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History of Changes from the VAERS Wayback Machine |
VAERS ID: | 936043 |
VAERS Form: | 2 |
Age: | 98.0 |
Sex: | Female |
Location: | California |
Vaccinated: | 2021-01-04 |
Onset: | 2021-01-05 |
Submitted: | 0000-00-00 |
Entered: | 2021-01-11 |
Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA | 037K20A / 1 | LA / IM |
Administered by: Senior Living Purchased by: ??
Symptoms: Unresponsive to stimuli
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2021-01-05
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? No
Previous Vaccinations:
Other Medications: atorvastatin,
Current Illness: S82.001D Unspecified fracture of right patella, subsequent encounter for closed fracture with routine healing(Primary, Admission), M62.81 Muscle weakness (generalized), R29.3 Abnormal posture, M19.90 Unspecified osteoarthritis, unspecified site, E11.9 Type 2 diabetes mellitus without complications, Z86.73 Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, E03.9 Hypothyroidism, unspecified, E78.5 Hyperlipidemia, unspecified, F03.90 Unspecified dementia
Preexisting Conditions: S82.001D Unspecified fracture of right patella, subsequent encounter for closed fracture with routine healing(Primary, Admission), M62.81 Muscle weakness (generalized), R29.3 Abnormal posture, M19.90 Unspecified osteoarthritis, unspecified site, E11.9 Type 2 diabetes mellitus without complications, Z86.73 Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, E03.9 Hypothyroidism, unspecified, E78.5 Hyperlipidemia, unspecified, F03.90 Unspecified dementia
Allergies: PENICILLINS
Diagnostic Lab Data:
CDC 'Split Type':
Write-up: RESIDENT 1ST DOSE OF MODERNA VACCINE ADMINISTERED ON 01/04/2021 AT 8:30PM, RESIDENT FOUND UNRESPONSIVE ON 01/05/2021.
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