostic Lab Data: BP 88/60, HR 66
CDC Split Type:

Write-up: Patient temporarily lost consciousness twice becoming incontinent after the second episode. Patient complained of lightheadedness, dry mouth and was pale throughout. EMT arrived and administered an IV ultimately transporting the patient to the hospital as they remained weak and unable to maintain balance.


VAERS ID: 1511290 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Female  
Location: Hawaii  
Vaccinated:2021-03-28
Onset:2021-07-28
   Days after vaccination:122
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001C21A / 1 - / -
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 003B21A / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Dry throat, Respiratory tract congestion, Rhinorrhoea, SARS-CoV-2 test positive
SMQs:, Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Infective pneumonia (broad), Dehydration (broad), Opportunistic infections (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: none
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data: covid test ordered on 7/28/21
CDC Split Type:

Write-up: Pt vaccinated on 3/28/21 and 4/25/21. Covid positive on 7/27/21. Runny nose, congestion, dry throat


VAERS ID: 1511852 (history)  
Form: Version 2.0  
Age: 15.0  
Sex: Female  
Location: Virginia  
Vaccinated:2021-07-27
Onset:2021-07-28
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Chest discomfort, Myocarditis, Tachycardia, Troponin increased
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad), Immune-mediated/autoimmune 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? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Strattera
Current Illness:
Preexisting Conditions:
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Tachycardia in the 170s, chest pressure, elevated troponin. Diagnosed with myocarditis.


VAERS ID: 1512188 (history)  
Form: Version 2.0  
Age: 24.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 059E21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Asthenia, Confusional state, Flushing, Hyperhidrosis
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypersensitivity (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: Confusion-Mild, Systemic: Flushed/Sweating-Mild, Systemic: Weakness-Mild. Additional Details: BP 110/62 Pulse Ox 90. Placed in rescue position and ambulance called. Patient is autistic and mother was with him. She stated he has anxiety.


VAERS ID: 1512190 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0198 / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Flushing, Hyperhidrosis, Syncope, 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), 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? 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: Dizziness / Lightheadness-Severe, Systemic: Fainting / Unresponsive-Severe, Systemic: Flushed / Sweating-Severe, Additional Details: Was walking around and started to get dizzy, and blacked out fell. He woke up and thought he hit his head and yelled for help. Called an ambulance and they took to the ER. No trouble breathing.


VAERS ID: 1512191 (history)  
Form: Version 2.0  
Age: 40.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 088D21A / 1 LA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Syncope, Unresponsive to stimuli
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), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Vestibular disorders (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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Systemic: Dizziness / Lightheadness-Severe, Systemic: Fainting / Unresponsive-Severe, Additional Details: Patient had an event of syncope after the injection and fainted in the chair. I assisted the patient to the ground and had them lie flat and elevated their legs using a chair. Patient regained consciousness and was responsive within 1 min. I checked BP and heart rate (BP was 124/82 and Pulse was 76 b/m). Per store Policy EMS was called by store LOD. EMS arrived and took patient to local hospital. Pts was responsive when they left pharmacy.


VAERS ID: 1512195 (history)  
Form: Version 2.0  
Age: 32.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EY0584 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Hyperventilation, Tremor
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Parkinson-like events (broad), Noninfectious encephalopathy/delirium (broad), Eosinophilic pneumonia (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: hemophlegic episode - per husband-Severe, Systemic: Hyperventilation-Medium, Systemic: Shakiness-Medium, Additional Details: pt get anxiety, have history on other vaccines, needs iv fluids and becomes normal - per pt husband, called 911, transferred to ER.


VAERS ID: 1512196 (history)  
Form: Version 2.0  
Age: 36.0  
Sex: Female  
Location: Rhode Island  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 059E21A / 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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Error: Wrong Vaccine Formulation (ex. different manufact. initial and booster)-


VAERS ID: 1512199 (history)  
Form: Version 2.0  
Age: 50.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 207A21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Condition aggravated, Dizziness, Nausea, Syncope, Unresponsive to stimuli, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic 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), 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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Systemic: Dizziness / Lightheadness-Medium, Systemic: Fainting / Unresponsive-Medium, Systemic: Nausea-Mild, Systemic: Vomiting-Mild, Additional Details: Pt previously had episodes of fainting after getting blood drawn in the past


