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From the 1/14/2022 release of VAERS data:

Found 1,031,637 cases where Vaccine is COVID19 and Patient Did Not Die

Government Disclaimer on use of this data



Case Details (Reverse Sorted by Onset Date)

This is page 457 out of 10,317

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VAERS ID: 2029366 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:2021-11-24
Onset:2021-11-25
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2022-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 1F1012A / 1 - / OT

Administered by: Other       Purchased by: ?
Symptoms: Deafness
SMQs:, Hearing impairment (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: PRASUGREL; COAPROVEL; LIPOROSA; ASPIRINE PROTECT
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Blood pressure high; Hypertension arterial
Allergies:
Diagnostic Lab Data:
CDC Split Type: FRPFIZER INC202101879685

Write-up: Hearing loss; This is a spontaneous report received from a contactable reporter(s) (Consumer or other non HCP) from the Agency Regulatory Authority-WEB. The reporter is the patient. Regulatory number: FR-AFSSAPS-DJ20214499 Regulatory Authority. A 65 year-old male patient received bnt162b2 (COMIRNATY), intramuscular, administration date 24Nov2021 (Lot number: 1F1012A) as dose 1, single for covid-19 immunisation. Relevant medical history included: "Hypertension arterial" (unspecified if ongoing); "High blood pressure" (unspecified if ongoing). Concomitant medication(s) included: PRASUGREL; COAPROVEL; LIPOROSA; ASPIRINE PROTECT. The following information was reported: DEAFNESS (medically significant) with onset 25Nov2021, outcome "not recovered", described as "Hearing loss". Additional information: After received the vaccine Symptoms manifest on waking up without improvement during the day. Did not measure his blood pressure, no signs indicating hypertension surge. the vaccination, fairly intense pain in the right shoulder which lasted all night, but marked improvement upon waking up. No follow-up attempts are possible. No further information is expected.


VAERS ID: 2029383 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:2021-06-17
Onset:2021-11-25
   Days after vaccination:161
Submitted: 0000-00-00
Entered: 2022-01-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FC6984 / 1 LA / OT

Administered by: Other       Purchased by: ?
Symptoms: COVID-19, Drug ineffective, Dyspnoea, SARS-CoV-2 test
SMQs:, Anaphylactic reaction (broad), Lack of efficacy/effect (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), 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? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: COVID-19 (with hospitalization); Sleep apnoea syndromes (Paired sleep apnea syndrome)
Allergies:
Diagnostic Lab Data: Test Date: 20211125; Test Name: SARS-CoV-2 test; Test Result: Positive ; Comments: Variant search: unknown - result: unknown
CDC Split Type: FRPFIZER INC202200025455

Write-up: Dyspnoea; Vaccination failure; COVID-19; This is a spontaneous report received from a contactable reporter from the Regulatory Authority and product quality group. Regulatory number: FR-AFSSAPS-LY202113482. A 48 year-old male patient received bnt162b2, intramuscular, administered in arm left, administration date 17Jun2021 (Lot number: FC6984) as dose 1, 30ug single for covid-19 immunisation. The patient''s concomitant medications were not reported. The following information was reported: drug ineffective onset and COVID-19 both with onset 25Nov2021 and dyspnea with onset 30Nov2021 and all with outcome as recovering. On 30Nov2021, the patient is hospitalized with the onset of dyspnea. It was reported that rechallenge was done, outcome unknown. No follow-up attempts are possible. No further information is expected.


VAERS ID: 2029847 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-11-25
Onset:2021-11-25
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2022-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 3 - / -

Administered by: Other       Purchased by: ?
Symptoms: Arrhythmia, Immunisation, Interchange of vaccine products, Off label use
SMQs:, Cardiomyopathy (broad), Cardiac arrhythmia terms, nonspecific (narrow), 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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Prostatectomy
Allergies:
Diagnostic Lab Data:
CDC Split Type: GBPFIZER INC202101885715

Write-up: Off label use; Interchange of vaccine products; Booster; Arrhythmia; This is a spontaneous report received from a contactable reporter(s) (Consumer or other non HCP) from the regulatory authority (UK-MHRA). The reporter is the patient. Regulatory number: GB-MHRA-WEBCOVID-202112300950048830-HB0VT (MHRA). Other Case identifier(s): GB-MHRA-ADR 26414582 (MHRA). A 69 year-old male patient received bnt162b2 (COMIRNATY), administration date 25Nov2021 (Batch/Lot number: unknown) at the age of 69 years as dose 3 (booster), single for covid-19 immunisation. Relevant medical history included: "Prostatectomy", start date: 2013 (unspecified if ongoing). There were no concomitant medications. Not currently taking any medication. Had Prostatectomy in 2013 and currently under observation with a Consultant Oncologist. Patient has not had symptoms associated with COVID-19. Not had a COVID-19 test. Vaccination history included: Covid-19 vaccine astrazeneca (Dose 1), administration date: 18Feb2021, for COVID-19 immunization; Covid-19 vaccine astrazeneca (Dose 2), administration date: 21Apr2021, for COVID-19 immunization. The following information was reported: OFF LABEL USE (medically significant) with onset 25Nov2021, outcome "unknown", described as "Off label use"; INTERCHANGE OF VACCINE PRODUCTS (medically significant) with onset 25Nov2021, outcome "unknown", described as "Interchange of vaccine products"; IMMUNISATION (medically significant) with onset 25Nov2021, outcome "unknown", described as "Booster"; ARRHYTHMIA (medically significant) with onset 25Nov2021, outcome "recovered" (26Nov2021), described as "Arrhythmia". Clinical course: Following the Pfizer booster the patient experienced arrhythmia for a period of 24 hours non stop. This is the first and only time the patient had experienced arrhythmia for more than 3 or 4 seconds. Patient had no symptoms with the Astra Zeneca jabs. Patient has not tested positive for COVID-19 since having the vaccine. Patient is not enrolled in clinical trial. No follow-up attempts are possible; information about lot/batch number cannot be obtained. No further information is expected.


VAERS ID: 2030505 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:2021-11-25
Onset:2021-11-25
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2022-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 3 - / -

Administered by: Other       Purchased by: ?
Symptoms: Abdominal discomfort, Abdominal pain, Dizziness, Duodenal ulcer haemorrhage, Endoscopy upper gastrointestinal tract, Faeces discoloured, Flatulence, Gastric haemorrhage, Haematocrit, Immunisation, Pain, Presyncope
SMQs:, Acute pancreatitis (broad), Haemorrhage terms (excl laboratory terms) (narrow), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Gastrointestinal perforation, ulcer, haemorrhage, obstruction non-specific findings/procedures (broad), Gastrointestinal ulceration (narrow), Gastrointestinal haemorrhage (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (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? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: LEPUR
Current Illness: Smoker (5-6 cigarettes a day)
Preexisting Conditions: Medical History/Concurrent Conditions: Gastric bleeding; Gastric ulcer
Allergies:
Diagnostic Lab Data: Test Date: 202112; Test Name: gastroscopy; Result Unstructured Data: Test Result:duodenal ulcer bleeding; Comments: duodenal ulcer bleeding; Test Date: 20211210; Test Name: Hematocrit; Result Unstructured Data: Test Result:32; Test Date: 202112; Test Name: Hematocrit; Result Unstructured Data: Test Result:31; Comments: decreased
CDC Split Type: GRPFIZER INC202101879901

