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

This is VAERS ID 1775842

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Case Details

VAERS ID: 1775842 (history)  
Form: Version 2.0  
Age: 15.0  
Sex: Female  
Location: California  
Vaccinated:2021-10-10
Onset:2021-10-10
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-10-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH FF2590 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (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: None reported
Current Illness: None reported
Preexisting Conditions: None reported
Allergies: None reported
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient fainted 10 to 15 minutes after receiving COVID vaccination.


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