0 - Mycological Society of America

111. What were symptoms of poisoning? Check all symptoms listed below:
0 Nausea 0 Vomiting 0 Intestinal cramps
0 Fever I3 chills 0 Diarrhea
0 Weakness 0 Rash 0 Flushing
0 Sweating 0 Salivation 0 Dizziness
Were there other symptoms? Yes 0 No 0 Don't know 0
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What were the other symptoms?
4
B. Did person ever eat this mushroom before? Yes 0 No Don't know
C. Were the effects the same? Same0 Different a Don ' t know
Some same, Some Different
What were the different effects? '& V
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1
D. Was treatment given? Yes NO n
I
I
1
Don ' t know n
What was the treatment? (1.
What were the results of treatment?
Don't know a 1
Don ' t know a
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Case/chart number (if available)
1
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Patient's name (optional)
IV. About the mushroom:
A. Name the species of mushroom
9. Who identified the species?
Herbarium specimen number, if available
Don ' t know 0
Don ' t know 0
C. Here any special mushroom tests done? ~ e s a
List the tests and results: $.
No= Don't k n o w n
I I
V. Other comnents about the case or the mushroom:
Please send completed form to: Dr. Kenneth W. Cochran
Department of Epidemiology, SPH
University of Michigan
Ann Arbor, MI 48109 - 2029
Please duplicate if additional copies are needed, or request copies from the
above address or by telephone to (313) 764-5469, 764-5453, or 971-2552.
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