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From the 9/10/2021 release of VAERS data:

This is VAERS ID 1484907



Case Details

VAERS ID: 1484907 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Female  
Location: Arkansas  
Vaccinated:2021-04-05
Onset:2021-07-18
   Days after vaccination:104
Submitted: 0000-00-00
Entered: 2021-07-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027A21A / UNK LA / IM
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016B21A / UNK LA / IM

Administered by: Private       Purchased by: ?
Symptoms: COVID-19, SARS-CoV-2 test positive
SMQs:, Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 2 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: unknown.
Current Illness: unknown
Preexisting Conditions: Gastroesophageal reflux disease; H/O: depression; Hypertensive disorder;
Allergies: Sulfa, Penicillin
Diagnostic Lab Data: COVID positive via PCR test 7/18/21
CDC Split Type:

Write-up: Patient admitted to hospital on 7/18/21 with Dx of lab confirmed COVID 19


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1484907


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