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This is VAERS ID 1765139

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History of Changes from the VAERS Wayback Machine

First Appeared on 10/8/2021

VAERS ID: 1765139
VAERS Form:2
Age:79.0
Sex:Female
Location:Michigan
Vaccinated:2021-10-04
Onset:2021-10-04
Submitted:0000-00-00
Entered:2021-10-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0179 / 3 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Interchange of vaccine products

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: alrex 0.2% drops, ascorbate calcium, aspirin, azelastine nasal spray, zyrtec, vitamin D, B-12, Colace
Current Illness: axillary lipoma
Preexisting Conditions: hypertension, asthma, dyspepsia, gastroesophageal reflux,
Allergies: amlodipine, clonidine, cephalosporins, Morphine, Lisinopril, Prilosec, Tramadol
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient''s first 2 doses were Moderna. Patient did not have vaccination card and system to verify was down. Patient reported Pfizer first 2 doses.

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