NAMA
EMAIL REPORT FORM
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.

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

Person filing report:
Reporter's name: (Required)
Reporter's address:

Reporter's email: (Required)
Reporter's phone:
Report is about:
Choose 1
adult
child
animal-dog
animal-cat
animal-other
Gender:
Choose 1
male
female
Age::
About the incident:
Mushroom:
Choose 1
was eaten raw
was eaten cooked
was only handled
spores were inhaled
How much mushroom was eaten:
Was more than one kind of mushroom involved:
Yes
No
Was the mushroom eaten:
Choose 1
for food
accidentally
for research
for recreation
Was the mushroom eaten at more than one meal:
Choose 1
yes
no
unknown
Alcohol consumed within 24 hours:
Choose 1
yes
no
unknown
How many people ate mushrooms:
How many became ill:
Were there people in the group who did not eat mushrooms who became ill:
Choose 1
yes
no
unknown
If so, how many:
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:
Was a species known or suspected of being toxic consumed without any adverse symptoms:
Choose 1
yes
no
unknown
Did the person ever eat 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:
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 :
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