| Days after vaccination:||0
|Vaccination / Manufacturer
||Lot / Dose
||Site / Route|
|COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA
||- / 1
||LA / SYR
Administered by: Pharmacy Purchased by: ?
Symptoms: Abdominal pain upper,
Blood pressure increased,
Injection site pain,
SMQs:, Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Pseudomembranous colitis (broad), Dystonia (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Extravasation events (injections, infusions and implants) (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Glaucoma (broad), Hypertension (narrow), Cardiomyopathy (broad), Arthritis (broad), Noninfectious diarrhoea (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)
Life Threatening? No
Birth Defect? No
Permanent Disability? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Previous Vaccinations: Sore arm where shot was given
Other Medications: None were taken.
Current Illness: Hypothyroidism & Hypertension
Preexisting Conditions: N/A
Allergies: Allergies to: Penicillin, Ampicillin, Betadine, and Sulfur.
Diagnostic Lab Data: None at this time
CDC Split Type:
Write-up: Chest pains, sore left arm where shot was given, painful swollen lymph nodes under left arm pit, bad head pain, eye pain from the head pain, elevated blood pressure (even after medication), body pain everywhere, diarrhea, nausea, lost of appetite, neck pain from the head pain, constipation, left/right side stomach pain, left/right muscle spasms in both calves, dry mouth, thirsty, dry nostrils, and ear drainage from right ear.