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

This is VAERS ID 1371746



Case Details

VAERS ID: 1371746 (history)  
Form: Version 2.0  
Age: 34.0  
Sex: Male  
Location: Georgia  
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 (MODERNA)) / MODERNA 049C21A / 2 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Dizziness, Loss of consciousness, Sensory disturbance
SMQs:, Torsade de pointes/QT prolongation (broad), Peripheral neuropathy (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), 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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient was fine at time of injection. Patient stated he started feeling the vaccine throughout his body and that he was going to pass out. Patient passed out and came back to quickly; patient drank a bottle of water once he came to. I had the patient wait for 30 minutes in the pharmacy; he was fine at the time he left. Called back at 3:11pm; he states he is doing fine. He passed out with the first vaccination as well.


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