6RA-30154-12272
3 vaccinations
7 coded responses
32 check-ins
7 free-text entries
1 call case
- Sex
- Male
- Age at first dose
- 66+
- ZIP prefix
- 124 / NY
- Registered
- 2021-01-21
- Relationship
- Self
- Race
- White
- Ethnicity
- Not Hispanic or Latino
Timeline
-
2021-01-20
Dose 1 — Moderna
-
2021-01-21
Registered in v-safe
- 2021-01-22
- 2021-01-23
- 2021-01-24
- 2021-01-25
- 2021-01-26
- 2021-01-27
- 2021-02-04
- 2021-02-10
-
2021-02-17
Dose 2 — Moderna
-
2021-02-18
Survey response — days 1–6 daily, dose 2MedDRA: Back pain — Feeling: Good · Site: Pain · Joint pains, Muscle or body achesFree text: Chronic lower back pain appears a little worse today but may not be related.MedDRA releases: 2021-09,2023-04,2024-11 · check-in free text available
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2021-02-19
Survey response — days 1–6 daily, dose 2MedDRA: Back pain — Feeling: Good · Muscle or body achesFree text: Lower back pain. It is chronic but does feel worse then normal.MedDRA releases: 2021-09,2023-04,2024-11 · check-in free text available
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2021-02-20
Survey response — days 1–6 daily, dose 2MedDRA: Back pain — Feeling: Good · Site: Pain · Muscle or body achesFree text: Lower back pain has been worse since the second shot. PT told me today that many of her patients are seeing older injuries flaifimg up since getting second shot.MedDRA releases: 2021-09,2023-04,2024-11 · check-in free text available
- 2021-02-21
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2021-02-22
Survey response — days 1–6 daily, dose 2MedDRA: Back pain — Feeling: GoodFree text: Chronic back pain is a little worse then my base lineMedDRA releases: 2021-09,2023-04,2024-11 · check-in free text available
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2021-02-23
Survey response — days 1–6 daily, dose 2MedDRA: Back pain — Feeling: GoodFree text: Chronic lower back pain probably at base line so not sure if it was ever really associated with the shot.MedDRA releases: 2021-09,2023-04,2024-11 · check-in free text available
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2021-02-24
Survey response — day 7, dose 2MedDRA: Back pain, Pre-existing disease — Feeling: Good · Muscle or body achesFree text: Chronic lower back pain slightly worse then base lineMedDRA releases: 2021-09,2023-04,2024-11 · check-in free text available
- 2021-03-05
- 2021-03-11
- 2021-03-17
- 2021-03-24
- 2021-03-31
- 2021-05-19
- 2021-08-18
-
2021-10-22
Dose 3 — Moderna
-
2021-10-26
Health check-in — days 1–6 daily, dose 3Feeling: Good · Headache, Fatigue or tirednessAdult check-in
- 2021-10-28
- 2021-10-29
- 2021-11-12
- 2021-11-19
- 2021-11-26
- 2021-12-06
- 2022-01-21
- 2022-04-22
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2022-10-22
Survey response — 12 months, dose 3MedDRA: Arthralgia, Office visit, Shoulder injury related to vaccine administration — Feeling: Good · Get care from a doctor or other healthcare professional · Outpatient clinic or urgent care clinic visitFree text: Shoulder pain. Told by doctor that it likely was SIRVA from the booster shot.MedDRA releases: 2024-11 · check-in free text available
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2022-10-22
Report sent to call center — 12 months, dose 3Get care from a doctor or other healthcare professionalOutpatient clinic or urgent care clinic visit · 1 call case(s)
- 2022-10-26
- 2022-10-26
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2022-10-26
Call successfulParticipant prefers to complete VAERS report online
Vaccinations
| Dose | Date | Manufacturer | Co-administered |
|---|---|---|---|
| 1 | 2021-01-20 | Moderna | |
| 2 | 2021-02-17 | Moderna | |
| 3 | 2021-10-22 | Moderna | No |
Call center
1 call center case
1 successful
Free text
Release 4 — days 1–6 daily, dose 2
Systemic reaction (other): Chronic lower back pain appears a little worse today but may not be related.
Systemic reaction (other): Lower back pain. It is chronic but does feel worse then normal.
Systemic reaction (other): Lower back pain has been worse since the second shot. PT told me today that many of her patients are seeing older injuries flaifimg up since getting second shot.
Systemic reaction (other): Chronic back pain is a little worse then my base line
Systemic reaction (other): Chronic lower back pain probably at base line so not sure if it was ever really associated with the shot.
Release 4 — day 7, dose 2
Systemic reaction (other): Chronic lower back pain slightly worse then base line
Release 12 — 12 months, dose 3
Symptoms: Shoulder pain. Told by doctor that it likely was SIRVA from the booster shot.
Each entry is dated by the survey it was written in (the CDC re-sent the releases with survey dates in 2025); click a date to see that survey response. The CDC cut some text off at about 250 characters: symptoms in every release, and the other two fields in releases 9-12. Those entries are marked "cut off by CDC".
MedDRA terms by release
| Field | Preferred term | 2021-09 | 2023-04 | 2024-11 |
|---|---|---|---|---|
| SD | Arthralgia | · | · | ✓ |
| SD | Office visit | · | · | ✓ |
| SD | Shoulder injury related to vaccine administration | · | · | ✓ |
| SRO | Back pain | ✓ | ✓ | ✓ |
| SRO | Pre-existing disease | ✓ | ✓ | ✓ |
✓ active code · ○ coded but marked inactive · blank = not in that release