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

This is VAERS ID 1415776



Case Details

VAERS ID: 1415776 (history)  
Form: Version 2.0  
Age: 32.0  
Sex: Male  
Location: Foreign  
Vaccinated:2021-06-04
Onset:2021-06-04
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / -

Administered by: Other       Purchased by: ?
Symptoms: Blood pressure measurement, Electrocardiogram, Loss of consciousness, Malaise, SARS-CoV-2 test, Syncope, Vaccination site haemorrhage
SMQs:, Torsade de pointes/QT prolongation (broad), Haemorrhage terms (excl laboratory terms) (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad), COVID-19 (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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data: Test Name: Blood pressure; Result Unstructured Data: Test Result:Unknown Result; Test Name: ECG; Result Unstructured Data: Test Result:Unknown Result; Test Date: 20201019; Test Name: COVID-19 virus test; Test Result: Negative ; Comments: No - Negative COVID-19 test
CDC Split Type: GBPFIZER INC2021657854

Write-up: loss of consciousness; Fainting; felt sick; Bleeding a lot at site of vaccine; This is a spontaneous report from a contactable consumer received from the regulatory authority (RA). The regulatory authority report number is GB-MHRA-WEBCOVID-202106041836507160-WYVGE, Safety Report Unique Identifier GB-MHRA-ADR 25422972. A 32-year-old male patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 04Jun2021 (Lot number was not reported, at age of 32-year-old) as single dose for covid-19 immunisation. The patient medical history was not reported. No medical history. Patient has not had symptoms associated with COVID-19. Patient is not enrolled in clinical trial. The patient''s concomitant medications were not reported. The patient previously took epinephrine adrenaline [ADRENALINE]. Instantly after having the vaccine on 04Jun2021, patient felt sick. Patient was bleeding a lot at site of vaccine too. After the patient went to sit down, within 10 seconds patient passed out. After he came back around instantly again, patient had loss of consciousness again and had to have adrenaline. Patient has not tested positive for COVID-19 since having the vaccine. The patient underwent lab tests included COVID-19 virus test: negative on 19Oct2020 No - Negative COVID-19 test, blood pressure: unknown result on an unspecified date, electrocardiogram (ECG): unknown result on an unspecified date. The outcome of the events was unknown. The seriousness was reported as hospitalization. No follow-up attempts are possible, information about batch number cannot be obtained.


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