VAERS ID: 1512200 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Male  
Location: New York  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FA7484 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Asthenia, Dizziness, Fatigue, Flushing, Hyperhidrosis, Hypotension, Lethargy, Syncope, Unresponsive to stimuli, Visual impairment
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Glaucoma (broad), Optic nerve disorders (broad), Cardiomyopathy (broad), Lens disorders (broad), Retinal disorders (broad), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (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: Dizziness / Lightheadness-Severe, Systemic: Exhaustion / Lethargy-Medium, Systemic: Fainting / Unresponsive-Mild, Systemic: Flushed / Sweating-Severe, Systemic: Hypotension-Medium, Systemic: Visual Changes/Disturbances-Severe, Systemic: Weakness-Severe, Additional Details: EMS arrived on scene, gave patient o2 and monitored vitals until stable


VAERS ID: 1512201 (history)  
Form: Version 2.0  
Age: 39.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0180 / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Nausea, Syncope, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (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)

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-Medium, Systemic: Nausea-Medium, Additional Details: 911 was called patient refused treatment.


VAERS ID: 1512202 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 054C21A / 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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Error: Booster Given Too Early-


VAERS ID: 1512206 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 054C21A / 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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Error: Booster Given Too Early-


VAERS ID: 1512209 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-04-07
Onset:2021-07-28
   Days after vaccination:112
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6208 / 1 LA / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH ER8737 / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19 pneumonia, Chronic obstructive pulmonary disease, Dyspnoea, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Infective pneumonia (narrow), Opportunistic infections (broad), COVID-19 (narrow)

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: The patient was seen on 7/28/21 in the ED for SOB and chest pain and tested positive for covid. The patient was discharged home from the ED and was not admitted. On 12/07/2020 the patient was admitted as an inpatient for pneumonia due to Covid 19 virus so this is the second positive covid for this patient. Also, the patient was an observation patient on med/surg between 6/24-6/26/2021 for COPD exacerbation. The patient was fully vaccinated at the time of his second infection.


VAERS ID: 1512361 (history)  
Form: Version 2.0  
Age: 40.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-02-02
Onset:2021-07-28
   Days after vaccination:176
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 AR / IM
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 2 AR / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, Chills, Fatigue, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (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 completed the Pfizer vaccination series (1st dose on 2/2/21 and 2nd dose on 2/28/21). Patient developed symptoms on 7/28/21 (chills and fatigue) and test positive for COVID-19 on the same day


VAERS ID: 1512364 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Female  
Location: Indiana  
Vaccinated:2021-07-27
Onset:2021-07-28
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Public       Purchased by: ?
Symptoms: Chills, Fatigue, Headache, Pain, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (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:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies: Bactrum, bee stings
Diagnostic Lab Data:
CDC Split Type:

Write-up: Chills, fever, fatigue, body aches, headache


VAERS ID: 1512365 (history)  
Form: Version 2.0  
Age: 44.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 054C21A / 2 RA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Chills, Headache, Pyrexia, Sleep disorder
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (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: Moderna 1st shot
Other Medications:
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: After receiving my 2nd shot my right arm hurt, I had severe headaches and last night (7/28/21) I was up all night due to severe chills. I had a fever of 101 that resolved this morning. I still have the headaches and arm pain.


VAERS ID: 1512378 (history)  
Form: Version 2.0  
Age: 50.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-07-26
Onset:2021-07-28
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006D21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Chest pain, Eye irritation, Eye pain, Lymphadenopathy, Swelling of eyelid
SMQs:, Anaphylactic reaction (broad), Angioedema (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Glaucoma (broad), Cardiomyopathy (broad), Corneal disorders (broad), Periorbital and eyelid disorders (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: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Chest pains, lymph node under arm, woke up with right eyelid swollen, irritated and in pain


VAERS ID: 1512380 (history)  
Form: Version 2.0  
Age: 34.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / 1 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Dizziness, Nausea, Pallor
SMQs:, Acute pancreatitis (broad), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (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: Very nausea, pale, low BP (70/50), almost fainting - gave him water, sprite, and ice packs on neck - recovered in about 10 minutes


VAERS ID: 1512391 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Pennsylvania  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007B21A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Dizziness, Pharyngeal swelling, Pruritus, Swelling face, Tinnitus
SMQs:, Anaphylactic reaction (narrow), Angioedema (narrow), Anticholinergic syndrome (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Hearing impairment (narrow), Vestibular disorders (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? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Armour thyroid 90mg
Current Illness: None
Preexisting Conditions: Fibromyalgia, hypothyroidism
Allergies: Blue dye
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: About 20 minutes after injection, felt like my face was swelling but didn''t appear to be. Ears ringing, dizziness ensued. Throat felt a little tight. Itching at armpits, crotch, belly but no hives. Itchiness went away but it''s now 24 hours after the injection and I''m still very dizzy with ringing ears.


