0 - Mycological Society of America

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