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

This is VAERS ID 1485176



Case Details

VAERS ID: 1485176 (history)  
Form: Version 2.0  
Age: 48.0  
Sex: Male  
Location: California  
Vaccinated:2021-07-01
Onset:2021-07-01
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-07-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN 203A21A / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Fall, 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), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypoglycaemia (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? No
Previous Vaccinations:
Other Medications: None listed
Current Illness:
Preexisting Conditions:
Allergies: No known drug allergies
Diagnostic Lab Data:
CDC Split Type:

Write-up: A few minutes after receiving the vaccine, the pharmacist was informed that the patient was falling over in our waiting area. The pharmacist got to the patient and caught him before he hit the floor. He lost consciousness for less than a minute and EMS were contacted. The patient was helped into a sitting position, given water and monitored. The patient was alert and by the time the paramedics arrived. He was assessed by them and the patient did not go to the hospital.


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