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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1719540

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Case Details

VAERS ID: 1719540 (history)  
Form: Version 2.0  
Age: 80.0  
Sex: Male  
Location: California  
Vaccinated:2021-02-15
Onset:2021-09-12
   Days after vaccination:209
Submitted: 0000-00-00
Entered: 2021-09-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Cough, Decreased appetite, Fatigue, Pyrexia, Rhinorrhoea
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: fatigue fever slight cough Runny nose decreased appetite


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