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

This is VAERS ID 1371238



Case Details

VAERS ID: 1371238 (history)  
Form: Version 2.0  
Age: 27.0  
Sex: Male  
Location: New Jersey  
Vaccinated:2021-06-03
Onset:2021-06-03
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 203A21A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Altered state of consciousness, Dizziness, Fall, Immediate post-injection reaction
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Vestibular disorders (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (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: No other medications.
Current Illness: No other illnesses.
Preexisting Conditions: No chronic health conditions.
Allergies: No known allergies.
Diagnostic Lab Data:
CDC Split Type:

Write-up: Approximately 1 minute after administering vaccine, patient asked for water with complaints of lightheadedness. As he walked up to pharmacy door for water, he collapsed to the ground. He went in and out of consciousness while laying on the ground for about ten minutes. He had no other complaints other than lightheadedness. He did not eat any food today. He said in the past he had fainted after getting a numbing injection for a dental procedure and believes it may be a similar reaction. The paramedics were called and evaluated him. His blood pressure and HR were within normal limits. He refused to be taken to the hospital for further evaluation.


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