0 - Mycological Society of America
0 - Mycological Society of America
0 - Mycological Society of America
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NORTH At9ERICAi4 MYCOLOGICAL ASSOCIATIO'J-MUSiiROO+1 POISONIi4G REPORT FORM<br />
THIS IS ONLY A REPORTING FORM: FOR EMERGENCY TREATMENT, CONTACT YOUR PHYSICIAN,<br />
NEAREST POISON CENTER OR HOSPITAL EMERGENCY ROOM<br />
Please answer the questions on this form @ checking the appropriate box<br />
or by - in -- the information requested.<br />
Please check the "don't know" box if you do not know the answer.<br />
I. Name <strong>of</strong> person filling out this form:<br />
Address :<br />
This form is about:<br />
myself 17 patient U Student<br />
club member O Other u<br />
About the incident: Don ' t Know<br />
idas mushroom eaten RAbJ or COOKED 0<br />
How much mushroom was eaten? I2<br />
Was mushroom eaten: by a child accidentally n I'<br />
for food , intentionally for recreation<br />
E l 0'<br />
El<br />
Was mushroom eaten at more thanmemeal? Yes 0 No 1 [i<br />
Was more than one kind <strong>of</strong> mushroom eaten? Yes 0 No n<br />
When was the mushroom collected? l.3<br />
When was mushroom eaten? Date Time I 3<br />
When was the first sign <strong>of</strong> illness? Date<br />
Time Onset interval : hours<br />
Was any alcohol consumed with or within 24 hours after mushroom<br />
was eaten? Yes<br />
0 n<br />
How many persons ate mushroom?<br />
Were - all persons who ate mushrooms ill? Yes [ No a n<br />
Were persons in the group who did not eat mushrooms ill?<br />
Yes