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This is VAERS ID 1693514

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History of Changes from the VAERS Wayback Machine

First Appeared on 9/17/2021

VAERS ID: 1693514
VAERS Form:2
Age:12.0
Sex:Male
Location:Texas
Vaccinated:2021-09-12
Onset:2021-09-12
Submitted:0000-00-00
Entered:2021-09-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA FE3592 / 1 RA / -

Administered by: Pharmacy      Purchased by: ??
Symptoms: Loss of consciousness

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)? Yes
Hospitalized? No
Previous Vaccinations: Unknown all previous vaccines, but has had with flu shots in prior years, although never as quick as episode today. Patient gets
Other Medications: unknown
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Patient was alert and oriented leading up to injection. Upon completion of immunization, patient lost consciousness and went in and out several more times over next 5 minutes. Patient was able to regain consciousness, drink water, and was checked out by emergency personnel where blood pressure was normal. Patient was able to walk out of pharmacy with no additional interventions needed. Patient has had fainting spells with immunizations before per mother, which were disclosed AFTER immunization was given.

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