Write-up: Pain aggravated; Dizziness; Tendency to faint; Black stools; Gastric bleeding; BOOSTER; Gastrointestinal discomfort; Cramp abdominal; Flatulence; Duodenal ulcer bleeding; This is a spontaneous report received from a contactable reporter (Consumer, patient) from the Regulatory Authority-WEB. The reporter is the patient. Regulatory number: GR-GREOF-202110077 (RA). A 60 year-old male patient received bnt162b2 (COMIRNATY), administration date 25Nov2021 (Batch/Lot number: unknown) as dose 3 (booster), single for covid-19 immunisation. Relevant medical history included: "Smoker" (ongoing), notes: 5-6 cigarettes a day; "Gastric ulcer" (unspecified if ongoing); "Gastric bleeding", start date: 2001 (unspecified if ongoing). Concomitant medication(s) included: LEPUR. Vaccination history included: Covid-19 vaccine (Dose 1, Manufacturer : Unknown), for covid-19 immunization; Covid-19 vaccine (Dose 2, Manufacturer : Unknown), for covid-19 immunization. The following information was reported: IMMUNISATION (hospitalization, medically significant) with onset 25Nov2021, outcome "unknown", described as "BOOSTER"; GASTRIC HAEMORRHAGE (prolonged hospitalization) with onset 29Nov2021, outcome "recovered" (10Dec2021), described as "Gastric bleeding"; ABDOMINAL DISCOMFORT (hospitalization) with onset 2021, outcome "unknown", described as "Gastrointestinal discomfort"; ABDOMINAL PAIN (hospitalization) with onset 2021, outcome "unknown", described as "Cramp abdominal"; FLATULENCE (hospitalization) with onset 2021, outcome "unknown", described as "Flatulence"; PAIN (prolonged hospitalization) with onset 07Dec2021, outcome "unknown", described as "Pain aggravated"; DIZZINESS (prolonged hospitalization) with onset 07Dec2021, outcome "unknown", described as "Dizziness"; PRESYNCOPE (prolonged hospitalization, medically significant) with onset 07Dec2021, outcome "unknown", described as "Tendency to faint"; FAECES DISCOLOURED (prolonged hospitalization) with onset 07Dec2021, outcome "unknown", described as "Black stools"; DUODENAL ULCER HAEMORRHAGE (prolonged hospitalization) with onset 2021, outcome "recovered" (10Dec2021), described as "Duodenal ulcer bleeding". The patient was hospitalized for immunisation, abdominal discomfort, abdominal pain, flatulence (start date: 07Dec2021, discharge date: 10Dec2021, hospitalization duration: 3 day(s)); the patient prolonged hospitalization for gastric haemorrhage, pain, dizziness, presyncope, faeces discoloured, duodenal ulcer haemorrhage (start date: 07Dec2021, discharge date: 10Dec2021, hospitalization duration: 3 day(s)). The patient underwent the following laboratory tests and procedures: endoscopy upper gastrointestinal tract: (Dec2021) duodenal ulcer bleeding, notes: duodenal ulcer bleeding; haematocrit: (10Dec2021) 32; (Dec2021) 31, notes: decreased. Clinical course: Few days after vaccination with the third dose of the vaccine, patient started to have gastrointestinal discomfort (flatulence, cramps). On 06Dec2021 the symptoms worsened. On 07Dec2021, patient developed severe pains, dizziness, tendency to faint and black stools. Patient called an ambulance. At the hospital they did a gastroscopy and found a duodenal ulcer bleeding. Hematocrit dropped down to 31. Patient was administered Iron and the drug Nexium (intravenous). Patient was discharged on 10Dec2021 as it seems that the bleeding stopped/recovered since the hematocrit reached 32. No follow-up attempts are possible; information about lot/batch number cannot be obtained. No further information is expected.


VAERS ID: 2030575 (history)  
Form: Version 2.0  
Age:   
Sex: Female  
Location: Foreign  
Vaccinated:2021-11-25
Onset:2021-11-25
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2022-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 3 RA / OT

Administered by: Other       Purchased by: ?
Symptoms: Affective disorder, Cognitive disorder, Depression, Immunisation, Pain, Paranoia, Senile dementia
SMQs:, Dementia (narrow), Psychosis and psychotic disorders (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Hostility/aggression (broad), Depression (excl suicide and self injury) (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? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: TRITTICO; LAMICTAL; URSOBIL; URBASON SOLUB
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Crohn''s disease; Ulcerative colitis
Allergies:
Diagnostic Lab Data:
CDC Split Type: ITPFIZER INC202101879829

Write-up: Worsening of paranoia, worsening of pain, mild senile dementia, cognition, depression, mood, despite taking painkillers, and heavy psychiatric drugs; Worsening of paranoia, worsening of pain, mild senile dementia, cognition, depression, mood, despite taking painkillers, and heavy psychiatric drugs; Worsening of paranoia, worsening of pain, mild senile dementia, cognition, depression, mood, despite taking painkillers, and heavy psychiatric drugs; Worsening of paranoia, worsening of pain, mild senile dementia, cognition, depression, mood, despite taking painkillers, and heavy psychiatric drugs; Worsening of paranoia, worsening of pain, mild senile dementia, cognition, depression, mood, despite taking painkillers, and heavy psychiatric drugs; Worsening of paranoia, worsening of pain, mild senile dementia, cognition, depression, mood, despite taking painkillers, and heavy psychiatric drugs; booster; This is a spontaneous report received from a contactable reporter(s) (Consumer or other non HCP) from the regulatory authority-WEB. Regulatory number: IT-MINISAL02-824898. A 80 year-old female patient received bnt162b2 (COMIRNATY), intramuscular, administered in arm right, administration date 25Nov2021 (Batch/Lot number: unknown) as dose 3 (booster), single for covid-19 immunisation. Relevant medical history included: "Crohn''s disease" (unspecified if ongoing); "Ulcerative colitis" (unspecified if ongoing). Concomitant medication(s) included: TRITTICO; LAMICTAL; URSOBIL; URBASON SOLUB. Vaccination history included: Covid-19 vaccine (1st dose, manufacturer unknown), for covid-19 immunisation; Covid-19 vaccine (2nd dose, manufacturer unknown), for covid-19 immunisation. The following information was reported: IMMUNISATION (hospitalization) with onset 25Nov2021, outcome "unknown", described as "booster"; SENILE DEMENTIA (hospitalization, medically significant), PAIN (hospitalization), DEPRESSION (hospitalization), PARANOIA (hospitalization), AFFECTIVE DISORDER (hospitalization), COGNITIVE DISORDER (hospitalization) all with onset 01Dec2021, outcome "unknown" and all described as "Worsening of paranoia, worsening of pain, mild senile dementia, cognition, depression, mood, despite taking painkillers, and heavy psychiatric drugs". Therapeutic measures were taken as a result of pain, depression, paranoia, senile dementia, affective disorder, cognitive disorder which includes painkillers, and heavy psychiatric drugs. Reporter Comment: Crohn disease, ulcerative colitis The lot number for bnt162b2 was not provided and will be requested during follow up.; Reporter''s Comments: Crohn disease, ulcerative colitis


VAERS ID: 2032839 (history)  
Form: Version 2.0  
Age:   
Sex: Male  
Location: Foreign  
Vaccinated:2021-09-03
Onset:2021-11-25
   Days after vaccination:83
Submitted: 0000-00-00
Entered: 2022-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FF2834 / 2 LA / OT

Administered by: Other       Purchased by: ?
Symptoms: COVID-19, SARS-CoV-2 test, Vaccination failure
SMQs:, Lack of efficacy/effect (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? Yes, 15 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Arterial hypertension
Allergies:
Diagnostic Lab Data: Test Date: 20211125; Test Name: SARS-CoV-2 test; Test Result: Positive ; Comments: unknown variant search - unknown result
CDC Split Type: FRPFIZER INC202200025438

Write-up: Vaccination failure; Covid-19; This is a spontaneous report received from a contactable reporter(s) (Pharmacist) from the Regulatory Authority-WEB and product quality group. Regulatory number: FR-AFSSAPS-LY202113484. A 80 year-old male patient received bnt162b2 (COMIRNATY), intramuscular, administered in arm left, administration date 03Sep2021 (Lot number: FF2834) as dose 2, single and intramuscular, administered in arm left, administration date 13Aug2021 (Lot number: FE7051) as dose 1, single for covid-19 immunisation. Relevant medical history included: "Arterial hypertension" (unspecified if ongoing). The patient''s concomitant medications were not reported. The following information was reported: VACCINATION FAILURE (hospitalization, medically significant) with onset 25Nov2021, outcome "recovering", described as "Vaccination failure"; COVID-19 (hospitalization, medically significant) with onset 25Nov2021, outcome "recovering", described as "Covid-19". The patient was hospitalized for vaccination failure, covid-19 (start date: 25Nov2021, discharge date: 10Dec2021, hospitalization duration: 15 day(s)). The patient underwent the following laboratory tests and procedures: sars-cov-2 test: (25Nov2021) positive, notes: unknown variant search - unknown result. clinical course: The patient was admitted to hospital on the same day due to an altered general condition with loss of balance, asthenia and dizziness. in the process of recovery, return home on 10Dec2021. No follow-up attempts are possible. No further information is expected.


VAERS ID: 1896528 (history)  
Form: Version 2.0  
Age: 47.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-11-22
Onset:2021-11-24
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 067FZIA / 3 - / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Arthralgia, Fatigue, Headache, Pain, Pyrexia
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arthritis (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

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

Write-up: fever 103.5, extreme fatigue, headache, body ached, joint pain


VAERS ID: 1896547 (history)  
Form: Version 2.0  
Age: 34.0  
Sex: Male  
Location: North Carolina  
Vaccinated:2021-11-23
Onset:2021-11-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Abnormal dreams, Nightmare
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: N/A
Current Illness: N/A
Preexisting Conditions: HIV
Allergies: N/A
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Extremely vivid and graphic nightmares


VAERS ID: 1896967 (history)  
Form: Version 2.0  
Age: 24.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-11-23
Onset:2021-11-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FH8028 / 2 LA / IM

Administered by: Military       Purchased by: ?
Symptoms: Blood electrolytes normal, C-reactive protein increased, Chest pain, Dizziness, Electrocardiogram normal, Headache, Myocardial necrosis marker normal
SMQs:, Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Vestibular disorders (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? 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: Mildly elevated CRP (10.5--nml=7.5) ECG normal. Cardiac enzymes negative, electrolyes within normal limits. (11/24/2021)
CDC Split Type:

Write-up: Reported headache, chest pain and dizziness.


