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This is VAERS ID 908120

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History of Changes from the VAERS Wayback Machine

First Appeared on 4/1/2021

VAERS ID: 908120
VAERS Form:2
Age:43.0
Sex:Male
Location:New York
Vaccinated:2020-12-23
Onset:2020-12-23
Submitted:0000-00-00
Entered:2020-12-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Electrocardiogram, Syncope

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)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: none
Preexisting Conditions: Thyroid disease - Hypothyroid
Allergies: None
Diagnostic Lab Data: 12/23/2020: ekg
CDC 'Split Type':

Write-up: Syncopal episode after receiving vaccine


Changed on 5/7/2021

VAERS ID: 908120 Before After
VAERS Form:2
Age:43.0
Sex:Male
Location:New York
Vaccinated:2020-12-23
Onset:2020-12-23
Submitted:0000-00-00
Entered:2020-12-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Electrocardiogram, Syncope

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)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: none
Preexisting Conditions: Thyroid disease - Hypothyroid
Allergies: None None
Diagnostic Lab Data: 12/23/2020: ekg
CDC 'Split Type':

Write-up: Syncopal episode after receiving vaccine


Changed on 5/21/2021

VAERS ID: 908120 Before After
VAERS Form:2
Age:43.0
Sex:Male
Location:New York
Vaccinated:2020-12-23
Onset:2020-12-23
Submitted:0000-00-00
Entered:2020-12-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Electrocardiogram, Syncope

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)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: none
Preexisting Conditions: Thyroid disease - Hypothyroid
Allergies: None None
Diagnostic Lab Data: 12/23/2020: ekg
CDC 'Split Type':

Write-up: Syncopal episode after receiving vaccine

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