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From the 11/26/2021 release of VAERS data:

This is VAERS ID 1772567

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Case Details

VAERS ID: 1772567 (history)  
Form: Version 2.0  
Age: 52.0  
Sex: Male  
Location: California  
Vaccinated:2021-09-14
Onset:2021-10-04
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-10-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 LA / SYR

Administered by: Pharmacy       Purchased by: ?
Symptoms: Asthma, Influenza
SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (narrow), Eosinophilic pneumonia (broad), Hypersensitivity (broad), Infective pneumonia (broad), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Graves and Hashimoto?s
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Asthma, flu


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