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This is VAERS ID 640300

History of Changes from the VAERS Wayback Machine

First Appeared on 7/14/2016

VAERS ID: 640300
VAERS Form:
Age:10.0
Gender:Male
Location:Vermont
Vaccinated:2016-05-25
Onset:2016-05-25
Submitted:2016-05-25
Entered:2016-05-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. L043213 / 0 RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U5228BA / 0 RA / IM
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS 9Y57K / 0 LA / IM

Administered by: Private      Purchased by: Public
Symptoms: Fall, Seizure, Face injury, Tooth fracture, Immediate post-injection reaction

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Hx of 34 week prematurity; mild pulmonary stenosis
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt was given MENACTRA and HPV in (R) arm. Seconds later was given Tdap in (L) arm and immediately fell forward off table and hit face on floor. Seizure for less than 20 seconds. Broke off tooth in process. Pt with hx anxiety with vaccines especially.


Changed on 9/14/2017

VAERS ID: 640300 Before After
VAERS Form:(blank) 1
Age:10.0
Gender:Male
Location:Vermont
Vaccinated:2016-05-25
Onset:2016-05-25
Submitted:2016-05-25
Entered:2016-05-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. L043213 / 0 1 RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U5228BA / 0 1 RA / IM
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS 9Y57K / 0 1 LA / IM

Administered by: Private      Purchased by: Public
Symptoms: Fall, Seizure, Face injury, Tooth fracture, Immediate post-injection reaction

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Hx of 34 week prematurity; mild pulmonary stenosis
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt was given MENACTRA and HPV in (R) arm. Seconds later was given Tdap in (L) arm and immediately fell forward off table and hit face on floor. Seizure for less than 20 seconds. Broke off tooth in process. Pt with hx anxiety with vaccines especially.


Changed on 2/14/2018

VAERS ID: 640300 Before After
VAERS Form:1
Age:10.0
Gender:Male
Location:Vermont
Vaccinated:2016-05-25
Onset:2016-05-25
Submitted:2016-05-25
Entered:2016-05-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. L043213 / 1 RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U5228BA / 1 RA / IM
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS 9Y57K / 1 LA / IM

Administered by: Private      Purchased by: Public
Symptoms: Fall, Seizure, Face injury, Tooth fracture, Immediate post-injection reaction

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Hx of 34 week prematurity; mild pulmonary stenosis
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt was given MENACTRA and HPV in (R) arm. Seconds later was given Tdap in (L) arm and immediately fell forward off table and hit face on floor. Seizure for less than 20 seconds. Broke off tooth in process. Pt with hx anxiety with vaccines especially.


Changed on 6/14/2018

VAERS ID: 640300 Before After
VAERS Form:1
Age:10.0
Gender:Male
Location:Vermont
Vaccinated:2016-05-25
Onset:2016-05-25
Submitted:2016-05-25
Entered:2016-05-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. L043213 / 1 RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U5228BA / 1 RA / IM
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS 9Y57K / 1 LA / IM

Administered by: Private      Purchased by: Public
Symptoms: Fall, Seizure, Face injury, Tooth fracture, Immediate post-injection reaction

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Hx of 34 week prematurity; mild pulmonary stenosis
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt was given MENACTRA and HPV in (R) arm. Seconds later was given Tdap in (L) arm and immediately fell forward off table and hit face on floor. Seizure for less than 20 seconds. Broke off tooth in process. Pt with hx anxiety with vaccines especially.


Changed on 8/14/2018

VAERS ID: 640300 Before After
VAERS Form:1
Age:10.0
Gender:Male
Location:Vermont
Vaccinated:2016-05-25
Onset:2016-05-25
Submitted:2016-05-25
Entered:2016-05-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. L043213 / 1 RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U5228BA / 1 RA / IM
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS 9Y57K / 1 LA / IM

Administered by: Private      Purchased by: Public
Symptoms: Fall, Seizure, Face injury, Tooth fracture, Immediate post-injection reaction

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Hx of 34 week prematurity; mild pulmonary stenosis
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt was given MENACTRA and HPV in (R) arm. Seconds later was given Tdap in (L) arm and immediately fell forward off table and hit face on floor. Seizure for less than 20 seconds. Broke off tooth in process. Pt with hx anxiety with vaccines especially.


Changed on 9/14/2018

VAERS ID: 640300 Before After
VAERS Form:1
Age:10.0
Gender:Male
Location:Vermont
Vaccinated:2016-05-25
Onset:2016-05-25
Submitted:2016-05-25
Entered:2016-05-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
HPV4: HPV (GARDASIL) / MERCK & CO. INC. L043213 / 1 RA / IM
MNQ: MENINGOCOCCAL CONJUGATE (MENACTRA) / SANOFI PASTEUR U5228BA / 1 RA / IM
TDAP: TDAP (BOOSTRIX) / GLAXOSMITHKLINE BIOLOGICALS 9Y57K / 1 LA / IM

Administered by: Private      Purchased by: Public
Symptoms: Fall, Seizure, Face injury, Tooth fracture, Immediate post-injection reaction

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? Yes
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Hx of 34 week prematurity; mild pulmonary stenosis
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt was given MENACTRA and HPV in (R) arm. Seconds later was given Tdap in (L) arm and immediately fell forward off table and hit face on floor. Seizure for less than 20 seconds. Broke off tooth in process. Pt with hx anxiety with vaccines especially.

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