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

This is VAERS ID 1775083

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Case Details

VAERS ID: 1775083 (history)  
Form: Version 2.0  
Age: 24.0  
Sex: Female  
Location: North Carolina  
Vaccinated:2021-10-09
Onset:2021-10-09
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-10-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FE3592 / 3 LA / IM
FLU4: INFLUENZA (SEASONAL) (AFLURIA QUADRIVALENT) / SEQIRUS, INC. P100352329 / 1 RA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Eye movement disorder, Fall, Loss of consciousness, Musculoskeletal stiffness
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), Dystonia (broad), Parkinson-like events (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Ocular motility disorders (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Arthritis (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? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: Unknown
Preexisting Conditions: Asthma
Allergies: None
Diagnostic Lab Data:
CDC Split Type:

Write-up: Patient stated she was "feeling dizzy and felt like passing out" after receiving the Afluria vaccine as her Pfizer vaccine was administered. She started with rapid eye roll, lost consciousness, stiff movement of arms and legs, and fell backwards on head. 911 was called and she was taken to hospital


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