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This is VAERS ID 915956

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/7/2021

VAERS ID: 915956
VAERS Form:2
Age:47.0
Sex:Male
Location:New Jersey
Vaccinated:2020-12-24
Onset:2020-12-25
Submitted:0000-00-00
Entered:2020-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / UNK LA / IM

Administered by: Work      Purchased by: ??
Symptoms: COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions:
Allergies: nkda
Diagnostic Lab Data: COVID PCR + 12/27/2020
CDC 'Split Type':

Write-up: Patient received dose 1 of COVID vaccine 12/24. He developed symptoms consistent with COVID infection on 12/25. He was seen in the emergency room at Hospital on 12/27,was diagnosed as COVID positive, and was discharged to home. He returned to the emergency room on 12/29 and was admitted to the hospital for treatment related to COVID infection. He is currently admitted to Hospital.


Changed on 5/7/2021

VAERS ID: 915956 Before After
VAERS Form:2
Age:47.0
Sex:Male
Location:New Jersey
Vaccinated:2020-12-24
Onset:2020-12-25
Submitted:0000-00-00
Entered:2020-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / UNK LA / IM

Administered by: Work      Purchased by: ??
Symptoms: COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions:
Allergies: nkda nkda
Diagnostic Lab Data: COVID PCR + 12/27/2020
CDC 'Split Type':

Write-up: Patient received dose 1 of COVID vaccine 12/24. He developed symptoms consistent with COVID infection on 12/25. He was seen in the emergency room at Hospital on 12/27,was diagnosed as COVID positive, and was discharged to home. He returned to the emergency room on 12/29 and was admitted to the hospital for treatment related to COVID infection. He is currently admitted to Hospital.


Changed on 5/14/2021

VAERS ID: 915956 Before After
VAERS Form:2
Age:47.0
Sex:Male
Location:New Jersey
Vaccinated:2020-12-24
Onset:2020-12-25
Submitted:0000-00-00
Entered:2020-12-31
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / UNK LA / IM

Administered by: Work      Purchased by: ??
Symptoms: COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions:
Allergies: nkda nkda
Diagnostic Lab Data: COVID PCR + 12/27/2020
CDC 'Split Type':

Write-up: Patient received dose 1 of COVID vaccine 12/24. He developed symptoms consistent with COVID infection on 12/25. He was seen in the emergency room at Hospital on 12/27,was diagnosed as COVID positive, and was discharged to home. He returned to the emergency room on 12/29 and was admitted to the hospital for treatment related to COVID infection. He is currently admitted to Hospital.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=915956&WAYBACKHISTORY=ON


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