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From the 9/17/2021 release of VAERS data:

This is VAERS ID 1392085



Case Details

VAERS ID: 1392085 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-02-09
Onset:2021-06-03
   Days after vaccination:114
Submitted: 0000-00-00
Entered: 2021-06-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Deep vein thrombosis
SMQs:, Embolic and thrombotic events, venous (narrow), Thrombophlebitis (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? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: azelastine, Effexor, ergocalciferol, ibuprofen, lisinopril, metoprolol, Montelukast, Mucinex, singulair, Tamsulosin, trazodone, vitamin c
Current Illness: none
Preexisting Conditions: glaucoma, hypercholesterolemia, hypertension, prostate cancer, vitamin d deficiency
Allergies: mold, dust
Diagnostic Lab Data:
CDC Split Type:

Write-up: DVT-hospitalized on 6/3/2021


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