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

This is VAERS ID 1706455

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Case Details

VAERS ID: 1706455 (history)  
Form: Version 2.0  
Age: 15.0  
Sex: Male  
Location: Texas  
Vaccinated:2021-09-12
Onset:2021-09-12
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-09-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 30130BA / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Asthenia, Fatigue, Flushing, Hypotension, Lethargy, Vision blurred, Visual impairment
SMQs:, Anaphylactic reaction (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Glaucoma (broad), Optic nerve disorders (broad), Lens disorders (broad), Retinal disorders (broad), Hypersensitivity (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

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

Write-up: Systemic: Exhaustion / Lethargy-Severe, Systemic: Flushed / Sweating-Mild, Systemic: Hypotension-Severe, Systemic: Visual Changes/Disturbances-Medium, Systemic: Weakness-Severe, Additional Details: Patient became extremely lethargic while sitting on the chair 2 to 3 mins after receive first dose of pfizer covid-19 vaccination. Alert and oriented x3, c/o intermitent blurry vision, Bp 73/28 HR 108. Asked for water, given above 5oz. No s/s allergic reaction. Taken to ER by ambulance 4 to 5mins later while still extremely lethargic.


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