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This is VAERS ID 1366354

History of Changes from the VAERS Wayback Machine

First Appeared on 6/4/2021

VAERS ID: 1366354
VAERS Form:2
Age:43.0
Sex:Male
Location:Idaho
Vaccinated:2021-06-01
Onset:2021-06-01
Submitted:0000-00-00
Entered:2021-06-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0178 / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Blepharospasm, Disorientation, Staring, Musculoskeletal stiffness

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: no known
Current Illness: no known
Preexisting Conditions: none
Allergies: no known
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was administered shot by RN and he immediately stiffened up and eyes became distant and twitched. He was like this for 10 sec and was disoriented when he became aware of surroundings. EMS was contacted. They assessed him and took him to the hospital

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1366354&WAYBACKHISTORY=ON

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