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This is VAERS ID 1027141

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1027141
VAERS Form:2
Age:79.0
Sex:Male
Location:Oregon
Vaccinated:2021-01-29
Onset:2021-01-29
Submitted:0000-00-00
Entered:2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-12
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Acidophilus Capsule BID, Metamucil (Generic) 1 packet/day, Metformin HCL 500 Generic BID, Omeprazole 20 mg Daily, Potassium Cloride ER 20 MEQ tablet PO daily with breakfast, Prenatal Vitamin plus low iron daily with breakfast, Tamsulosin Hc
Current Illness: None, Last prior illness was November 2020 he had Cdiff and was at Hospital but per facility the patient was fully recovered from this.
Preexisting Conditions: Forgetfulness/Mild Dementia, Diabetes, Obese, Urinary Flow Issues all per facility and MAR
Allergies: NKDA
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: The patient reported feeling well. I discussed with him the Covid-19 vaccine and he was able to state that he wanted it and to sign his consent form. The facility reported they had discussed this with him and he had agreed prior to my visit.


Changed on 5/7/2021

VAERS ID: 1027141 Before After
VAERS Form:2
Age:79.0
Sex:Male
Location:Oregon
Vaccinated:2021-01-29
Onset:2021-01-29
Submitted:0000-00-00
Entered:2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-12
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Acidophilus Capsule BID, Metamucil (Generic) 1 packet/day, Metformin HCL 500 Generic BID, Omeprazole 20 mg Daily, Potassium Cloride ER 20 MEQ tablet PO daily with breakfast, Prenatal Vitamin plus low iron daily with breakfast, Tamsulosin Hc
Current Illness: None, Last prior illness was November 2020 he had Cdiff and was at Hospital but per facility the patient was fully recovered from this.
Preexisting Conditions: Forgetfulness/Mild Dementia, Diabetes, Obese, Urinary Flow Issues all per facility and MAR
Allergies: NKDA NKDA
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: The patient reported feeling well. I discussed with him the Covid-19 vaccine and he was able to state that he wanted it and to sign his consent form. The facility reported they had discussed this with him and he had agreed prior to my visit.


Changed on 5/14/2021

VAERS ID: 1027141 Before After
VAERS Form:2
Age:79.0
Sex:Male
Location:Oregon
Vaccinated:2021-01-29
Onset:2021-01-29
Submitted:0000-00-00
Entered:2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-12
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Acidophilus Capsule BID, Metamucil (Generic) 1 packet/day, Metformin HCL 500 Generic BID, Omeprazole 20 mg Daily, Potassium Cloride ER 20 MEQ tablet PO daily with breakfast, Prenatal Vitamin plus low iron daily with breakfast, Tamsulosin Hc
Current Illness: None, Last prior illness was November 2020 he had Cdiff and was at Hospital but per facility the patient was fully recovered from this.
Preexisting Conditions: Forgetfulness/Mild Dementia, Diabetes, Obese, Urinary Flow Issues all per facility and MAR
Allergies: NKDA NKDA
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: The patient reported feeling well. I discussed with him the Covid-19 vaccine and he was able to state that he wanted it and to sign his consent form. The facility reported they had discussed this with him and he had agreed prior to my visit.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1027141&WAYBACKHISTORY=ON


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