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From the 9/3/2021 release of VAERS data:

This is VAERS ID 1377921



Case Details

VAERS ID: 1377921 (history)  
Form: Version 2.0  
Age: 61.0  
Sex: Male  
Location: Florida  
Vaccinated:2021-05-12
Onset:2021-06-04
   Days after vaccination:23
Submitted: 0000-00-00
Entered: 2021-06-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Private       Purchased by: ?
Symptoms: Deep vein thrombosis, Ultrasound scan
SMQs:, Embolic and thrombotic events, venous (narrow), Thrombophlebitis (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Xarelto 15 mg, Rivaroxaban 20 mg tablet, losartan 100 mg tablet, atorvastatin 40 mg tablet, meloxicam 15 mg tablet. aspirin 325 mg delayed release tablet, one a day men''s vitamin
Current Illness: N/A
Preexisting Conditions: Vitamin B12 deficiency, Atherosclerotic heart disease of native coronary artery without angina pectoris, osteoarthritis of knee, major depressive disorder single episode moderal, metabolic syndrome, nonrheumatic aortic (valve) stenoisis with insufficiency, obstructive sleep apnea, actinic keratosis, type 2 diabetes mellitus without complications, hypertension
Allergies: None
Diagnostic Lab Data: Confirmed by ultrasound 06/04/21
CDC Split Type:

Write-up: Developed DVT of right leg


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