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
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If other, please specify
Gender
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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
Was the mushroom consumed raw, lightly cooked, or well cooked?
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Has the person/animal ever eaten this mushroom before
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If yes, were the effects the same
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If no, describe different effects
For human poisonings, was alcohol consumed prior to, during, or after consumption of the mushroom?
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For human poisonings, was alcohol consumed after the meal but prior to symptoms appearing?
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For human poisonings, did more than one person consume the mushroom?
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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
Did all persons who became ill suffer the same symptoms?
Choose 1
If no, please explain.

Was treatment given
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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.
Yes
No
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