VAERS ID: 1512398 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Female  
Location: New Hampshire  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Interchange of vaccine products
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: UNKNOWN
Current Illness: UNKNOWN
Preexisting Conditions: UNKNOWN
Allergies: DENIES ON SCREENER
Diagnostic Lab Data:
CDC Split Type:

Write-up: denied having another COVID vaccine prior to administering dose. When data entered into, she had received a Janssen Vaccine. She was not willing to share where or when she had received the Janssen, but did admit she had one.


VAERS ID: 1512408 (history)  
Form: Version 2.0  
Age: 31.0  
Sex: Female  
Location: Rhode Island  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 041A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Injection site pain, Pain
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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies: shellfish, apple, cherry, gluten, nuts, peach, plum, lidocaine, mepivacaine, almond
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient with history of allergies presented to retail pharmacy for COVID-19 vaccination. Within 3 minutes of receipt of vaccine patient reported injection site pain radiating to hand. Within 6 minutes of administration patient reported dizziness. Help called and patient brought to ED for evaluation and observation. Review of ED visit note shows no evidence of lip or tongue swelling and no respiratory distress. Upon evaluation and observation in ED, patient discharged.


VAERS ID: 1512413 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 201A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Immediate post-injection reaction, Loss of consciousness, Presyncope
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), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), 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: none
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data: none, examined by EMT
CDC Split Type:

Write-up: Pt had 2 episodes of vasovagal responses , pt passed out within 10 seconds of receiving vaccine, she recovered then passed out again 10 minutes later for a longer period, paramedics were called. BP was initially at 90/52 with a pulse of 58. A physician was on site and patient was not experiencing any symptoms of stroke or other issues


VAERS ID: 1512420 (history)  
Form: Version 2.0  
Age: 35.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FA6780 / 1 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Chest pain, Erythema, Pruritus
SMQs:, Anaphylactic reaction (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), 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:
Other Medications: NONE.
Current Illness: NONE
Preexisting Conditions: NONE
Allergies: NONE
Diagnostic Lab Data: None.
CDC Split Type:

Write-up: Pt. states on the way home his ears turned bright red and itching, hands, legs and face started itching. He did state that he had chest pain and contributed the chest pain to anxiety. Pt. called and advised Pt. to take Benadryl and if he get worst to contact the EMS and seek medical attention. Pt. did go home and took Benadryl for the itching. 07/29/2021 @ 0835: Telephone call to follow up with Pt. this morning he states that he is better, no shortness of breath. Pt. voice over the telephone was calm and speech is clear. Pt. states he is not planning to get his 2nd vaccine. Pt. advised to contact his medical provider for guidance for 2nd vaccine, Pt. agrees.


VAERS ID: 1512435 (history)  
Form: Version 2.0  
Age: 32.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN - / UNK RA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Extra dose administered, No adverse event
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 has no reported adverse reactions at this time. Pt. received the vaccine in May 2021, signed consent that he had not had it, and received it again on 7/28/21.


VAERS ID: 1512441 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: New York  
Vaccinated:2021-07-26
Onset:2021-07-28
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / -

Administered by: Private       Purchased by: ?
Symptoms: Asymptomatic COVID-19, Fall, SARS-CoV-2 test positive
SMQs:, Accidents and injuries (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (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: Atrial fibrillation, hypertension, s/p CVA, anemia, constipation
Allergies: Amlodipine
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was seen in the Emergency Department on 07/28/21 for frequent falls. He was swabbed for COVID-19 in anticipation for possible hospital admission. Pt tested positive for COVID-19. With no upper respiratory or GI symptoms. He did not want to stay in the hospital and was discharged home. Pt previously tested positive for COVID-19 on 05/07/21.


VAERS ID: 1512463 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-04-07
Onset:2021-07-28
   Days after vaccination:112
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 201A21A / UNK - / -

Administered by: Public       Purchased by: ?
Symptoms: Cough, Rhinorrhoea
SMQs:, Anaphylactic reaction (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 exhibiting runny nose and cough


VAERS ID: 1512483 (history)  
Form: Version 2.0  
Age: 50.0  
Sex: Male  
Location: Tennessee  
Vaccinated:2021-07-28
Onset:2021-07-28
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 006D21A / 2 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Inappropriate schedule of product administration, No adverse event
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: unknown
Preexisting Conditions: unknown
Allergies: nkda
Diagnostic Lab Data: n/a
CDC Split Type:

Write-up: Patient received 2nd dose of the Moderna vaccine 14 days after his 1st dose. Patient denies any adverse reactions.


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