VAERS ID: |
930910 (history) |
Form: |
Version 2.0 |
Age: |
52.0 |
Sex: |
Female |
Location: |
Hawaii |
Vaccinated: | 2021-01-08 |
Onset: | 2021-01-08 |
Days after vaccination: | 0 |
Submitted: |
0000-00-00 |
Entered: |
2021-01-09 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
012L20A / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ? Symptoms: Death SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-08
Days after onset: 0
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Other Medications: Patient was refusing to take all medications for over a year Current Illness: None Preexisting Conditions: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, major depressive disorder, aphasia following cerebral infarction, muscle weakness, dysphagia, hypothyrodism, type 2 diabetes, hyperlipidemia, hypomagnesemia, hypokalemia, hypertension, gastro esophageal reflux disease, gastritis, constipation Allergies: Metformin, morphine, statins, latex Diagnostic Lab Data: CDC Split Type:
Write-up: Patient received COVID vaccination around 12:15pm. Patient was monitored for the appropriate amount of time by nursing staff. Patient passed away at 2:15pm. |