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This is VAERS ID 1222021

History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1222021
VAERS Form:2
Age:64.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-02-16
Onset:2021-02-16
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007MA20A / 1 - / IM

Administered by: Private      Purchased by: ??
Symptoms: Asthenia, Dizziness, Malaise

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-19
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: lisinopril,gabapentin,budesonide,albuterol,oxycontin, tramadol
Current Illness: dental visit for amoxillin
Preexisting Conditions: hypertension, Coronary Artery Disease
Allergies: unknown
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Client became ill approximately one hour after COVID immunization. Symptoms include weakness, light headed, general malaise. Client refused wife''s offer for medical assistance.


Changed on 5/7/2021

VAERS ID: 1222021 Before After
VAERS Form:2
Age:64.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-02-16
Onset:2021-02-16
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007MA20A / 1 - / IM

Administered by: Private      Purchased by: ??
Symptoms: Asthenia, Dizziness, Malaise

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-19
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: lisinopril,gabapentin,budesonide,albuterol,oxycontin, tramadol
Current Illness: dental visit for amoxillin
Preexisting Conditions: hypertension, Coronary Artery Disease
Allergies: unknown unknown
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Client became ill approximately one hour after COVID immunization. Symptoms include weakness, light headed, general malaise. Client refused wife''s offer for medical assistance.


Changed on 5/14/2021

VAERS ID: 1222021 Before After
VAERS Form:2
Age:64.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-02-16
Onset:2021-02-16
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007MA20A / 1 - / IM

Administered by: Private      Purchased by: ??
Symptoms: Asthenia, Dizziness, Malaise

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-19
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: lisinopril,gabapentin,budesonide,albuterol,oxycontin, tramadol
Current Illness: dental visit for amoxillin
Preexisting Conditions: hypertension, Coronary Artery Disease
Allergies: unknown unknown
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Client became ill approximately one hour after COVID immunization. Symptoms include weakness, light headed, general malaise. Client refused wife''s offer for medical assistance.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1222021&WAYBACKHISTORY=ON

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