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From the 9/17/2021 release of VAERS data:

This is VAERS ID 1366577

Case Details

VAERS ID: 1366577 (history)  
Form: Version 2.0  
Age: 14.0  
Sex: Female  
Location: Illinois  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Pharmacy       Purchased by: ?
Symptoms: Anxiety, Dizziness, Loss of consciousness, Pallor, Vomiting
SMQs:, Torsade de pointes/QT prolongation (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad)

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

Write-up: Patient felt dizzy immediately after the shot was given. She said she was going to pass out, and did for about 10 seconds. She was sitting up in a chair during this time, with her mom holding her up. She came to, the about 20 seconds later, she passed out again for another 10 seconds. She came to, and was given some water to drink, but 20 seconds after that she threw up the water. I took her blood pressure, and it was 60/40, with a pulse of 60. She was very pale. After resting in the chair and taking deep breaths, her color returned and she felt much better. she also said her vision wasn''t blurry anymore. Ten minutes later, she left with her mom, feeling ok. She was very anxious about getting the shot, and told me she had passed out in the pass after giving blood.

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