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This is VAERS ID 107005

History of Changes from the VAERS Wayback Machine

Already in VAERS on 12/31/2003

VAERS ID: 107005
VAERS Form:
Age:12.1
Sex:Male
Location:Pennsylvania
Vaccinated:1998-01-13
Onset:1998-01-13
Submitted:1998-01-20
Entered:1998-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: TRIPEDIA / CONNAUGHT LABS 6F81441 / 3 LA / IM
MMR: MMR II / MSD 1238D / 1 RA / SC
PPV: PNU-IMUNE(R)23 / LEDERLE 441228 / 3 - / PO

Administered by: Private      Purchased by: Unknown
Symptoms: SYNCOPE

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-01-13
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: Risperdal;wellbutin
Current Illness: OM
Preexisting Conditions: NKDA;obesity, depression
Allergies:
Diagnostic Lab Data: NA
CDC 'Split Type':

Write-up: pt reportedly collapsed @ home suddenly


Changed on 12/8/2009

VAERS ID: 107005 Before After
VAERS Form:
Age:12.1
Sex:Male
Location:Pennsylvania
Vaccinated:1998-01-13
Onset:1998-01-13
Submitted:1998-01-20
Entered:1998-01-28 1998-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: TRIPEDIA DTAP (TRIPEDIA) / CONNAUGHT LABS CONNAUGHT LABORATORIES 6F81441 / 3 LA / IM
MMR: MMR II MEASLES + MUMPS + RUBELLA (MMR II) / MSD MERCK & CO. INC. 1238D / 1 RA / SC
PPV: PNU-IMUNE(R)23 PNEUMO (PNU-IMUNE) / LEDERLE LEDERLE LABORATORIES 441228 / 3 - / PO

Administered by: Private      Purchased by: Unknown Public
Symptoms: Syncope, SYNCOPE

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-01-13
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: Risperdal;wellbutin
Current Illness: OM
Preexisting Conditions: NKDA;obesity, depression
Allergies:
Diagnostic Lab Data: NA
CDC 'Split Type':

Write-up: pt reportedly collapsed @ home suddenly


Changed on 2/14/2017

VAERS ID: 107005 Before After
VAERS Form:
Age:12.1 12.0
Sex:Male
Location:Pennsylvania
Vaccinated:1998-01-13
Onset:1998-01-13
Submitted:1998-01-20
Entered:1998-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 6F81441 / 3 LA / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1238D / 1 RA / SC
PPV: PNEUMO (PNU-IMUNE) / LEDERLE LABORATORIES 441228 / 3 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Syncope

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-01-13
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: Risperdal;wellbutin
Current Illness: OM
Preexisting Conditions: NKDA;obesity, depression
Allergies:
Diagnostic Lab Data: NA
CDC 'Split Type':

Write-up: pt reportedly collapsed @ home suddenly


Changed on 5/14/2017

VAERS ID: 107005 Before After
VAERS Form:
Age:12.0
Sex:Male
Location:Pennsylvania
Vaccinated:1998-01-13
Onset:1998-01-13
Submitted:1998-01-20
Entered:1998-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 6F81441 / 3 LA / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1238D / 1 RA / SC
PPV: PNEUMO (PNU-IMUNE) / LEDERLE LABORATORIES PFIZER/WYETH 441228 / 3 - / PO

Administered by: Private      Purchased by: Public
Symptoms: Syncope

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-01-13
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: ~ ()~~~In patient
Other Medications: Risperdal;wellbutin
Current Illness: OM
Preexisting Conditions: NKDA;obesity, depression
Allergies:
Diagnostic Lab Data: NA
CDC 'Split Type':

Write-up: pt reportedly collapsed @ home suddenly


Changed on 9/14/2017

VAERS ID: 107005 Before After
VAERS Form:(blank) 1
Age:12.0
Sex:Male
Location:Pennsylvania
Vaccinated:1998-01-13
Onset:1998-01-13
Submitted:1998-01-20
Entered:1998-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 6F81441 / 3 4 LA / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1238D / 1 2 RA / SC
PPV: PNEUMO (PNU-IMUNE) / PFIZER/WYETH 441228 / 3 4 - MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Syncope

