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This is VAERS ID 1376813

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First Appeared on 6/11/2021

VAERS ID: 1376813
VAERS Form:2
Age:26.0
Sex:Male
Location:Oregon
Vaccinated:2021-06-04
Onset:2021-06-04
Submitted:0000-00-00
Entered:2021-06-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 203A21A / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Dizziness, Loss of consciousness, Malaise, Syncope, Face injury, Seizure like phenomena

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: Unknown - patient does not fill RX here at Pharmacy
Current Illness: unknown
Preexisting Conditions: unknown
Allergies: no medications listed on vaccine form
Diagnostic Lab Data: blood pressure was around 40 at time paramedics arrived, started to climb to around 60 by the time patient was being carted off in ambulance.
CDC 'Split Type':

Write-up: Patient recieved Covid vaccination from our intern and 10 seconds later reported feeling dizzy and unwell. Pt sat down immediately in consult room but then fainted and fell out of the chair and landed face first on the floor and experienced seizing motions. Patient was out for 30 seconds to a 1 minute. The patient came to and reported feeling better, wanted to sit up and wanted water. A water bottle was provided for the patient. 911/paramedics were called and 3-5 minutes later the patient fainted with seizing motions again but was supported and did not fall out of chair again. shortly after the second fall, paramedics arrived and took over. patient ate 4.5 hours prior to vaccination and also reported never fainting before after or while getting a vaccine.

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