Poison Control Hotline Intake
Use this form to share the exposure details, current symptoms, and contact information so the hotline can give immediate guidance.
Exposure Details
Date and Time of Exposure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Estimated Time Since Exposure or Symptom Onset
Substance Involved
Exposure Route
*
Swallowed
Inhaled
Skin contact
Eye contact
Injected
Unknown
Symptoms and Immediate Actions
Current symptoms and condition
*
None
Nausea/Vomiting
Dizziness
Drowsiness
Trouble Breathing
Seizures
Burns/Irritation
Confusion
Other
Has first aid or decontamination already been performed?
*
Yes
No
What was done?
Has the person been exposed to anything else or taken any other substances/medications since the incident?
*
Yes
No
Patient and Contact Information
Relationship to the affected person
*
Self
Parent/guardian
Spouse/partner
Family member
Caregiver
Friend
Teacher/school staff
Employer
Other
Affected person’s age or age range
*
Approximate weight (lb)
Submit
Should be Empty: