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:


Last Name:


Email:




Person filing report:

Reporter's name
 
Reporter's address
 
Reporter's email
 
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
 
To complete the process, click the Submit button below.


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