XUA-65214-52210

3 vaccinations 15 coded responses 34 check-ins 16 free-text entries 1 call case

Sex: Male
Age at first dose: 61-65
ZIP prefix: 972 / OR
Registered: 2021-02-03

Relationship: Self
Race: White
Ethnicity: Not Hispanic or Latino

Timeline

Registration Vaccinations Survey responses Call reports Cases without a report Call attempts Call successful Pregnancy survey

2021-02-03
Registered in v-safe
2021-02-03
Dose 1 — Moderna
2021-02-03
Survey response — 0 day, dose 1
MedDRA: Disturbance in attention, Dizziness, Feeling abnormal — Feeling: Good

MedDRA releases: 2021-09,2023-04,2024-11 · check-in answers available
2021-02-04
Health check-in — days 1–6 daily, dose 1
Feeling: Good · Site: Pain · None

Adult check-in
2021-02-05
Health check-in — days 1–6 daily, dose 1
Feeling: Good · None

Adult check-in
2021-02-06
Health check-in — days 1–6 daily, dose 1
Feeling: Good · None

Adult check-in
2021-02-08
Health check-in — days 1–6 daily, dose 1
Feeling: Good · None

Adult check-in
2021-02-10
Health check-in — 7 day, dose 1
Feeling: Good · None

Adult check-in
2021-02-17
Health check-in — 14 day, dose 1
Feeling: Good

Adult check-in
2021-02-24
Health check-in — 21 day, dose 1
Feeling: Good

Adult check-in
2021-03-03
Dose 2 — Moderna
2021-03-03
Health check-in — 0 day, dose 2
Feeling: Good · Site: Pain · None

Adult check-in
2021-03-04
Survey response — days 1–6 daily, dose 2
MedDRA: Feeling abnormal — Feeling: Fair · Site: Pain, Swelling · Fatigue or tiredness · Be unable to work

MedDRA releases: 2021-09,2023-04,2024-11 · check-in answers available
2021-03-05
Survey response — days 1–6 daily, dose 2
MedDRA: Fatigue — Feeling: Good · Site: Pain · Headache

MedDRA releases: 2021-09,2023-04,2024-11 · check-in answers available
2021-03-06
Health check-in — days 1–6 daily, dose 2
Feeling: Good · None

Adult check-in
2021-03-07
Health check-in — days 1–6 daily, dose 2
Feeling: Good · None

Adult check-in
2021-03-08
Health check-in — days 1–6 daily, dose 2
Feeling: Good · None

Adult check-in
2021-03-09
Survey response — days 1–6 daily, dose 2
MedDRA: Cough — Feeling: Good

MedDRA releases: 2021-09,2023-04,2024-11 · check-in answers available
2021-03-10
Survey response — 7 day, dose 2
MedDRA: Cough — Feeling: Good

MedDRA releases: 2021-09,2023-04,2024-11 · check-in answers available
2021-03-17
Survey response — 14 day, dose 2
MedDRA: Pain in extremity — Feeling: Fair

MedDRA releases: 2021-09,2023-04,2024-11 · check-in answers available
2021-03-24
Survey response — 21 day, dose 2
MedDRA: Neuralgia, Pain in extremity — Feeling: Good

MedDRA releases: 2021-09,2023-04,2024-11 · check-in answers available
2021-03-31
Survey response — 28 day, dose 2
MedDRA: Burning sensation, Hypoaesthesia, Pain in extremity, Radicular pain, Radiculitis brachial — Feeling: Good

MedDRA releases: 2021-09,2023-04,2024-11 · check-in answers available
2021-04-07
Health check-in — 35 day, dose 2
Feeling: Good

Adult check-in
2021-04-14
Survey response — 42 day, dose 2
MedDRA: Pain in extremity — Feeling: Fair

MedDRA releases: 2021-09,2023-04,2024-11 · check-in answers available
2021-06-02
Survey response — 3 month, dose 2
MedDRA: Condition aggravated, Herpes zoster reactivation, Myalgia, Pre-existing disease, Self-medication, Swelling of eyelid, Tendonitis — Feeling: Good · Get care from a doctor or other healthcare professional

MedDRA releases: 2021-09,2023-04,2024-11 · check-in answers available
2021-06-02
Report sent to call center — 3 month, dose 2
Get care from a doctor or other healthcare professional

1 call case(s)
2021-09-01
Health check-in — 6 month, dose 2
Feeling: Good

Adult check-in
2021-11-19
Dose 3 — Moderna
2021-11-22
Survey response — days 1–6 daily, dose 3
MedDRA: Oedema peripheral — Feeling: Fair · Site: Pain, Swelling · Fatigue or tiredness

MedDRA releases: 2024-11 · check-in answers available
2021-11-23
Health check-in — days 1–6 daily, dose 3
Feeling: Fair · Site: Swelling

