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This is VAERS ID 1032321

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1032321
VAERS Form:2
Age:87.0
Sex:Male
Location:California
Vaccinated:2021-01-07
Onset:2021-01-19
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-20
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: Regular diet, Regular texture NX: 2CAL HN 120CC 1 CAN PO three times a day WITH MEDPASS DIET: RICE PORRIDGE ALL MEALS PER RESIDENT''S REQUEST three times a day NX: 4OZ. HEALTHSHAKE PO three times a day BETWEEN MEALS Docusate Sodium Capsu
Current Illness: none
Preexisting Conditions: Wedge Compression Fracture of T-11-T12 Atrial Fibrillation BPH GERD
Allergies: NKA
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Resident has shortness of breath on 1/19/2021 and was transferred to Hospital 1/20/2021


Changed on 5/7/2021

VAERS ID: 1032321 Before After
VAERS Form:2
Age:87.0
Sex:Male
Location:California
Vaccinated:2021-01-07
Onset:2021-01-19
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-20
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: Regular diet, Regular texture NX: 2CAL HN 120CC 1 CAN PO three times a day WITH MEDPASS DIET: RICE PORRIDGE ALL MEALS PER RESIDENT''S REQUEST three times a day NX: 4OZ. HEALTHSHAKE PO three times a day BETWEEN MEALS Docusate Sodium Capsu
Current Illness: none
Preexisting Conditions: Wedge Compression Fracture of T-11-T12 Atrial Fibrillation BPH GERD
Allergies: NKA NKA
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Resident has shortness of breath on 1/19/2021 and was transferred to Hospital 1/20/2021


Changed on 5/14/2021

VAERS ID: 1032321 Before After
VAERS Form:2
Age:87.0
Sex:Male
Location:California
Vaccinated:2021-01-07
Onset:2021-01-19
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 RA / IM

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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-20
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: Regular diet, Regular texture NX: 2CAL HN 120CC 1 CAN PO three times a day WITH MEDPASS DIET: RICE PORRIDGE ALL MEALS PER RESIDENT''S REQUEST three times a day NX: 4OZ. HEALTHSHAKE PO three times a day BETWEEN MEALS Docusate Sodium Capsu
Current Illness: none
Preexisting Conditions: Wedge Compression Fracture of T-11-T12 Atrial Fibrillation BPH GERD
Allergies: NKA NKA
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Resident has shortness of breath on 1/19/2021 and was transferred to Hospital 1/20/2021

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1032321&WAYBACKHISTORY=ON

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