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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1376875

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Case Details

VAERS ID: 1376875 (history)  
Form: Version 2.0  
Age: 28.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-06-04
Onset:2021-06-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 203A21A / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Anxiety, Feeling cold
SMQs:, 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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: History of seizures per parents
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: The patient was very nervous before the injection. Approximately 5 minutes post-injection, the patient felt very anxious and reported feeling cold. Her parents had her lay on the floor. I held an ammonia inhalant close to her. She was breathing normally, but visibly nervous. I asked about her medical history and parents reported a history of seizures. They said she normally experiences flashing lights before a seizure; but she did not report a prodrome. I called for an ambulance for her to be assessed. The parents asked for her to be hospitalized for a workup.


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