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History of Changes from the VAERS Wayback Machine |
VAERS ID: | 937152 |
VAERS Form: | 2 |
Age: | 91.0 |
Sex: | Female |
Location: | Arkansas |
Vaccinated: | 2020-12-22 |
Onset: | 2020-12-24 |
Submitted: | 0000-00-00 |
Entered: | 2021-01-12 |
Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA | 025L20A / 1 | RA / IM |
Administered by: Senior Living Purchased by: ??
Symptoms: SARS-CoV-2 test positive
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2021-01-11
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: Metoprolol, Cephalexin, Brimonidine, Donepezil, Losartan, Latanoprost, Timolol
Current Illness: High blood pressure, pain, eye issues
Preexisting Conditions: Blood pressure, pain
Allergies: None
Diagnostic Lab Data:
CDC 'Split Type':
Write-up: The facility had positive cases for COVID 19 when the vaccine was received and administered to patient. With her advanced age and chronic conditions, she did not have time to build immunity between the time of vaccination and her testing positive.
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