VAERS ID: 1896982 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-11-22
Onset:2021-11-24
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 3 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Balance disorder, Dizziness, Headache
SMQs:, Anticholinergic syndrome (broad), Guillain-Barre 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: Effexor, Atavan, wellbutrin, metformin, statin.
Current Illness: None.
Preexisting Conditions: Asthma, depression. Immunocompromised from cancer 2008
Allergies: Penicillin upsets my stomach, codeine makes me hyper.
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Woozy feeling, headache, unsteady.


VAERS ID: 1896987 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: Virginia  
Vaccinated:2021-11-22
Onset:2021-11-24
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 067F21A / 3 LA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Back pain, Fatigue, Gait disturbance, Incorrect dose administered, Injection site pain, Pain, Pain in extremity
SMQs:, Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Extravasation events (injections, infusions and implants) (broad), Tendinopathies and ligament disorders (broad), Medication errors (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: Bupropion 150 2 x daily, Lorazepam 1 mg 2 x daily adderall 20 mg 1 x daily, Misoprostaol 200 mcg, , Meloxicam 15 mg, lamatrogine 150 mg @ bedtime, Levothyroxine 100 mcg in AM
Current Illness: Spondylothesis, stenosis lumbar spine
Preexisting Conditions: Back
Allergies: Penecillin, Sulfa
Diagnostic Lab Data: none
CDC Split Type:

Write-up: First day 11-22 Sore arm at injection site second say 11-23 sore arm at injection site, Fatigue, achy, worse then first day third day *today. Woke up and hard to walk, severe ache pain in back and all right leg, * I think i got. a full dose instead of 1/2 dose booster


VAERS ID: 1897012 (history)  
Form: Version 2.0  
Age: 6.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-11-23
Onset:2021-11-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0186 / 1 LA / IM

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

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

Write-up: Patient was given 0.2ml of the adult formulation of the Pfizer adult formulation.


VAERS ID: 1897042 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1855194 / 1 LA / 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? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: UNKNOWN
Current Illness: UNKNOWN
Preexisting Conditions: UNKNOWN
Allergies: UNKNOWN
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: CLIENT STATED HE HAD NOT RECEIVED A COVID VACCINE & REQUESTED JANSSEN TODAY. AFTER ADMINISTERING VACCINE, WHEN ENTERING VACCINE DOSE GIVEN INTO database IT WAS FOUND THAT CLIENT HAD RECEIVED A MODERNA VACCINE AT ANOTHER FACILITY ON 6/16/2021.


VAERS ID: 1897068 (history)  
Form: Version 2.0  
Age: 62.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-11-23
Onset:2021-11-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 300308D / 3 - / -
VARZOS: ZOSTER (SHINGRIX) / GLAXOSMITHKLINE BIOLOGICALS 72P9H / 1 - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Chest pain, Myocarditis, Pain in extremity
SMQs:, Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (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? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient reported waking up at approximately 2:30 am with symptoms of "myocarditis" had chest pain and arm pain, patient spoke to physician office this morning and was told to go to emergency room, patient declined at time, reports feeling better this morning when spoke to spouse, advised that they should go to emergency room if symptoms persisted or got worse


VAERS ID: 1897083 (history)  
Form: Version 2.0  
Age: 40.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-11-04
Onset:2021-11-24
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FG3527 / 3 LA / -

Administered by: Private       Purchased by: ?
Symptoms: Ocular hyperaemia, Ocular hypertension, Ophthalmological examination, Visual field tests
SMQs:, Anaphylactic reaction (broad), Glaucoma (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? Yes
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: 1. COMPREHENSIVE EYE EXAMINATION 2. OCT 3. VISUAL FIELD TEST
CDC Split Type:

Write-up: ACUTE RED EYE OS WITH OCULAR HYPERTENSION OU. IOP OD 40, OS 28


VAERS ID: 1897101 (history)  
Form: Version 2.0  
Age: 52.0  
Sex: Female  
Location: New York  
Vaccinated:2021-11-17
Onset:2021-11-24
   Days after vaccination:7
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 9399909 / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Chills, Pyrexia, Rash
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (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:
Current Illness:
Preexisting Conditions:
Allergies: PCN
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Started with a fever of 102 degrees and chills after IMZ. After 72 hours she developed a rash on her torso in a band. She went to hospital to be seen and is continuing care.


VAERS ID: 1897110 (history)  
Form: Version 2.0  
Age: 17.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FF2590 / 3 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Extra dose administered, 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: unknown
Current Illness: unknown
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Pfizer booster given to 17 year old patient.


VAERS ID: 1897135 (history)  
Form: Version 2.0  
Age: 38.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-11-23
Onset:2021-11-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 3 LA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Chills, Dehydration, Headache, Palpitations, Pyrexia, Temperature intolerance
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (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: COVID-19 Pfizer Shots 1 and 2 - Chills, Fever, Headache, Fatigue
Other Medications: Levothyroxine, Escitalopram, Advair, Omeprazole, Wellbutrin
Current Illness:
Preexisting Conditions: Anxiety, Depression, Obesity, Acid Reflux, Barrett''s Esophagus
Allergies: Reglan, Demerol
Diagnostic Lab Data:
CDC Split Type:

Write-up: Chills, Fever/heat intolerance, Dehydration, Headache, Pounding heart/palpitations (shaking body)


VAERS ID: 1897153 (history)  
Form: Version 2.0  
Age: 10.0  
Sex: Female  
Location: South Carolina  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5127 / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? 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: Medical assistant administered 0.2 ml of undiluted dose. No immediate adverse reactions noted.


VAERS ID: 1897163 (history)  
Form: Version 2.0  
Age: 6.0  
Sex: Male  
Location: South Carolina  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5127 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Product preparation issue
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:
Current Illness:
Preexisting Conditions: sickle cell trait
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Medical assistant administered 0.2 ml undiluted dose to patient


VAERS ID: 1897213 (history)  
Form: Version 2.0  
Age: 58.0  
Sex: Female  
Location: New York  
Vaccinated:2021-11-23
Onset:2021-11-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031H21A / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Asthma, Condition aggravated, Cough, Wheezing
SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (narrow), Eosinophilic pneumonia (broad), Hypersensitivity (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: 2/17/21 Covid 2nd shot - fever, chills, aches, tiredness onset 24 hours after 2nd dose , lasted for 24 hours.
Other Medications: 5mg Lisinopril
Current Illness: none
Preexisting Conditions: none
Allergies: Papaya
Diagnostic Lab Data: none
CDC Split Type:

Write-up: Asthma attack while sleeping (wheezing, coughing). Responded to Benadryl. Have not had an asthma attack in over 20 years. Still having some wheezing next day. Called doctor for inhaler in case of emergency.


VAERS ID: 1897216 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FG3527 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Dysgeusia, Gaze palsy, Lymphadenopathy, Nausea, Neck pain
SMQs:, Acute pancreatitis (broad), Taste and smell disorders (narrow), Anticholinergic syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Vestibular disorders (broad), Ocular motility disorders (narrow), Arthritis (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? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ibuprofen
Current Illness: none
Preexisting Conditions: n/a
Allergies: all vaccines
Diagnostic Lab Data:
CDC Split Type:

Write-up: 15 mins after the patient had the vaccine she began to have metallic taste in her mouth, pain in left side of the neck with lymphnode swelling, and nausea. PT also began to have lightheadedness and nausea. Pt was asked to stay an additional 20 mins for observation. Pt denies sob or difficulty breathing. PT throat was not swollen. PT dizziness improved but she began to have a headache.


VAERS ID: 1897225 (history)  
Form: Version 2.0  
Age: 45.0  
Sex: Male  
Location: New York  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 80777-273-98-03 / 3 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Hypoaesthesia, Paraesthesia, Skin warm
SMQs:, Peripheral neuropathy (broad), Guillain-Barre 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: Allergy meds
Current Illness: None
Preexisting Conditions: Allergies
Allergies: Dust, pollen, grass
Diagnostic Lab Data: Examination by MD Right hand Grip strength maintained Negative Tinnel''s sign Maintained movement in all digits No discoloration / hand warm to touch
CDC Split Type:

Write-up: Gradual onset of numbness and tingling in the right hand while under observation Slight improvement upon leaving observation Recommended that individual see his primary physician for assessment


VAERS ID: 1897229 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-11-23
Onset:2021-11-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 065F21A / 3 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Diarrhoea, Myalgia, Nausea, Pyrexia
SMQs:, Rhabdomyolysis/myopathy (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Pseudomembranous colitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Eosinophilic pneumonia (broad), Noninfectious diarrhoea (narrow), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

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

Write-up: Severe nausea, diarrhea, muscle aches, fever $g101


VAERS ID: 1897238 (history)  
Form: Version 2.0  
Age: 23.0  
Sex: Male  
Location: Iowa  
Vaccinated:2021-11-23
Onset:2021-11-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 211D21A / 2 LA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Headache, Heart rate increased, Pain, Paraesthesia
SMQs:, Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (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: Duloxetine 90mg daily Guanfacine 2mg daily
Current Illness:
Preexisting Conditions: Major Depression General Anxiety Tinnitus
Allergies: Amoxicillin
Diagnostic Lab Data:
CDC Split Type:

Write-up: Tingling all over body, headache, increased heart rate, dizzy, pain all over body


VAERS ID: 1897266 (history)  
Form: Version 2.0  
Age: 19.0  
Sex: Female  
Location: Maryland  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 213D21A / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: fainting, feeling dizzy
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies: FAINTS AT SIGHT OF NEEDLES
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient fainted about ten minutes after vaccine administration.