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-01-13
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: ~ ()~~~In patient
Other Medications: Risperdal;wellbutin
Current Illness: OM
Preexisting Conditions: NKDA;obesity, depression
Allergies:
Diagnostic Lab Data: NA
CDC 'Split Type':

Write-up: pt reportedly collapsed @ home suddenly


Changed on 2/14/2018

VAERS ID: 107005 Before After
VAERS Form:1
Age:12.0
Sex:Male
Location:Pennsylvania
Vaccinated:1998-01-13
Onset:1998-01-13
Submitted:1998-01-20
Entered:1998-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 6F81441 / 4 LA / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1238D / 2 RA / SC
PPV: PNEUMO (PNU-IMUNE) / PFIZER/WYETH 441228 / 4 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Syncope

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-01-13
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: ~ ()~~~In patient
Other Medications: Risperdal;wellbutin
Current Illness: OM
Preexisting Conditions: NKDA;obesity, depression
Allergies:
Diagnostic Lab Data: NA
CDC 'Split Type':

Write-up: pt reportedly collapsed @ home suddenly


Changed on 6/14/2018

VAERS ID: 107005 Before After
VAERS Form:1
Age:12.0
Sex:Male
Location:Pennsylvania
Vaccinated:1998-01-13
Onset:1998-01-13
Submitted:1998-01-20
Entered:1998-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 6F81441 / 4 LA / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1238D / 2 RA / SC
PPV: PNEUMO (PNU-IMUNE) / PFIZER/WYETH 441228 / 4 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Syncope

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-01-13
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: ~ ()~~~In patient
Other Medications: Risperdal;wellbutin
Current Illness: OM
Preexisting Conditions: NKDA;obesity, depression
Allergies:
Diagnostic Lab Data: NA
CDC 'Split Type':

Write-up: pt reportedly collapsed @ home suddenly


Changed on 8/14/2018

VAERS ID: 107005 Before After
VAERS Form:1
Age:12.0
Sex:Male
Location:Pennsylvania
Vaccinated:1998-01-13
Onset:1998-01-13
Submitted:1998-01-20
Entered:1998-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 6F81441 / 4 LA / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1238D / 2 RA / SC
PPV: PNEUMO (PNU-IMUNE) / PFIZER/WYETH 441228 / 4 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Syncope

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-01-13
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: ~ ()~~~In patient
Other Medications: Risperdal;wellbutin
Current Illness: OM
Preexisting Conditions: NKDA;obesity, depression
Allergies:
Diagnostic Lab Data: NA
CDC 'Split Type':

Write-up: pt reportedly collapsed @ home suddenly


Changed on 9/14/2018

VAERS ID: 107005 Before After
VAERS Form:1
Age:12.0
Sex:Male
Location:Pennsylvania
Vaccinated:1998-01-13
Onset:1998-01-13
Submitted:1998-01-20
Entered:1998-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 6F81441 / 4 LA / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1238D / 2 RA / SC
PPV: PNEUMO (PNU-IMUNE) / PFIZER/WYETH 441228 / 4 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Syncope

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-01-13
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: ~ ()~~~In patient
Other Medications: Risperdal;wellbutin
Current Illness: OM
Preexisting Conditions: NKDA;obesity, depression
Allergies:
Diagnostic Lab Data: NA
CDC 'Split Type':

Write-up: pt reportedly collapsed @ home suddenly


Changed on 10/14/2018

VAERS ID: 107005 Before After
VAERS Form:1
Age:12.0
Sex:Male
Location:Pennsylvania
Vaccinated:1998-01-13
Onset:1998-01-13
Submitted:1998-01-20
Entered:1998-01-27
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
DTAP: DTAP (TRIPEDIA) / CONNAUGHT LABORATORIES 6F81441 / 4 LA / IM
MMR: MEASLES + MUMPS + RUBELLA (MMR II) / MERCK & CO. INC. 1238D / 2 RA / SC
PPV: PNEUMO (PNU-IMUNE) / PFIZER/WYETH 441228 / 4 MO / PO

Administered by: Private      Purchased by: Public
Symptoms: Syncope

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:1998-01-13
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: ~ ()~~~In patient
Other Medications: Risperdal;wellbutin
Current Illness: OM
Preexisting Conditions: NKDA;obesity, depression
Allergies:
Diagnostic Lab Data: NA
CDC 'Split Type':

Write-up: pt reportedly collapsed @ home suddenly

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