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This is VAERS ID 1111042

History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1111042
VAERS Form:2
Age:71.0
Sex:Male
Location:Indiana
Vaccinated:2021-03-10
Onset:2021-03-15
Submitted:0000-00-00
Entered:2021-03-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / UNK LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Pain in extremity, Respiratory arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-15
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: Atorvastin, Lantus, Bacid, Ferrous Sulfate, Flomax, Gabapentin, Lasix, Metoprolol, Norvasc, Duloxatine
Current Illness: None, admitted to this facility on 2/4/21. Recently declining condition, decreased appetite.
Preexisting Conditions: DM, Unspecified behavioral syndromes associated w/ physiological disturbances and physical factors, CAD, HTN, Chronic pain syndrome, physical deconditioning, anemia, CKD, hyperlipidemia
Allergies: NKA
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: RHC 3/15/21. No significant reaction from vaccine. Had sore arm.

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