VAERS ID: 1897287 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Maine  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FH8030 / 3 LA / IM

Administered by: Private       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 and wife were at vaccine clinic to receive both flu and covid vaccines. Nurse had four vaccine''s in front of her, two flu and two covid. When administering vaccine, patient accidently received two covid vaccines, instead of one covid and one flu. Patient is aware two pfizer covid vaccines were administered to him and will watch for symptoms.


VAERS ID: 1897291 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-11-23
Onset:2021-11-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 939903 / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Oropharyngeal discomfort, Respiratory rate increased
SMQs:, Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow)

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

Write-up: pt got vaccine at 12pm and woke up at 12am after sleeping on his stomach with liquid in throat and rapid breathing 2-3 times normal rate. lasted for 3 hours and then resolved without intervention.


VAERS ID: 1897323 (history)  
Form: Version 2.0  
Age: 17.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FJ1620 / 3 RA / IM

Administered by: Public       Purchased by: ?
Symptoms: Interchange of vaccine products, 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: None
CDC Split Type:

Write-up: Client had received Moderna primary series in January 20 21 and February 2021. At the time client was 16 years old. Client presented today for Moderna booster and it was identified the patient was not eligible for Moderna due to being under 18. However Pfizer is approved for under 18 Pfizer was administered as a booster and patient is still not eligible for a booster due to age under 18 .


VAERS ID: 1897338 (history)  
Form: Version 2.0  
Age: 9.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FG3257 / 1 LA / IM

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

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

Write-up: PATIENT WAS SUPPOSED TO GET THE PEDIATRIC DOSE WHICH WE DON''T CARRY AND ADULT DOSE WAS GIVEN. i MONITORED PATIENT AND SHE WAS OK. MOTHER SAID PATIENT WAS OK ALSO. SHE WILL GET HER SECOND SHOT AT A STORE WITH THE PEDIATRIC VACCINE. IT''S A COMPUTER GLITCH THAT ALLOWED HER TO BOOK AT OUR STORE. I WILL FOLLOW UP WITH PATIENT.


VAERS ID: 1897342 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-02-09
Onset:2021-11-24
   Days after vaccination:288
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 1 - / -
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6205 / 2 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Asymptomatic COVID-19, COVID-19, SARS-CoV-2 test positive, Vaccine breakthrough infection
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? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Fully vaccinated with COVID breakthrough infection. Asymptomatic COVID + while hospitalized for non COVID reason.


VAERS ID: 1897345 (history)  
Form: Version 2.0  
Age: 28.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FG3527 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Asthenia, 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), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypersensitivity (broad), Hypoglycaemia (broad)

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

Write-up: Systemic: Fainting / Unresponsive-Mild, Systemic: Flushed / Sweating-Mild, Systemic: Weakness-Mild, Additional Details: Stated she watched the nurse administer vaccine and said she passes out very easily with blood draws and other health issues. She was sitting and fainted, but didn''t fall to the floor as she had her boyfriend with her and he was able to hold her up. 911 was called. She came to, and was flushed. We gave her a bottle of water and sat her on the floor at her request. EMS arrived and took over care.


VAERS ID: 1897381 (history)  
Form: Version 2.0  
Age: 7.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5618 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Burning sensation, Pruritus
SMQs:, Anaphylactic reaction (broad), Peripheral neuropathy (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? 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: 11/24/21 BP 99/74 Important (BP Location: Left arm, Patient Position: Sitting) Pulse 84 Temp 36.6 �C (97.9 �F) (Tympanic) Resp 20 Ht 1.265 m Wt 30.3 kg SpO2 98% RA BMI 18.94 kg/m� BSA 1.03 m� Pain Sc 2
CDC Split Type:

Write-up: Patient is a 7 year old female. Presents to the clinic with her mother for Pfizer Vaccination #1. HPI Healthy female with no past medical history of chronic diseases, no known allergies complains of a burning sensation and itching in her Left upper arm approximately 12 minutes after obtaining Pfizer Covid Vaccination. Patient denies metallic taste in mouth, swelling of lips, face, tongue, respiratory distress, shortness of breath, wheezing,bronchospasam, stridor, headache, dizziness, flushing, vomiting, nausea, abdominal pain, urinary incontinence, itching eyes or nose, sneezing, clear watery eye Discharge, and nasal discharge. Patient''s mother denies vaccine reactions in the past.


VAERS ID: 1897394 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Virginia  
Vaccinated:2021-11-23
Onset:2021-11-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 3 LA / SYR

Administered by: Public       Purchased by: ?
Symptoms: Arthralgia, Back pain, Gait disturbance, Joint lock, Mobility decreased
SMQs:, Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Arthritis (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Same adverse reaction following the first two doses
Other Medications: Slo-Niacin,liquid vitamin supplements
Current Illness: None
Preexisting Conditions: Herniated discs
Allergies: Statin drugs,shellfish
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Severe back and hip pain.Back and hips lock up making it hard to bend over and walk.


VAERS ID: 1897419 (history)  
Form: Version 2.0  
Age: 5.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5618 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Eye movement disorder, Fall, Fatigue, Somnolence
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Ocular motility disorders (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: Triamcinolone 0.1% ointment.
Current Illness: No illnesses reported.
Preexisting Conditions: None.
Allergies: NKDA.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Was sitting in chair after the vaccine. 2-3 min after given pt fell to the floor from sitting position, mom opened door to alert us. Pt was awake and responsive, mom states that she did not think he passed out as when she knealed down he was looking at her. Pt stood up with help form mom and went and sat in chair again. Not pale, no increased RR. When asking pt how he felt he said good. Asked him if room was spinning and he said no. While asking him these his questions he kept closing his eyes or his eyes were rolling back. Lifted pt up onto exam table and had him lay down. He was responsive but did seem a little more tired. Asked him and he said he was a little sleepy. Asked him if he had felt that way before the vaccine and he said yes. Took BP and was on low side 89/58. Pt laid down and monitored in office for 40 min. Recheck BP 30 min after was- 97/62. Pt was fully responsive although quiet, said he was still sleepy. Informed mom for next vaccine he will need to lay down while getting it and remain laying down the whole 30 min.


VAERS ID: 1897431 (history)  
Form: Version 2.0  
Age: 5.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5618 / 1 RA / IM

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

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

Write-up: Patient moved arm during administration and received < half of the dose. Dose repeated in clinic same day.


VAERS ID: 1897464 (history)  
Form: Version 2.0  
Age: 11.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5127 / UNK LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Dizziness, Fatigue, Somnolence
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: C/O sleepiness, fatigue and lightheaded.


VAERS ID: 1897468 (history)  
Form: Version 2.0  
Age: 31.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 211D21A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Adverse reaction, Amnesia, Dizziness, Eye movement disorder, Feeling hot, Mental status changes
SMQs:, Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Vestibular disorders (broad), Ocular motility disorders (narrow)

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

Write-up: After administering the vaccine to the customer, he was advised to wait 15-20 minutes in the waiting area, which he did. I returned to the pharmacy and after a few minutes, another customer in the waiting area said the source individual was having a bad reaction. I immediately rushed over and say the patient reclined more than normal in his chair. There was a rack holding canes behind his chair which he had knocked over, presumably with his head. I approached the patient and his eyes were rolling all over (back and forth, left and right) for approximately ten seconds, during which time he was totally unaware of his surroundings. After approximately ten seconds, he mentally returned "to normal", for the first time noticed that I was standing there and asked "what happened?" I explained to him he was having an adverse reaction to the COVID shot. He said he felt lightheaded and extremely warm, so I advised him that we should take his sweatshirt off, which he did. We also gave him an ice pack to place on his forehead and a bottle of cold water to drink. He was completely coherent by this point and said he had no other symptoms. 911 was called upon my immediate entrance to the scene by the front end manager. I stayed with the patient until first responders came. Soon after, EMS arrived to evaluate the patient. I returned to the pharmacy at this point. After a few minutes, I returned to the waiting area and the patient along with EMS were gone. It is unknown if the patient received any medical treatment or if he was taken by EMS to the hospital.


