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From the 9/17/2021 release of VAERS data:

This is VAERS ID 965715



Case Details

VAERS ID: 965715 (history)  
Form: Version 2.0  
Age: 57.0  
Sex: Female  
Location: Florida  
Vaccinated:2021-01-08
Onset:2021-01-08
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, Blood test, Catheterisation cardiac, Chest pain, Echocardiogram, Electrocardiogram, Magnetic resonance imaging, Myocarditis, Viral cardiomyopathy
SMQs:, Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: None
Current Illness: None
Preexisting Conditions: Breast Cancer 2010
Allergies: None
Diagnostic Lab Data: Blood work, EKG, Echocardiogram, MRI, cardiac catheterization
CDC Split Type:

Write-up: viral cardiomyopathy, myopericarditis, weakness, chest pains


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