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This is VAERS ID 1749911

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History of Changes from the VAERS Wayback Machine

First Appeared on 10/1/2021

VAERS ID: 1749911
VAERS Form:2
Age:28.0
Sex:Male
Location:New York
Vaccinated:2021-09-30
Onset:2021-09-30
Submitted:0000-00-00
Entered:2021-09-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (UNKNOWN)) / UNKNOWN MANUFACTURER 212A21A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Dizziness, Loss of consciousness, Memory impairment, Muscle twitching, Eye movement disorder

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: Client passed out approximately 2 minutes after receiving J&J vaccine, client had no recollection of passing out after, rolling back of eyes and slight right arm muscle twitch upon awakening. On site EMS called to client''s side, observation provided . Client stated he did not remember passing out but he does remember feeling dizzy prior to passing out, Pt awoke within less than a minute. Client has no history of fainting.

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