Person filing report:
Reporter's postal address:
e-mail address:
Phone:

1. Report is about:

   adult childanimal-doganimal-catanimal-.... male female Age:

2. About the incident:

   1. Mushroom was eaten: raw cooked
   2. How much mushroom was eaten?
   3. Was mushroom eaten: accidentally for food intentionally for recreation
   4. Was more than one kind of mushroom eaten? Yes No Unknown
   5. Was mushroom eaten at more than one meal? Yes No Unknown
   6. When was mushroom collected?
      Where was mushroom collected?[State or Province]
   7. When was mushroom eaten? Date:Time:
   8. When was first sign of illness? Date: Time:
      Onset interval: hours
   9. Was any alcohol consumed with mushroom or within 24 hours after mushroom was eaten? Yes No Unknown
   10. How many persons ate mushrooms?
   11. Were all persons who ate mushrooms ill? Yes No
       number:
   12. Were persons in the group ill who did not eat mushrooms? Yes
       number: No

3. What were symptoms of poisoning?
   1. Check all symptoms occurring.
      chills flushing fever diarrhea hallucination salivation dizziiness intestinal cramps sweating disorientation muscle spasm vomiting drowsiness nausea weakness headache

      Were there other symptoms? yes no

      What were the other symptoms?

   2. Did person ever eat this mushroom before? yes no
   3. Were the effects the same? yes no Describe different effects:
   4. Was treatment given? Yes No What was the treatment?
      What were results of treatment?
      Case/chart number (important for follow-up):
      Hospital name:
      Attending physician:
      Patient's Name (OPTIONAL):

4. About the mushroom:
   1. Who identified the species?
      Herbarium number (if available):
   2. Were any special mushroom tests done? yes no List tests and results:
5. Other comments about the case or mushroom; for example, what species did the collector expect: