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This is VAERS ID 1368103

History of Changes from the VAERS Wayback Machine

First Appeared on 6/4/2021

VAERS ID: 1368103
VAERS Form:2
Age:27.0
Sex:Male
Location:Minnesota
Vaccinated:2021-06-01
Onset:2021-06-01
Submitted:0000-00-00
Entered:2021-06-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022B21A / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Dizziness, Fall, Head injury, Syncope

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)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient received a vaccine and was told that he needed to stay in the store for 15 minutes. He went to purchase a water about 5 minutes after vaccine in a different register and was feeling lightheaded. After the transaction he fainted with the back of his head fell on the hard floor. He was being assisted by the store staff as well as a pedestrian who claimed to be a health care professional. He was given an orange juice, one water and a battery powered fan to provide cool air. He also requested to lay down on the floor, and he ended up laying on the floor for about 30 minutes. After that he stood up and regained color on his face. He then walked out of the store. Staff asked him if he wanted the ambulance to be called and he declined. Pharmacist called patient the next day to check on patient, and was unable to reach the patient.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1368103&WAYBACKHISTORY=ON


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