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From the 7/23/2021 release of VAERS data:

This is VAERS ID 1328072



Case Details

VAERS ID: 1328072 (history)  
Form: Version 2.0  
Age: 37.0  
Sex: Male  
Location: Pennsylvania  
Vaccinated:2021-05-18
Onset:2021-05-18
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-05-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 205A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Fall, Loss of consciousness, Musculoskeletal discomfort, Nausea, Respiration abnormal, Skin abrasion, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Rhabdomyolysis/myopathy (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Respiratory failure (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness: none
Preexisting Conditions: none
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient in chair sitting position at time of vaccination, minutes later fell out of chair face forward and on carpet floor lying on left side breathing hard. Patient had rug burns on face. Patient lost consciousness for about 1 to 1 and a half minute patient snapped back immediately and slowly came back to being oriented. EMS arrived to check over patient, patient was nauseated and vomited. Patient complained of neck discomfort, EMS pressed on patients neck and EMS felt it was muscle related. Patient refused additional service from EMS. EMS advised patient to seek additional services from hospital if symptoms worsen.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1328072


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