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This is VAERS ID 1420367

History of Changes from the VAERS Wayback Machine

First Appeared on 6/25/2021

VAERS ID: 1420367
VAERS Form:2
Age:40.0
Sex:Male
Location:Florida
Vaccinated:2021-06-20
Onset:2021-06-20
Submitted:0000-00-00
Entered:2021-06-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 054C21A / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Dizziness, Fall, Hypotension, Pallor, Syncope, Visual impairment

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Systemic: Dizziness / Lightheadness-Mild, Systemic: Fainting / Unresponsive-Mild, Systemic: Hypotension-Mild, Systemic: Visual Changes/Disturbances-Mild, Additional Details: patient had some dizziness, pale color, fell out of chair and on to floor after receiving shot. patient was alert and responsive, sat down again and held on to counter for about 30 minutes. patient stated he no longer felt dizzy or strange. I took patient''s BP and it was 99/58 with HR of 55 bpm, patient stated he is very fit and this was normal for him. I allowed patient to leave at that point, contacted him on 6/22, he said he was well and had experienced no additional issues after leaving.

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