Adult check-in
2021-11-24
Survey response — days 1–6 daily, dose 3
MedDRA: Lymphoedema, Oedema peripheral — Feeling: Good · Site: Swelling

MedDRA releases: 2024-11 · check-in answers available
2021-11-25
Survey response — days 1–6 daily, dose 3
MedDRA: Lymphoedema — Feeling: Good · Site: Swelling

MedDRA releases: 2024-11 · check-in answers available
2021-11-26
Survey response — 7 day, dose 3
MedDRA: Lymphoedema, Oedema peripheral, Swelling — Feeling: Good · Site: Swelling · Fatigue or tiredness

MedDRA releases: 2024-11 · check-in answers available
2021-12-03
Health check-in — 14 day, dose 3
Feeling: Good

Adult check-in
2021-12-10
Health check-in — 21 day, dose 3
Feeling: Good

Adult check-in
2021-12-20
Health check-in — 28 day, dose 3
Feeling: Good

Adult check-in
2022-02-18
Survey response — 3 month, dose 3
MedDRA: Joint swelling — Feeling: Good

MedDRA releases: 2024-11 · check-in answers available
2022-04-01
Call 1 — Left Voicemail
2022-05-20
Health check-in — 6 month, dose 3
Feeling: Good

Adult check-in
2022-11-19
Health check-in — 12 month, dose 3
Feeling: Good

Adult check-in

Vaccinations

Dose	Date	Manufacturer	Co-administered
1	2021-02-03	Moderna
2	2021-03-03	Moderna
3	2021-11-19	Moderna	No

Call center

Reported	Outcome	VAERS-related outcome
2021-06-02	Unsuccessful

Free text

Release 3

Systemic reaction (other): Mild spaciness/light headedness, slight difficulty concentrating today.

Release 5

Systemic reaction (other): Brain fog (mild), amotivational.

Systemic reaction (other): Fatigue improved.

Systemic reaction (other): Mild dry cough for the 4 days

Systemic reaction (other): Mild rare dry cough

Symptoms: Pain in my right distal anterolateral upper arm, right biceps and right dorsal forearm present over the last 5 days. Injections were on the opposite side, however, on my left arent.

Release 6

Symptoms: Neuralgia-like burning and ache in my non-injected arms biceps muscle. Intermittent. Somewhat positionally related.

Symptoms: Ongoing variable right arm dull, burning/aching, like a radiculitis, in antecubital, dorsal forearm and dorsal wrist distribution. Began within a week of 2nd Moderna injection. Injection was in left arm, though.

Release 7

Symptoms: Continued pain in the distal biceps region of the non-vaccination site arm (right).

Release 8

Symptoms: Still a sore right biceps/arm on the opposite side from my vaccinations. Biceps Tendinitis? Began 1 week after my 2nd Vax. I also had a recurrence of a swollen right eyelid that was likely due to herpes zoster flare which I previously had in 2/20. cut off by CDC

Healthcare visit (other): Self care w/ acyclovir - I am a physician.

Release 10

Systemic reaction (other): Axillarynseelling/edema

Systemic reaction (other): Non-nodular, non-painful axillary swelling/lymphedema of armpit ipsilateral to injection site persists but is lessening.

Systemic reaction (other): Lymphedema in my axilla ipsilateral to the injection.

Systemic reaction (other): Still residual lateral chest and axillary swelling / lymphedema on the ipsilateral side as my injection.

Release 11

Symptoms: Olecranon bursa swelling on the same arm I received the booster injection 11/19/21.

Release 12

Systemic reaction (other): Unilateral axillary lymphedema on same side as the deltoid injection.

Free-text releases are not linked to a specific 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
HCVO	Self-medication	✓	✓	✓
SD	Burning sensation	✓	✓	✓
SD	Condition aggravated	✓	·	✓
SD	Herpes zoster reactivation	○	✓	○
SD	Hypoaesthesia	✓	·	✓
SD	Joint swelling	·	·	✓
SD	Myalgia	✓	✓	✓
SD	Neuralgia	✓	✓	✓
SD	Pain in extremity	✓	✓	✓
SD	Pre-existing disease	✓	✓	✓
SD	Radicular pain	○	✓	○
SD	Radiculitis brachial	✓	·	✓
SD	Swelling of eyelid	○	✓	○
SD	Tendonitis	○	✓	○
SRO	Cough	✓	✓	✓
SRO	Disturbance in attention	✓	✓	✓
SRO	Dizziness	✓	✓	✓
SRO	Fatigue	✓	✓	✓
SRO	Feeling abnormal	✓	✓	✓
SRO	Lymphoedema	·	·	✓
SRO	Oedema peripheral	·	·	✓
SRO	Swelling	·	·	✓

✓ active code · ○ coded but marked inactive · blank = not in that release