Mpox Case Investigation Form
Case Number
Date of Investigation
 -
Month
 -
Day
Year
Date
1. Patient Identity
Patient Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
Date
Age
Gender
Please Select
Male
Female
N/A
Occupation
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
2. Patient Status
Status of the Patient
Alive
Dead
If dead, date of death
 -
Month
 -
Day
Year
Date
Place of death
3. Clinical History
Date of onset of symptoms
 -
Month
 -
Day
Year
Date
Place where the patient got ill
Did the patient travel anytime in the three weeks before becoming ill?
Yes
No
Indicate places.
Did the patient travel during illness?
Yes
No
Indicate places.
Does the patient have a cutanueous eruption/rash?
Yes
No
Date of onset for the rash
 -
Month
 -
Day
Year
Date
Did the patient have fever?
Yes
No
Date of onset for the fever
 -
Month
 -
Day
Year
Date
If there is active disease, are the lesions in the same state of development on the body?
Yes
No
If there is active disease, are all of the lesions the same size?
Yes
No
If there is active disease, are the lesions deep and profound?
Yes
No
Localization of the lesions
Face
Legs
Soles of the fee
Palms of the hands
Thorax
Arms
Genitals
All over the body
Other
Did the patient develop ulcers?
Yes
No
Does or did the patient have any of the following symptoms? (Check all that apply.)
Vomiting/nausea
Cough
Lymphadenopathy, inguinal
Lymphadenopathy, axillary
Lymphadenopathy, cervical
Chills or sweats
Sore throat when swallowing
Oral ulcers
Headache
Lesions that itch
Muscle pain (myalgia)
Fatigue
Conjunctivitis
Sensitivity to light
Is the patient bedridden?
If female, pregnancy status
Pregnant
Not pregnant
HIV Status
Negative
Positive
Unknown
Any other unknown medical conditions
4. Exposure
During the three weeks preceding the onset of symptoms, did the patient have contact with one or more persons who had similar symptoms?
Yes
No
Name
First Name
Last Name
Relationship with the patient
First date of contact
 -
Month
 -
Day
Year
Date
Did the patient touch a domestic or wild animal during the three weeks preceding symptom onset?
Yes
No
What kind of animal?
Date of contact
 -
Month
 -
Day
Year
Date
Type of contact (Check all that apply.)
Rodents alive in the house
Dead animal found in the forest
Alive animal living in the forest
Animal bought for meat
Other
5. Laboratory
Was a specimen collected?
Yes
No
Date of collection
 -
Month
 -
Day
Year
Date
Type
Crust
Swab
Blood
6. Hospital Information
Was the patient sent to a hospital?
Yes
No
Was the patient admitted in the isolation ward?
Yes
No
Name of hospital
Hospitalization date
 -
Month
 -
Day
Year
Date
Date of discharge or date of death
 -
Month
 -
Day
Year
Date
Submit
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