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From the 10/8/2021 release of VAERS data:

This is VAERS ID 904210



Case Details

VAERS ID: 904210 (history)  
Form: Version 2.0  
Age: 32.0  
Sex: Female  
Location: Colorado  
Vaccinated:2020-12-17
Onset:2020-12-17
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-12-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 RA / IM

Administered by: Private       Purchased by: ?
Symptoms: Anaphylactic reaction
SMQs:, Anaphylactic reaction (narrow), Anaphylactic/anaphylactoid shock conditions (narrow), Hypersensitivity (narrow)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Levothyroxine, metformin, lisinopril, wellbutrin, vitamin c, zinc, vitamin d, fish oil, vitamin b12
Current Illness: None
Preexisting Conditions: Anxiety, hypothyroid, pcos, migraine
Allergies: Latex
Diagnostic Lab Data: Emergency room visit on 12/17/20
CDC Split Type:

Write-up: Anaphylaxis within 15 minutes of administration


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=904210

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