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From the 11/19/2021 release of VAERS data:

This is VAERS ID 1703879

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Case Details

VAERS ID: 1703879 (history)  
Form: Version 2.0  
Age: 59.0  
Sex: Female  
Location: Georgia  
Vaccinated:2021-08-13
Onset:2021-09-13
   Days after vaccination:31
Submitted: 0000-00-00
Entered: 2021-09-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Anxiety, Blepharospasm, Headache, Muscle spasms, Peripheral swelling, Pruritus, Rash
SMQs:, Cardiac failure (broad), Anaphylactic reaction (broad), Angioedema (broad), Dystonia (broad), Extravasation events (injections, infusions and implants) (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Periorbital and eyelid disorders (narrow), Ocular motility disorders (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (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: Vitamin d3, C, Zinc, multi vitamin
Current Illness:
Preexisting Conditions:
Allergies: Cashews
Diagnostic Lab Data:
CDC Split Type:

Write-up: Headache, swollen arm for 3 days size of a golf ball, itching, eye twitch on going at this time, anxiety Muscle cramps, 99 temp on and off., and small bumps on arm. Took two Tylenol. Anxiety still ongoing. Never had this with vaccine before. Will not get second shot. Have not visited doctor yet. If eye continues to twitch will go to optometrist or neurologist.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1703879


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