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This is VAERS ID 966178

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/29/2021

VAERS ID: 966178
VAERS Form:2
Age:89.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-01-19
Onset:2021-01-22
Submitted:0000-00-00
Entered:2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Dyspnoea

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-22
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: acetaminophen 600 mg every 4 hrs, albuterol 2 puffs every 6 hrs, Symbicort 2puffs 2 x days, vitamin D, B12, Prozac 20 mg once per day, Veramyst 1 spray once per day, Lisinopril 5 mg once per day, Prilosec 40 mg once per day, Probiotic daily
Current Illness: skin ulcer of lower right leg due to old gun shot wound
Preexisting Conditions: alcoholism in remission, aortic stenosis-mild, arthritis, blood loss anemia, carpel tunnel syndrome bilateral, cellulitis of right leg, chronic insomnia, COPD, diverticulosis of sigmoid and descending colon, eczema, gun shot wound of leg, heart murmur-right upper external border, hemorrhoids, history of blood transfusion, history of falling, lyme disease, osteoarthritis of left knee, pneumonia, polyp of colon flat, peripyloric ulcer, peptic ulcer disease, sleep apnea, unspecified essential hypertension, viral meningitis
Allergies: aminoglycosides and sulfa meds
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Pt called son to let him know he couldn''t breath around 2 AM. Pts son showed up at his house 10 minutes later and ambulance arrived with in 20 minutes at 2:15


Changed on 5/7/2021

VAERS ID: 966178 Before After
VAERS Form:2
Age:89.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-01-19
Onset:2021-01-22
Submitted:0000-00-00
Entered:2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Dyspnoea

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-22
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: acetaminophen 600 mg every 4 hrs, albuterol 2 puffs every 6 hrs, Symbicort 2puffs 2 x days, vitamin D, B12, Prozac 20 mg once per day, Veramyst 1 spray once per day, Lisinopril 5 mg once per day, Prilosec 40 mg once per day, Probiotic daily
Current Illness: skin ulcer of lower right leg due to old gun shot wound
Preexisting Conditions: alcoholism in remission, aortic stenosis-mild, arthritis, blood loss anemia, carpel tunnel syndrome bilateral, cellulitis of right leg, chronic insomnia, COPD, diverticulosis of sigmoid and descending colon, eczema, gun shot wound of leg, heart murmur-right upper external border, hemorrhoids, history of blood transfusion, history of falling, lyme disease, osteoarthritis of left knee, pneumonia, polyp of colon flat, peripyloric ulcer, peptic ulcer disease, sleep apnea, unspecified essential hypertension, viral meningitis
Allergies: aminoglycosides and sulfa meds meds
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Pt called son to let him know he couldn''t breath around 2 AM. Pts son showed up at his house 10 minutes later and ambulance arrived with in 20 minutes at 2:15


Changed on 5/14/2021

VAERS ID: 966178 Before After
VAERS Form:2
Age:89.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-01-19
Onset:2021-01-22
Submitted:0000-00-00
Entered:2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Dyspnoea

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-22
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: acetaminophen 600 mg every 4 hrs, albuterol 2 puffs every 6 hrs, Symbicort 2puffs 2 x days, vitamin D, B12, Prozac 20 mg once per day, Veramyst 1 spray once per day, Lisinopril 5 mg once per day, Prilosec 40 mg once per day, Probiotic daily
Current Illness: skin ulcer of lower right leg due to old gun shot wound
Preexisting Conditions: alcoholism in remission, aortic stenosis-mild, arthritis, blood loss anemia, carpel tunnel syndrome bilateral, cellulitis of right leg, chronic insomnia, COPD, diverticulosis of sigmoid and descending colon, eczema, gun shot wound of leg, heart murmur-right upper external border, hemorrhoids, history of blood transfusion, history of falling, lyme disease, osteoarthritis of left knee, pneumonia, polyp of colon flat, peripyloric ulcer, peptic ulcer disease, sleep apnea, unspecified essential hypertension, viral meningitis
Allergies: aminoglycosides and sulfa meds meds
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Pt called son to let him know he couldn''t breath around 2 AM. Pts son showed up at his house 10 minutes later and ambulance arrived with in 20 minutes at 2:15

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