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This is VAERS ID 954011

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History of Changes from the VAERS Wayback Machine

First Appeared on 4/30/2021

VAERS ID: 954011
VAERS Form:2
Age:17.0
Sex:Female
Location:Colorado
Vaccinated:2021-01-14
Onset:2021-01-14
Submitted:0000-00-00
Entered:2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Product administered to patient of inappropriate age

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Zoloft, Estradiol, Clobetasol
Current Illness: None
Preexisting Conditions: Anxiety, Aphthous Stomatitis, Eczema
Allergies: NKDA
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient is under the age of 18 and should not have received the vaccine


Changed on 5/7/2021

VAERS ID: 954011 Before After
VAERS Form:2
Age:17.0
Sex:Female
Location:Colorado
Vaccinated:2021-01-14
Onset:2021-01-14
Submitted:0000-00-00
Entered:2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Product administered to patient of inappropriate age

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Zoloft, Estradiol, Clobetasol
Current Illness: None
Preexisting Conditions: Anxiety, Aphthous Stomatitis, Eczema
Allergies: NKDA NKDA
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient is under the age of 18 and should not have received the vaccine


Changed on 5/21/2021

VAERS ID: 954011 Before After
VAERS Form:2
Age:17.0
Sex:Female
Location:Colorado
Vaccinated:2021-01-14
Onset:2021-01-14
Submitted:0000-00-00
Entered:2021-01-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Product administered to patient of inappropriate age

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Zoloft, Estradiol, Clobetasol
Current Illness: None
Preexisting Conditions: Anxiety, Aphthous Stomatitis, Eczema
Allergies: NKDA NKDA
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient is under the age of 18 and should not have received the vaccine

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