VAERS ID: 1897491 (history)  
Form: Version 2.0  
Age: 43.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 330308D / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Immediate post-injection reaction, Interchange of vaccine products, Skin reaction
SMQs:, Hypersensitivity (narrow), Medication errors (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Localized reaction on the on the left arm. Sized reaction (~ 1 inch) immediately/instant following injection with Pfizer booster vaccine.
Current Illness: N/A
Preexisting Conditions: N/A
Allergies: N/A
Diagnostic Lab Data: Received J&J as the first dose
CDC Split Type:

Write-up: Localized reaction on the left arm immediately after injection. "Sized reaction immediately/instant following injection." The size was about ~1 inch in circular formation.


VAERS ID: 1897499 (history)  
Form: Version 2.0  
Age: 52.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-11-20
Onset:2021-11-24
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FH8030 / 3 LA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Vaccination complication
SMQs:

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: Charcot-Marie-Tooth
Allergies: Morphine
Diagnostic Lab Data:
CDC Split Type:

Write-up: Arthur?s Arm 4 days post injection


VAERS ID: 1897530 (history)  
Form: Version 2.0  
Age: 5.0  
Sex: Female  
Location: Iowa  
Vaccinated:2021-11-20
Onset:2021-11-24
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 LG / SYR
UNK: VACCINE NOT SPECIFIED (OTHER) / UNKNOWN MANUFACTURER - / N/A LG / SYR

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

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

Write-up: Given wrong Pfizer vaccine. Patient received 20 micrograms of adult (purple cap) Pfizer vaccine


VAERS ID: 1897531 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 071F21A / 2 LA / IM

Administered by: Work       Purchased by: ?
Symptoms: Abdominal pain upper
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: HYDROCORTISONE ALBUTEROL DIAZEPAM CYMBALTA PEPCID
Current Illness: ADRENAL INSUFFIENCY
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: UNKNOWN AT THIS TIME
CDC Split Type:

Write-up: PATIENT RECEIVED MODERNA VACCINE DOSE # 2 TO LEFT ARM AT 1:13PM, DIRECTED TO THE OBSERVATION AREA TO BE MONITORED FOR 15 MINUTES AND STARTED HAVING RIGHT UPPER QUADRANT ABD PAIN 10/10 AT 1:23. VITAL SIGNS OBTAINED, PATIENT WANTED TO GO TO URGENT CARE, PT TAKEN VIA WHEELCHAIR TO URGENT CARE.


VAERS ID: 1897550 (history)  
Form: Version 2.0  
Age: 55.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-11-23
Onset:2021-11-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013F21A / 3 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Palpitations, Vaccine positive rechallenge
SMQs:, Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (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: None
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient had 1 hour of heart palpitations in the middle of the night after receiving booster dose of Moderna. Had similar episodes that self resolved after 1st and 2nd doses as well. No further symptoms. Patient wanted to report it so it was documented.


VAERS ID: 1897551 (history)  
Form: Version 2.0  
Age: 41.0  
Sex: Female  
Location: California  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 033F21A / 1 LA / SYR

Administered by: Other       Purchased by: ?
Symptoms: Product storage 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: Error: Improper Storage (temperature)-


VAERS ID: 1897564 (history)  
Form: Version 2.0  
Age: 4.0  
Sex: Female  
Location: Connecticut  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5217 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None known
Preexisting Conditions: Sickle cell trait, history of wheezing, constipation
Allergies: Whole milk, Red Dye 2 & 40
Diagnostic Lab Data: None
CDC Split Type:

Write-up: 4 YR 7MO old given a COVID vaccine indicated for ages 5-11 years. Patient monitored for 20 minutes without side effects.


VAERS ID: 1897571 (history)  
Form: Version 2.0  
Age: 7.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5127 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Injection site pain, Vomiting
SMQs:, Acute pancreatitis (broad), Anticholinergic syndrome (broad), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Vestibular disorders (broad)

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

Write-up: Site: Pain at Injection Site-Mild, Systemic: Dizziness / Lightheadness-Mild, Additional Details: Patient received pediatric pfizer vaccine and had slight dizziness then recovered. Could not hold down water and threw up. 911 called and fire department showed up and examined patient to be fine. Father was present all this while with patient.


VAERS ID: 1897580 (history)  
Form: Version 2.0  
Age: 11.0  
Sex: Male  
Location: Maryland  
Vaccinated:2021-11-23
Onset:2021-11-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH KF5127 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Erythema, Urticaria
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: n/a
Preexisting Conditions: anxiety, depression, ADHD
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: RED HIVE/WELT ON RIGHT CHEEK


VAERS ID: 1897606 (history)  
Form: Version 2.0  
Age: 19.0  
Sex: Male  
Location: Michigan  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 211D21A / 2 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Fall, Nausea
SMQs:, Acute pancreatitis (broad), Anticholinergic syndrome (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), 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: n/a
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: PATIENT RECEIVED HIS FLU SHOT AND JANSSEN SHOT BOTH IN RIGHT ARM AND A FEW MINUTES LATER HE FELT DIZZY AND FELL TO THE GROUND BUT WAS STIL CONSCIOUS. WE RAISED HIS LEGS ON THE CHAIR TO HELP HIS BLOOD PRESSURE STABILIZE AND HE FELT BETTER.HE ALSO SAIDHE FELT NASUOUS, WE GAVE HIM WATER AND HE FELT BETTER. HE SAT DOWN FOR 15 MINUTES AND FELT BETTER AFTER.


VAERS ID: 1897612 (history)  
Form: Version 2.0  
Age: 19.0  
Sex: Male  
Location: Rhode Island  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FJ1611 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Blood pressure increased, Chills, Hyperhidrosis, Nausea, Nervousness, Tremor, Visual impairment
SMQs:, 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), Glaucoma (broad), Hypertension (narrow), Optic nerve disorders (broad), Lens disorders (broad), Retinal 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 on record
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: BP was taken 11/24/21 at 1:15pn, and was elevated.
CDC Split Type:

Write-up: Patient felt nervous and began to sweat, chills, visual disturbances, nausea and shaking. 911 was called and patient was evaluated on site. He began to feel better with no intervention.


VAERS ID: 1897613 (history)  
Form: Version 2.0  
Age: 53.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FC3181 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Lip swelling, Swollen tongue
SMQs:, Anaphylactic reaction (narrow), Angioedema (narrow), Oropharyngeal allergic conditions (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), 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: Lisinopril; B-12 shot monthly; iron; D3; possibly Advil
Current Illness: N/A
Preexisting Conditions: Psoriasis, Anemia and Arthitis
Allergies: N/A, just bad sinus on eg basis but when i was allergy tested the doctor did not find any
Diagnostic Lab Data: REPORTED TO MEIGERS PHARMACY SELF MEDICATED WITH BENADRYL
CDC Split Type:

Write-up: TONGUE AND LIPS SWELLED


VAERS ID: 1897615 (history)  
Form: Version 2.0  
Age: 12.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 023L21A / 1 RA / IM

Administered by: Military       Purchased by: ?
Symptoms: Interchange of vaccine products, 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: 12 year old patient mistakenly received Moderna COVID-19 vaccine instead of Pfizer BioNTech.


VAERS ID: 1897620 (history)  
Form: Version 2.0  
Age: 12.0  
Sex: Male  
Location: New York  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5618 / 1 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? 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 is 12 years old but received pediatric dose. No issues at time of administration or during 15 minute observation period. Mother notified after they left the facility. Patient will receive adult dose for second dose in series.


VAERS ID: 1897670 (history)  
Form: Version 2.0  
Age: 56.0  
Sex: Male  
Location: California  
Vaccinated:2021-11-23
Onset:2021-11-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027H218 / UNK - / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Fatigue, Headache, Injection site 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? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: None.
CDC Split Type:

Write-up: Mild soreness at injection site-started after injection. Mild headache-started day after injection. Mild tiredness-started day after injection.


VAERS ID: 1897674 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Male  
Location: Massachusetts  
Vaccinated:2021-11-23
Onset:2021-11-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 3 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Electric shock sensation
SMQs:, Peripheral neuropathy (broad), Guillain-Barre 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: very similar onset after dose 2 (not dose 1) of initial Pfizer COVID19 series (experienced on 18 May 2021).
Other Medications: largely ketotic diet, though slightly with more protein/sugar/starch than usual today, to anticipate translation & cell renewal needs magnesium citrate, potassium citrate
Current Illness: none
Preexisting Conditions: well lifestyle- and diet-controlled tendency toward high total & LDL cholesterol
Allergies: codeine, phenylpropanolamine
Diagnostic Lab Data: none
CDC Split Type:

Write-up: brain zaps (internal sensation of small shocks in head) began ~18-20h after my Moderna booster, just as they began ~18-20h after dose 2 in my original series (Pfizer). In dose 2 case, brain zaps subsided within ~6h. Waiting for same here. Intriguingly, this symptom is one that I had rarely if ever experienced since getting it often when quitting wellbutrin ~17-20 years ago.


