National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 920771

Government Disclaimer on use of this data

History of Changes from the VAERS Wayback Machine

First Appeared on 1/7/2021

VAERS ID: 920771
VAERS Form:2
Age:94.0
Sex:Female
Location:Illinois
Vaccinated:2020-12-29
Onset:2020-12-30
Submitted:0000-00-00
Entered:2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Tachycardia

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? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies: NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Tachycardia, resident was sent out to the hospital for evaluation on 12/30/2020 and came back to the facility on 12/31/2020.


Changed on 5/7/2021

VAERS ID: 920771 Before After
VAERS Form:2
Age:94.0
Sex:Female
Location:Illinois
Vaccinated:2020-12-29
Onset:2020-12-30
Submitted:0000-00-00
Entered:2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Tachycardia

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? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Tachycardia, resident was sent out to the hospital for evaluation on 12/30/2020 and came back to the facility on 12/31/2020.


Changed on 5/14/2021

VAERS ID: 920771 Before After
VAERS Form:2
Age:94.0
Sex:Female
Location:Illinois
Vaccinated:2020-12-29
Onset:2020-12-30
Submitted:0000-00-00
Entered:2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Tachycardia

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? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Tachycardia, resident was sent out to the hospital for evaluation on 12/30/2020 and came back to the facility on 12/31/2020.

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=920771&WAYBACKHISTORY=ON


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166