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

This is VAERS ID 1404501



Case Details

VAERS ID: 1404501 (history)  
Form: Version 2.0  
Age: 31.0  
Sex: Unknown  
Location: Foreign  
Vaccinated:2021-06-04
Onset:2021-06-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 3002332 / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Confusional state, Dizziness, Eye pain, Headache, Pain in extremity, Rhinalgia, SARS-CoV-2 test, Vision blurred
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (narrow), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Glaucoma (broad), Lens disorders (broad), Retinal disorders (broad), Vestibular disorders (broad), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: IBUPROFEN
Current Illness:
Preexisting Conditions: Comments: No medical history was reported.
Allergies:
Diagnostic Lab Data: Test Date: 20210528; Test Name: COVID-19 virus test; Test Result: Negative ; Result Unstructured Data: COVID-19 virus test
CDC Split Type: GBMODERNATX, INC.MOD20212

Write-up: Pain eye; Stinging of nose; Headache; Blurry vision; Dizzy; Painful arm; Confusion; This regulatory authority case was reported by a consumer and describes the occurrence of CONFUSIONAL STATE (Confusion), VISION BLURRED (Blurry vision), DIZZINESS (Dizzy), PAIN IN EXTREMITY (Painful arm), EYE PAIN (Pain eye), RHINALGIA (Stinging of nose) and HEADACHE (Headache) in a 31-year-old patient of an unknown gender who received mRNA-1273 (Moderna CoviD-19 Vaccine) (batch no. 3002332) for COVID-19 vaccination. No medical history was reported. Concomitant products included IBUPROFEN for Back pain. On 04-Jun-2021, the patient received first dose of mRNA-1273 (Moderna CoviD-19 Vaccine) (unknown route) 1 dosage form. On 04-Jun-2021, the patient experienced CONFUSIONAL STATE (Confusion) (seriousness criterion medically significant), DIZZINESS (Dizzy) (seriousness criterion medically significant) and PAIN IN EXTREMITY (Painful arm) (seriousness criterion medically significant). On 05-Jun-2021, the patient experienced VISION BLURRED (Blurry vision) (seriousness criterion medically significant). On 07-Jun-2021, the patient experienced EYE PAIN (Pain eye) (seriousness criterion medically significant), RHINALGIA (Stinging of nose) (seriousness criterion medically significant) and HEADACHE (Headache) (seriousness criterion medically significant). On 05-Jun-2021, VISION BLURRED (Blurry vision) had resolved. On 06-Jun-2021, CONFUSIONAL STATE (Confusion) had resolved. At the time of the report, DIZZINESS (Dizzy) and PAIN IN EXTREMITY (Painful arm) was resolving and EYE PAIN (Pain eye), RHINALGIA (Stinging of nose) and HEADACHE (Headache) had not resolved. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 28-May-2021, SARS-CoV-2 test: covid-19 virus test (Negative) COVID-19 virus test. The action taken with mRNA-1273 (Moderna CoviD-19 Vaccine) (Unknown) was unknown. Patient has not tested positive for COVID-19 since having the vaccine. No treatment information was provided. Company Comment Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded.; Sender''s Comments: Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded.


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