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This is VAERS ID 1371248

History of Changes from the VAERS Wayback Machine

First Appeared on 6/4/2021

VAERS ID: 1371248
VAERS Form:2
Age:56.0
Sex:Male
Location:Arkansas
Vaccinated:2021-06-03
Onset:2021-06-03
Submitted:0000-00-00
Entered:2021-06-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 477C21A / 2 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: No adverse event, Interchange of vaccine products

Life Threatening? No
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: trazodone, atorvastatin, breo ellipta, tizanidine, duloxetine, gabapentin, meloxicam, wellbutrin, furosemide, finasteride, potassium chloride, folic acid, vitamin d2, norco, ca-d3-mag#11-zinc-cupr-man, proventil hfa
Current Illness: none
Preexisting Conditions: hypertension hyperlipidemia RA
Allergies: PCN, lexapro
Diagnostic Lab Data: n/a
CDC 'Split Type':

Write-up: The patient has not experienced an adverse event. This report is being submitted because the patient was given Moderna vaccine for his 2nd dose, but was supposed to receive the Pfizer vaccine.

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