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Voluntary NAMA Poison Case Registry Email Report

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.

Person filing report:
  
Reporter's name:
Reporter's address:
Reporter's email:
Reporter's phone:
Report is about:
About the incident:
Mushroom:
Was the mushroom eaten:
How many became ill:
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 (check all that apply):








Other symptoms:
Did the person ever eat this mushroom before:
Were the effects the same:
If no, describe different effects:
Was treatment given:
If yes, what treatment:
Results of the treatment:
About the mushroom:
 
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.
To clear all fields and start over, click the Reset button.

Thank you for participating. The annual summary of reports to NAMA's Poison Case Registry is published in McIlvainea, the Journal of Amateur Mycology.

Dr. Michael W. Beug