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This is VAERS ID 1053176

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/5/2021

VAERS ID: 1053176
VAERS Form:2
Age:65.0
Sex:Male
Location:Indiana
Vaccinated:2021-02-08
Onset:2021-02-10
Submitted:0000-00-00
Entered:2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 1 UN / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Intensive care, Thrombocytopenia, Haemorrhage, Reaction to preservatives

Life Threatening? Yes
Birth Defect? No
Died? No
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:
Current Illness:
Preexisting Conditions: GERD, COPD, type 2 diabetes
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: severe reaction within 48 hours of the vaccine , sent to the hospital with uncontrollable bleeding, in ICU with thrombocytopenia


Changed on 5/7/2021

VAERS ID: 1053176 Before After
VAERS Form:2
Age:65.0
Sex:Male
Location:Indiana
Vaccinated:2021-02-08
Onset:2021-02-10
Submitted:0000-00-00
Entered:2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 1 UN / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Intensive care, Thrombocytopenia, Haemorrhage, Reaction to preservatives

Life Threatening? Yes
Birth Defect? No
Died? No
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:
Current Illness:
Preexisting Conditions: GERD, COPD, type 2 diabetes
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: severe reaction within 48 hours of the vaccine , sent to the hospital with uncontrollable bleeding, in ICU with thrombocytopenia


Changed on 5/21/2021

VAERS ID: 1053176 Before After
VAERS Form:2
Age:65.0
Sex:Male
Location:Indiana
Vaccinated:2021-02-08
Onset:2021-02-10
Submitted:0000-00-00
Entered:2021-02-24
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 004M20A / 1 UN / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Intensive care, Thrombocytopenia, Haemorrhage, Reaction to preservatives

Life Threatening? Yes
Birth Defect? No
Died? No
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:
Current Illness:
Preexisting Conditions: GERD, COPD, type 2 diabetes
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: severe reaction within 48 hours of the vaccine , sent to the hospital with uncontrollable bleeding, in ICU with thrombocytopenia

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