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This is VAERS ID 1718128

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History of Changes from the VAERS Wayback Machine

First Appeared on 9/24/2021

VAERS ID: 1718128
VAERS Form:2
Age:86.0
Sex:Male
Location:New Jersey
Vaccinated:2021-01-16
Onset:2021-09-10
Submitted:0000-00-00
Entered:2021-09-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA #013L20A / 2 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Vaccination site pain

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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20213

Write-up: soreness in the injection site.; This spontaneous case was reported by a consumer and describes the occurrence of VACCINATION SITE PAIN (soreness in the injection site.) in an 86-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 059E21O, #013L20A and #021M20A) for COVID-19 vaccination. No Medical History information was reported. On 16-Jan-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On 13-Feb-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to 1 dosage form. On 09-Sep-2021, received third dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to 1 dosage form. On 10-Sep-2021, the patient experienced VACCINATION SITE PAIN (soreness in the injection site.). At the time of the report, VACCINATION SITE PAIN (soreness in the injection site.) outcome was unknown. No Concomitant use were reported. No Treatment were reported Most recent FOLLOW-UP information incorporated above includes: On 10-Sep-2021: Non-Significant F/U Case.

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