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6UMre3j6tGgXyvMLEj9U5

Ciguatera (Fish) Poisoning Report

Good day,

If you have been diagnosed or suspect you had fish poisoning, specifically ciguatera poisoning from eating reef fish, please complete the report below.

An officer will contact you, if need be, if more information is needed.

Your information will be kept confidential.

Thank you!

First Name		Last Name
Date of Birth (dd-mm-yy)		Gender
Number		Email

Date Known:

1-2 months ago

3- 4 months ago

5 months ago

reset

<1day

1-3 days

4-6 days

7-10 days

10-15 days

>15 days

reset

Diarrhoea

Nausea

Vomiting

Abdominal pain/cramps

None

Numbness and/or tingling of extremities

Burning/pain/numbness/tingling of lips, mouth, throat

Dental pain

Metallic taste

Headache

Painful or unusual (e.g. electric shock-like) symptoms in contact with cold water (or when drinking water)

Increased tolerance to heat (e.g. hot showers)

Blurred vision

Difficulty speaking

Difficulty breathing

Intense itching

Joint pain

Muscle pain

Temperature Reversal when touching objects (e.g.Hot things feel cold and cold things feel hot)

None

Hands

Feet

Mild

Moderate

Severe

Slow heart rate

Rapid heart rate

Chest tightness

Dizziness

None

Expand

Yes

reset

Expand

Yes

reset

Emergency Department (ER)

Public Clinic

Private Medical Center

Road Town Clinic

Iris Penn Smith (East End) Clinic

Roselind Penn (Long Look) Clinic

Theresa Smith Blyden (Cappoons Bay Clinic)

Jost Van Dyke Clinic

Iris O' Neal Clinic (The Vally- VG)

North Sound (VG)

Romalia Smith Clinic (Anegada)

Apex Medical

Bain Medical

Bougainvillea

B&F Medical

Eureka (Medicure)

Penn Medical

PicSmith Medical

Advanced Medical Center

The Wellness Center

Yes

Unknown

reset

0-3 mths

3-6 mths

6-12 mths

12-18 mths

>18 mths

reset

Barracuda

Snapper

Grouper

Hind

Parrotfish

Lionfish

Sturgeon

Bass

Amberjack

Surgeonfish

Moray Eel

Yellow Tail

Old Wife (Trigger fish)

Coran

Unknown

Other:

Under 5 lbs

5-10lbs

10-20lbs

>20lbs

reset

Fillet

Soup

Curry

Baked /Roasted / Grilled

Stew

Fry

Steamed / Boiled

Other:

Head

Liver

Roe

Intestines

Flesh

Home

Restaurant

Hotel

Club

Other, specify:

Yes

reset

Yes

reset

Local fisherman

Restaurant

Hotel/Club

Market

Recreational fishing

Gift

Imported/ Overseas

Expand

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