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

This is VAERS ID 1330774



Case Details

VAERS ID: 1330774 (history)  
Form: Version 2.0  
Age: 13.0  
Sex: Male  
Location: New Hampshire  
Vaccinated:2021-05-19
Onset:2021-05-19
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-05-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0168 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Fall, Head injury, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Accidents and injuries (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Patient received dose of vaccine. While standing patient experienced syncope and fell to floor. Bumped head against wall while falling but was caught by father before hitting floor. He quickly regained consciousness and had a strong pulse.
Current Illness: none known
Preexisting Conditions: none known
Allergies: no know allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient received dose of vaccine. While standing patient experienced syncope and fell to floor. Bumped head against wall while falling but was caught by father before hitting floor. He quickly regained consciousness and had a strong pulse. He remained on the floor with feet elevated for 10 minutes. He then sat in chair IN front of pharmacy for an additional 15 minutes. At that point he felt fine and left the pharmacy with his father.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1330774


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