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

This is VAERS ID 1479064



Case Details

VAERS ID: 1479064 (history)  
Form: Version 2.0  
Age: 35.0  
Sex: Female  
Location: Ohio  
Vaccinated:2021-07-03
Onset:2021-07-03
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 050C21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Disorientation, Eye movement disorder, Loss of consciousness
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Ocular motility disorders (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Lamotrigine 200mg, valcyclovir 500mg
Current Illness:
Preexisting Conditions:
Allergies: kna
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient''s eyes rolled back, head fell back and patient passed out. 911 was called. Patient came to approximately 1 min later and felt disoriented. Medics arrived and took her to hospital for evaluation.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1479064


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