VAERS ID: 1897677 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Male  
Location: Missouri  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FF2593 / 4 LA / IM

Administered by: Work       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 now, received 4 COVID vaccines, MODERNA lot 025J20-2A 12/31/2020, MODERNA LOT 030L20A 1/27/2021, MODERNA 10/29/2021 LOT 939905, AND PFIZER FH8030 Patient failed to inform provider of complete vaccination history, 4th dose given. As of 11/24/2021 no adverse events have been reported.


VAERS ID: 1897699 (history)  
Form: Version 2.0  
Age: 40.0  
Sex: Female  
Location: Tennessee  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027H21B / N/A LA / IM

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

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None reported
Current Illness: None reported
Preexisting Conditions: None report
Allergies: None reported
Diagnostic Lab Data: Normal heart rate, respiratory rate, and blood pressure. Normal vital signs.
CDC Split Type:

Write-up: Patient reported pre syncope episode.


VAERS ID: 1897716 (history)  
Form: Version 2.0  
Age: 12.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-11-23
Onset:2021-11-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FH8020 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Muscle spasms, Neck pain
SMQs:, Dystonia (broad), Arthritis (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: Right neck muscle spasm, occurred when in class at school and turned around, then felt acute neck pain. Treated with heat, cervical collar, and low dose diazepam. Seen within hours after spasm first started.


VAERS ID: 1897726 (history)  
Form: Version 2.0  
Age: 32.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-03-01
Onset:2021-11-24
   Days after vaccination:268
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 1801518 / 1 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? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: covid 19 positive on 11/24/21
CDC Split Type:

Write-up: Patient had positive break through covid 19 test on


VAERS ID: 1897740 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 067F21A / 3 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: No adverse event
SMQs:

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

Write-up: 1st dose 05/14/21, 2nd dose 6/11/21. No symptoms alert, awake coherent.


VAERS ID: 1897749 (history)  
Form: Version 2.0  
Age: 17.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 051F21A / 3 RA / 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 mother requested a Moderna Vaccine booster for her teenagers when she was receiving her Moderna booster. She filled out the consent forms and the teenagers were incorrectly admininistered a Moderna booster (dose 0.25ml). She showed the immunizer a copy of the teenager''s vaccine card for the previous Covid vaccine doses. The other teenager (age 14). A separate VAERS form has been for. The boosters were administered outside of guidance for age and for the booster.


VAERS ID: 1897778 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 034F21A / 4 LA / IM

Administered by: Private       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: NA
Current Illness: NA
Preexisting Conditions: NA
Allergies: NA
Diagnostic Lab Data: None, no reaction present.
CDC Split Type:

Write-up: No reaction from patient, the patient received a Moderna Booster dose from us on 11/24/2021. However the patient had his third dose of Pfizer on 11/18/2021.


VAERS ID: 1897780 (history)  
Form: Version 2.0  
Age: 26.0  
Sex: Male  
Location: Mississippi  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FJ1620 / 1 LA / IM
FLUC4: INFLUENZA (SEASONAL) (FLUCELVAX QUADRIVALENT) / SEQIRUS, INC. 308451 / N/A RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: 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), 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 that i am aware of
Current Illness: none that i am aware of
Preexisting Conditions: none that i am aware of
Allergies: none that i am aware of
Diagnostic Lab Data: none that i am aware of
CDC Split Type:

Write-up: patient was administered both shots by pharmacy technician. He seemed fine and walked out to the waiting area for his wait time. He passed out but remained in his chair briefly about ten minutes later. EMTs came and checked him out, he seemed fine and his parents picked him up.


VAERS ID: 1897782 (history)  
Form: Version 2.0  
Age: 29.0  
Sex: Male  
Location: California  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 018F21A / 3 RA / SYR

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

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: Just switched diets per patient report
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: BP was 124/78 after patient recovered. All other vitals were within normal limits as well. He was kept at clinic location for 45 mins and ambulated without any recurrent symptoms prior to departure
CDC Split Type:

Write-up: Patient experienced vasovagal syncope about 1 minute after vaccination. Was unconscious for about 5 seconds then regained consciousness. He admitted to changing his diet recently but no new medications or personal history of syncope. States his father does have a history of syncope after vaccinations.


VAERS ID: 1897790 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-11-23
Onset:2021-11-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 05F21A / 3 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Injection site pain, Peripheral swelling
SMQs:, Cardiac failure (broad), Angioedema (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (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: Swollen hand began 5am after injection, was improving by 11:45am. Advised patient that improvement should continue, if it does not to contact us. No redness, fever. Pain in arm at injection site


VAERS ID: 1897794 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 065F21A / 3 LA / IM

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

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

Write-up: OUTSIDE OF GUIDELINESS THIRD PARTY STAFF ADMINISTERED FULL DOSE (0.5ML) OF MODERNA VACCINE INSTEAD OF BOOSTER DOSE (0.25ML)


VAERS ID: 1897804 (history)  
Form: Version 2.0  
Age: 16.0  
Sex: Female  
Location: New Jersey  
Vaccinated:2021-11-23
Onset:2021-11-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0191 / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Vaccine positive rechallenge
SMQs:

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: Patient had itchy eyes after dose 1 COVID-19 vaccine.
Other Medications: None
Current Illness: Pilonidal cyst
Preexisting Conditions: Pilonidal cyst
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient developed angioedema after both dose one and dose 2. More pronounced with itchy swollen eyes; improved with Benadryl.


VAERS ID: 1897809 (history)  
Form: Version 2.0  
Age: 26.0  
Sex: Female  
Location: Wyoming  
Vaccinated:2021-11-22
Onset:2021-11-24
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 3 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Urticaria, Vaccination site pruritus, Vaccination site reaction
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? 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:
CDC Split Type:

Write-up: 1.5 diameter puritic welt at vaccine site


VAERS ID: 1897812 (history)  
Form: Version 2.0  
Age: 19.0  
Sex: Male  
Location: Unknown  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0217 / 3 LA / IM

Administered by: Unknown       Purchased by: ?
Symptoms: Cold sweat, Dizziness, Pallor, Paraesthesia, Visual impairment
SMQs:, Peripheral neuropathy (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Glaucoma (broad), Optic nerve disorders (broad), Lens disorders (broad), Retinal disorders (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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: After administering flu and Pfizer vaccine at around 1205, noticed that patient was not getting up to leave. He stated he was dizzy and his vision was getting dark. He also felt clammy and pale. Asked if he had eaten anything today and he said no. Checked and O2 sat was 99% at 10L, HR 90, BP 98/77 L arm sitting. He also stated fingers on both hands were a little tingly. Gave juice to drink. After several minutes, Patient stated he was doing good and was able to stand up and walk with assistance to the cot and stayed there for further assessment and observation. Girlfriend was with patient at the time of incident. Patient ambulated to the observation cot with assistance, oxygen had been removed. He was instructed to lay down with his feet up on a box. 12:15 his vitals while laying down were 112/68, 83 HR, 97%02 on Room Air. 12:18 Patient was instructed to sit on the side of the cot. He was given crackers to eat. 12:19 vitals while sitting were 120/82, 75 HR, 98% 02 on Room Air 12:25 75 HR 98% 02 on Room Air 12:30 Patient instructed to stand beside the cot vitals were 122/80, 84 HR, 98% Patient was instructed to sit in a chair. He ambulated to the chair without assistance. He remained stable and stated he was feeling much better. He requested to leave at 12:40p and he left with his girlfriend without assistance.


VAERS ID: 1897822 (history)  
Form: Version 2.0  
Age: 71.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 065F21A / 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:
Current Illness:
Preexisting Conditions: HEART CONDITION, DIABETES
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: OUTSIDE OF GUIDELINESS THIRD PARTY STAFF ADMINISTERED FULL DOSE DOSE (0.5ML) OF MODERNA VACCINE INSTEAD OF BOOSTER DOSE (0.25ML)


VAERS ID: 1897833 (history)  
Form: Version 2.0  
Age: 44.0  
Sex: Female  
Location: Minnesota  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039D21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Flushing, Hyperhidrosis, Pharyngeal swelling, Swollen tongue
SMQs:, Anaphylactic reaction (narrow), Angioedema (narrow), Neuroleptic malignant syndrome (broad), Oropharyngeal allergic conditions (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), 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: Flowers, mango, nuts, Penicillins, sunflower oil, tea tree oil
Diagnostic Lab Data: Not applicable
CDC Split Type:

Write-up: Pt received first dose of Moderna 0.5ml. 15 minutes post injection pt c/o feeling sweaty and skin was flushed. 30 minutes post injection pt c/o tongue and throat swelling. Epi-pen was immediately administered (0.3mg) was administered to left thigh. 911 was called per protocol and albuterol (2.5mg/3ml) nebulizer was administered per protocol. EMS arrived 5 minutes after being called and pt was transported to ED. Pt symptoms were resolving upon departure.


