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This is VAERS ID 1759033

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History of Changes from the VAERS Wayback Machine

First Appeared on 10/8/2021

VAERS ID: 1759033
VAERS Form:2
Age:17.0
Sex:Female
Location:Missouri
Vaccinated:2021-10-04
Onset:2021-10-04
Submitted:0000-00-00
Entered:2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024C21A / 1 LA / SYR

Administered by: Private      Purchased by: ??
Symptoms: Product administered to patient of inappropriate age

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)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Flovent HFA, fluticasone propionate, ProAir HFA
Current Illness: none
Preexisting Conditions: Asthma
Allergies: Ibuprofen
Diagnostic Lab Data: Not medically necessary at this time.
CDC 'Split Type':

Write-up: Patient came in to receive COVID 19 vaccination. Grandmother asked for patient to receive Moderna, as that was the vaccine she received. After administration of the vaccine, it was realized that patient was not 18 years old.

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