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

This is VAERS ID 1377799



Case Details

VAERS ID: 1377799 (history)  
Form: Version 2.0  
Age: 28.0  
Sex: Male  
Location: California  
Vaccinated:2021-06-04
Onset:2021-06-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 036C21A / 2 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Blood pressure decreased, Malaise, Pallor, Presyncope
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad), Dehydration (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: Unknown
Current Illness: None provided by patient
Preexisting Conditions: No
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:

Write-up: About 5 minutes into his post-vaccination observation, patient felt unwell and tried to get up to get help. We are on-site pharmacy located inside the Health Center. At the time, a nurse is monitoring patients at the observation area. He noticed the patient was pale and he reached over to grab the patient as he was about to fall/faint. The nurse took him back into one of the patient''s room. His blood pressure was very low. Patient was given 2 boxes of apple juices and some Gatorade. He rested for another 30 minutes and he felt better. Then he left.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1377799


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