VAERS ID: 1897835 (history)  
Form: Version 2.0  
Age: 14.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-11-23
Onset:2021-11-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5127 / 1 LA / IM

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

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

Write-up: Patient received a pediatric Pfizer dose instead of an adult dose of Pfizer for his first dose received. This was an oversight completely as vaccine was appropriately diluted and administered per practice of a double check.


VAERS ID: 1897844 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 065F21A / 3 RA / IM

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

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

Write-up: OUTSIDE OF GUIDELINESS THIRD PARTY STAFF ADMINISTERED FULL DOSE (0.5ML) OF MODERNA VACCINE INSTEAD OF BOOSTER DOSE (0.25ML)


VAERS ID: 1897852 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Female  
Location: New York  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FH8030 / 3 RA / IM

Administered by: Pharmacy       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? 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 recieved moderna . Patient accidently received pfizer booser. Patient was informed and is it ok with it


VAERS ID: 1897861 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Male  
Location: New York  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FH8030 / UNK - / -

Administered by: Pharmacy       Purchased by: ?
Symptoms: Interchange of vaccine products
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: Patient received 1-2 doses of moderna. Patient wanted moderna booster. However, recieved pfizer by mistake.. Patient was informed and is ok with it


VAERS ID: 1897863 (history)  
Form: Version 2.0  
Age: 81.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031H21A / 3 LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031H21A / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Lip swelling, Swollen tongue
SMQs:, Anaphylactic reaction (narrow), Angioedema (narrow), Oropharyngeal allergic conditions (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), 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: unknown
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: nifedipine, codeine, demerol, nembutal, crab mea,
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient made appointment to receive the COVID moderna booster vaccination. Patient consented to vaccine and notified staff that she has had previous reactions to vaccinations, doctor recommended she still should receive this shot. Patient was informed to remain in pharmacy for 30 minutes for observation. About 10 minutes into the observation period patient disclosed to staff she was experiencing lip/tongue swelling. Pharmacy staff asked patient if she wanted benadryl but patient said she was not comfortable swallowing pills and wanted to have EMS assistance. EMS came on scene and ended up giving the patient the Benadryl tablets. The patient and EMS remained in pharmacy until patient''s son was able to get to her.


VAERS ID: 1897868 (history)  
Form: Version 2.0  
Age: 21.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-11-04
Onset:2021-11-24
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 939905 / 3 LA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Asthma, Blood urine present, Computerised tomogram, Condition aggravated, Cough, Influenza like illness, Nephrolithiasis, Pain, Urinary tract infection, Urine analysis abnormal, White blood cell count increased
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (narrow), Neuroleptic malignant syndrome (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Symbicort, Flonase, Zyrtec, Singulair
Current Illness: Chest cold
Preexisting Conditions: Asthma
Allergies: None
Diagnostic Lab Data: Blood work (high white blood cell count), urine sample (blood and bacteria in sample), CT scan
CDC Split Type:

Write-up: Developed flu-like symptoms and asthma got worse after booster. Cough did not go away, went to doctor and prescribed prednisone and have been taking cough medicine for past three weeks. Earlier today woke up in immense pain. Diagnosed with a Kidney stone, a Left ureteral stone, and a UTI.


VAERS ID: 1897876 (history)  
Form: Version 2.0  
Age: 69.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 065F21A / 3 LA / IM

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

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

Write-up: OUTSIDE OF GUIDELINESS THIRD PARTY STAFF ADMINISTERED FULL DOSE (0.5ML) OF MODERNA VACCINE INSTEAD OF BOOSTER DOSE (0.25ML)


VAERS ID: 1897889 (history)  
Form: Version 2.0  
Age: 12.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FJ8762 / 2 LA / IM

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

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

Write-up: Patient (Guardian) received text to come in for second dose today. appointment was initially for December 1, 2021. Patient received 2nd dose of covid vaccine 1 week too soon. The Nurse and Registration clerk both stated that the date on the card looked like it said 11/1/2021 as oppose to 11/10/2021 which is when they were actually vaccinated. Patient was informed that they would need to get another dose in 21 days to complete the series


VAERS ID: 1897900 (history)  
Form: Version 2.0  
Age: 79.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 065F21A / 3 LA / IM

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

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

Write-up: OUTSIDE OF GUIDELINESS THIRD PARTY STAFF ADMINISTERED FULL DOSE(0.5ML) OF MODERNA VACCINE INSTEAD OF BOOSTER DOSE (0.25ML)


VAERS ID: 1897901 (history)  
Form: Version 2.0  
Age: 7.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5127 / 2 LA / IM

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

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? 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 (Guardian) received text to come in for second dose today. appointment was initially for December 1, 2021. Patient received 2nd dose of covid vaccine 1 week too soon. The Nurse and Registration clerk both stated that the date on the card looked like it said 11/1/2021 as oppose to 11/10/2021 which is when they were actually vaccinated. Patient was informed that they would need to get another dose in 21 days to complete the series


VAERS ID: 1897903 (history)  
Form: Version 2.0  
Age: 17.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-11-23
Onset:2021-11-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5127 / 1 LA / IM

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

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

Write-up: Patient was given Pediatric vaccine instead of Adolescent/Adult vaccine. No adverse outcome


VAERS ID: 1897904 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Alabama  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 939909 / 3 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: none known
Current Illness: none known
Preexisting Conditions: none known
Allergies: none known
Diagnostic Lab Data: none
CDC Split Type:

Write-up: patient became dizzy after vaccine. she stayed dizzy for about an hour and then her daughter came to pick her up


VAERS ID: 1897908 (history)  
Form: Version 2.0  
Age: 35.0  
Sex: Female  
Location: D.C.  
Vaccinated:2021-11-22
Onset:2021-11-24
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FJ1620 / 3 LA / SYR

Administered by: Military       Purchased by: ?
Symptoms: Rash, Urticaria
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:
Current Illness: Step throat and sinus infection
Preexisting Conditions:
Allergies: Sulfa
Diagnostic Lab Data:
CDC Split Type:

Write-up: Rash/hives on chest


VAERS ID: 1897909 (history)  
Form: Version 2.0  
Age: 5.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5127 / 1 LA / IM
FLU4: INFLUENZA (SEASONAL) (FLULAVAL QUADRIVALENT) / GLAXOSMITHKLINE BIOLOGICALS - / N/A RA / IM

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

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: Parents stated he had an upset stomach in the last 24 hours. They told us this after he had and emesis.
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: O2 SATS WERE 97-100% AND HIS PULSE WAS 115
CDC Split Type:

Write-up: PATIENT HAD AN EMESIS SHORTLY AFTER RECEIVING THE COVID AND FLU VACCINES ON OPPOSITE ARMS. HE SAID HE FELT TIRED AND COLD


VAERS ID: 1897915 (history)  
Form: Version 2.0  
Age: 13.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-11-23
Onset:2021-11-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5127 / 1 LA / IM

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

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

Write-up: Pt received the Pediatric vaccine instead of Adolescent/Adult vaccine


VAERS ID: 1897916 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 065F21A / 3 LA / IM

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

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

Write-up: OUTSIDE OF GUIDELINESS THIRD PARTY STAFF ADMINISTERED FULL DOSE (0.5ML) OF MODERNA VACCINE INSTEAD OF BOOSTER DOSE (0.25ML)


VAERS ID: 1897918 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: Wisconsin  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FH8020 / 5 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Feeling hot, Musculoskeletal stiffness, Pallor, Syncope, Thirst
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dystonia (broad), Parkinson-like events (broad), Noninfectious encephalitis (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Arthritis (broad), Hypoglycaemia (broad), Dehydration (broad)

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

Write-up: We had an incident of Post Vaccination Syncope at store 4677. I gave an elderly lady her Pfizer Booster shot and asked her to wait in the post vaccination benches. Since she got the shot at 1:30 pm (the pharmacy closed at lunch) I told the patient I will be keeping an eye on how she is doing even though the doors are closed . When i went outside to see how the patient is doing her grandson who is a nurse told me that the patient is feeling warm and thirsty. When I looked at the patient she looked very Pale and stiff. She wasn''t comprehending very well when I asked her how she is doing. With the help of her grandson, we made the patient lie down on the benches and elevated her feet. Code white was alerted and I gave patient Cold Compress on her forehead and around the neck area. Shortly after doing cold compress patient started talking and she stated she is feeling better. We gave her some water and she waited in the pharmacy for about half an hour. Patient was very happy with the care she got throughout the episode and was very thankful!!


