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This is VAERS ID 1330954

History of Changes from the VAERS Wayback Machine

First Appeared on 5/21/2021

VAERS ID: 1330954
VAERS Form:2
Age:14.0
Sex:Male
Location:New York
Vaccinated:2021-05-19
Onset:2021-05-19
Submitted:0000-00-00
Entered:2021-05-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA EW0183 / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Fall, Syncope, Skin laceration, Skin abrasion, Product administered to patient of inappropriate age

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
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: None
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data: Vital signs: BP 100/80, Pulse 92, Resp 18, SaO2 98%. Staff recommends ambulance transport to Hospital, parents state will take patient to Urgent Care via personal vehicle.
CDC 'Split Type':

Write-up: Brief syncopal episode, fell from chair, struck head on floor, suffered small laceration and abrasion to left eyebrow.

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