| VAERS ID: |
992599 (history) |
| Form: |
Version 2.0 |
| Age: |
87.0 |
| Sex: |
Female |
| Location: |
California |
| Vaccinated: | 2020-12-31 |
| Onset: | 2021-01-03 |
| Days after vaccination: | 3 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-02-01 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL0142 / 1 |
RA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Erythema
SMQs:, Anaphylactic reaction (broad), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)
Life Threatening? Yes
Birth Defect? No
Died? Yes
Date died: 2021-01-03
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Lactobacillus Capsule MULTIVITAMINS TABLET CRANBERRY TABLET
Current Illness: COVID-19 POSITIVE 12/14/20
Preexisting Conditions: COPD, DM TYPE 2, CHF, GERD, HYPERTENSION, HYPERLIPIDEMIA
Allergies: Ciprofloxacin, Codeine, Bactrim, Lactose Intolerant
Diagnostic Lab Data:
CDC Split Type:
Write-up: right arm redness |