VAERS ID: 1897919 (history)  
Form: Version 2.0  
Age: 38.0  
Sex: Female  
Location: Nevada  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039F21A / 3 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: UNKNOWN
Current Illness: UNKNOWN
Preexisting Conditions: UNKNOWN
Allergies: NKDA (PER CONSENT FORM)
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient made an appointment for a COVID vaccine booster (she received Moderna as her primary series). Upon checking in at the pharmacy, Technician , asked the patient if she wanted the Moderna as the booster and patient confirmed. Her vaccine was processed as the Moderna booster and the nurse gave her the vaccine. Afterwards, the patient sees that we signed off on her vaccine card for the Moderna booster and claims that she was supposed to receive the Pfizer booster, as she made an appointment for the Pfizer booster (per her doctor''s recommendation). We do not assume that what the patient selects online for their vaccine is what they want. We always ask at the pharmacy to make sure we give the correct vaccine.


VAERS ID: 1897922 (history)  
Form: Version 2.0  
Age: 36.0  
Sex: Female  
Location: California  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FJ8762 / 3 LA / IM

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: N/A
Current Illness: N/A
Preexisting Conditions: N/A
Allergies: N/A
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient passed out after vaccination and states that she felt dizzy. Emergency services were called patient did not want to go the hospital. Patient was given an ice pack to apply


VAERS ID: 1897924 (history)  
Form: Version 2.0  
Age: 7.0  
Sex: Male  
Location: Minnesota  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FJ8757 / 1 RA / IM

Administered by: Private       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: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: 7 year old male was inadvertently given 0.2mL of the Pfizer 12+ serum instead of the 5-11 serum. No adverse side effects noted same day.


VAERS ID: 1897925 (history)  
Form: Version 2.0  
Age: 7.0  
Sex: Male  
Location: New Mexico  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5127 / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Neck pain, Vomiting
SMQs:, Acute pancreatitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Arthritis (broad)

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

Write-up: PATIENT HAD PFIZER KIDS 5-11 DOSE 1 AT 11:30 11/24/2021. PATIENT''S GUARDIAN CALLED ABOUT 14:30 TO REPORT THAT PATIENT HAD JUST VOMITED FOR NO APPARENT REASON. PATIENT WAS ALSO COMPLAINING OF NECK PAIN OF UNKNOWN ORIGIN. I SPOKE WITH THE GUARDIAN FOR ABOUT 5-7 MINUTES, BY THE END OF WHICH, THE MINOR PATIENT HAD REPORTED THAT HIS S/SX WERE GONE AND THAT HE FELT FINE.


VAERS ID: 1897929 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-11-22
Onset:2021-11-24
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 018F21A / 3 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Rash, Scratch
SMQs:, Anaphylactic reaction (broad), Accidents and injuries (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: Heliocare with Nicotinamide (B3)
Current Illness: N/A
Preexisting Conditions: no
Allergies: Erthromycin
Diagnostic Lab Data:
CDC Split Type:

Write-up: I noticed the day after my moderna booster shot which was on my left upper arm that I had a little scratch on my upper left chest. The following morning I had a rash on my left breast. Both of spots I noticed in the morning.


VAERS ID: 1897931 (history)  
Form: Version 2.0  
Age: 54.0  
Sex: Female  
Location: Illinois  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 034F21A / 3 LA / IM

Administered by: Other       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: the first 2 doses
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: The Pt started she felt dizzy about 10 minutes after receiving the Moderna Booster Vaccine. Pt was taken into the room to lie down. Pt told us she already felt a little bit dizzy before receiving the vaccine and that she felt the same reaction with her first 2 doses. Pt also said that the medication she takes for the attacks makes her dizzy. Vitals were taken at 11:35 am 131/82 Pulse:64 The patient received water; she drinks like 6 Oz of water. She was checked by Md at 11: 40 am. She asked the Pt what symptoms she had, check the numbers on virials. and check the lungs. The provider recommended that she wait another 15minutes and she can leave this if she feels better and was no longer dizzy. The provider came back at 11:58 am to check the Pt, she says she feels better, she was able to get up on her own and was checked by the provider before leaving. Advised her call to clinic id dizziness returned or call all if trouble breathing/ symptom worsens. we took the vitals 125/82 and pulse 55 pulses the Pt left at 12:02 Pm.


VAERS ID: 1897932 (history)  
Form: Version 2.0  
Age: 44.0  
Sex: Male  
Location: Oregon  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0198 / 3 UN / IM

Administered by: Work       Purchased by: ?
Symptoms: Dizziness, Syncope, Tremor
SMQs:, Torsade de pointes/QT prolongation (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Parkinson-like events (broad), Noninfectious encephalopathy/delirium (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: N/A
Current Illness: N/A
Preexisting Conditions: N/A
Allergies: N/A
Diagnostic Lab Data:
CDC Split Type:

Write-up: Pt received his booster shot and went to observation area to be monitored for 15 minutes. While sitting pt stated he became dizzy and felt lightheaded. Pt was told he could be taken to private room for closer monitoring. While pt was walking to room he fainted and started shaking slightly, closely resembled seizure activity for a few seconds. Pt was lifted by crews and taken into private room and assessed. Fire Department was called and pt was transported to hospital by fire department.


VAERS ID: 1897933 (history)  
Form: Version 2.0  
Age: 46.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 065F21A / 3 LA / IM

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

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

Write-up: OUTSIDE OF GUIDELINESS THIRD PARTY STAFF ADMINISTERED FULL DOSE (0.5ML) OF MODERNA VACCINE INSTEAD OF BOOSTER DOSE (0.25ML)


VAERS ID: 1897936 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: Washington  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 065F21A / 3 LA / SYR

Administered by: Other       Purchased by: ?
Symptoms: Aphthous ulcer, Arthralgia, Back pain, Blepharospasm, Chills, Cough, Dizziness, Dry eye, Eye disorder, Fatigue, Feeling abnormal, Injection site pain, Injection site swelling, Lymphadenopathy, Muscle twitching, Nasal discomfort, Nausea, Oral herpes, Oropharyngeal pain, Pain, Product administered at inappropriate site, Rhinorrhoea, Swelling, Upper-airway cough syndrome, Vision blurred
SMQs:, Anaphylactic reaction (narrow), Acute pancreatitis (broad), Angioedema (broad), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Dyskinesia (broad), Dystonia (broad), Drug abuse and dependence (broad), Oropharyngeal infections (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Haemodynamic oedema, effusions and fluid overload (narrow), Glaucoma (broad), Lens disorders (broad), Corneal disorders (broad), Retinal disorders (broad), Vestibular disorders (broad), Conjunctival disorders (narrow), Lacrimal disorders (narrow), Periorbital and eyelid disorders (narrow), Ocular motility disorders (narrow), Arthritis (broad), Medication errors (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Dehydration (broad), Opportunistic infections (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: Covid 19 Moderna 008B21A 3/30/2021 67
Other Medications: Metropolol 25mg, Losartan 50 mg, Multi Vitamin, Magnesium Oxide, 400 IU Estradiol Creme 0.01 g
Current Illness:
Preexisting Conditions: Hypertension, Age related Vaginal Atrophy
Allergies: Sulfa, Penicillin Lavendar oil Grasses, trees, mold,
Diagnostic Lab Data:
CDC Split Type:

Write-up: Shot given high on shoulder, swelling burning pain, extending from shot site to back of shoulder and into neck, woke up with heart attack symptoms, radiating pain to fingers and neck, jaw, mid back, wednesday 11/17 11/18- thru 11/23 All joints burning, swollen lymph nodes, muscle and eyelid twitches, dry blurry vision, eyes not working together, Cold sore, Canker sore,Chills, Lowback pain, Brain Fog, Tired, Dry cough, Runny Nose, Post Nasal Drip with pressure, White fluid on tongue, dizzy, Sore throat, Nausea. NO FEVER. All symptoms happened for 6 days.


VAERS ID: 1897938 (history)  
Form: Version 2.0  
Age: 4.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FK5127 / 1 LA / IM

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

Write-up: Given to patient before 5th birthday


VAERS ID: 1897942 (history)  
Form: Version 2.0  
Age: 12.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0177 / 2 LA / SYR

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

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

Write-up: Patient was given Pfizer COVID-19 vaccination that expired one day prior to administration.


VAERS ID: 1897943 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Female  
Location: Puerto Rico  
Vaccinated:2021-11-24
Onset:2021-11-24
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 065F21A / 3 RA / 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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: OUTSIDE OF GUIDELINESS THIRD PARTY STAFF ADMINISTERED FULL DOSE (0.5ML) OF MODERNA VACCINE INSTEAD OF BOOSTER DOSE (0.25ML)


VAERS ID: 1897947 (history)  
Form: Version 2.0  
Age: 13.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-11-23
Onset:2021-11-24
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-11-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0177 / 2 LA / SYR

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

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

Write-up: Patient was given Pfizer COVID-19 vaccination that expired one day prior to administration.


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