NAMA
REPORT A POISONING

For emergency treatment, contact your physician, the nearest poison center, or hospital emergency room first. After the episode, file a separate report for each patient using either email submission or use mail-in form, making sure to protect patient confidentiality. We desire reports about known or suspected toxic species that have been consumed without obvious adverse effect. If there is an entry where the information is not available or unknown, skip that box.

Disclaimer: Personal information provided to NAMA, and/or personal information which identifies an individual poisioned by mushrooms or other organisms will not be made available to the public, shared with third-parties, or used and stored by NAMA on this website.


First Name: (Required)
Last Name: (Required)
Email: (Required)

Address:

Phone:
Incident Information
Report is about:
Choose 1
adult
child
dog
cat
other
If other, please specify:
Gender:
Choose 1
male
female
Age::
About the incident:
How much mushroom was eaten:
Was more than one kind of mushroom involved:
Yes
No
City, state or province where mushroom was collected:
Date and time mushroom was eaten, handled or inhaled:
Date and time of first sign of illness:
Onset time in hours:
What were symptoms of poisoning:
Select all that apply
chills
flushing
fever
diarrhea
hallucinations
salivation
dizziness
intestinal cramps
sweating
disorientation
muscle spasms
vomiting
drowsiness
nausea
weakness
headache
rash
Other symptoms:
Has the person/animal ever eaten this mushroom before :
Choose 1
yes
no
unknown
If yes, were the effects the same:
Choose 1
yes
no
unknown
If no, describe different effects:
For human poisonings, was alcohol consumed prior to, during, or after consumption of the mushroom?:
Choose 1
Prior
During
After
Unknown
For human poisonings, was alcohol consumed after the meal but prior to symptoms appearing?:
Choose 1
Yes
No
Unknown
For human poisonings, did more than one person consume the mushroom?:
Choose 1
Yes
No
If yes, how many other people also consumed the mushroom?:
If more than one person consumed the mushroom, were any of them also adversely affected?:
Choose 1
Yes
No
Unknown
Did all persons who became ill suffer the same symptoms?:
Choose 1
Yes
No
Unknown
If no, please explain.:

Was treatment given:
Choose 1
yes
no
unknown
If yes, what treatment:
Results of the treatment:
About the mushroom:
Genus:
Species:
Who identified the species:
Specify any identification tests and results:
Other comments; e.g., what species did the collector expect :

Disclaimer: Personal information provided to NAMA, and/or personal information which identifies an individual poisioned by mushrooms or other organisms will not be made available to the public, shared with third-parties, or used and stored by NAMA on this website.

I grant permission to contact me regarding this poisoning.:
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No
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