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From the 9/10/2021 release of VAERS data:

This is VAERS ID 1365891



Case Details

VAERS ID: 1365891 (history)  
Form: Version 2.0  
Age: 14.0  
Sex: Male  
Location: California  
Vaccinated:2021-06-01
Onset:2021-06-01
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0180 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Amnesia, Fall, Headache, Nervousness, Tremor
SMQs:, Neuroleptic malignant syndrome (broad), Dementia (broad), Parkinson-like events (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Hypoglycaemia (broad)

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

Write-up: PT STARTED TO FEEL NERVOUS. PT SAID HE FELT HE NEEDED SOME AIR SO HE WALKED OUTSIDE. MOTHER WITNESSED HIS FALL. PT FELL ON HIS ELBOWS, HANDS SHOOK FOR 2 TO 3 SECONDS. PT DID NOT RECALL FAINTING. REPORTED HAVING A HEADACHE IMMEDIATELY AFTER.


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