Mpox Self-Screening Questionnaire
Have you had any of the following symptoms in the last 24 hours?
High temperature
Headache
Muscle aches
Backache
Swollen glands
Shivering (chills)
Exhaustion
Joint pain
Cough
Shortness of breath of difficulty breathing
None of them
Have you entered into the living space of a person with an mpox (regardless of whether the person with mpox is present) in the last 14 days?
Have you been within 6 feet for a total of 3 hours or more of an unmasked person with mpox without wearing a surgical mask or respirator in the last 14 days?
Have you been in contact between an exposed individual’s broken skin or mucous membranes with skin lesions or bodily fluids from a person with mpox in the last 14 days?
Have you been in contact between an exposed individual’s broken skin or mucous membranes with materials that have contacted the skin lesions or bodily fluids of a person with mpox in the last 14 days? (e.g., sharing food, handling or sharing of linens used by a person with mpox without having been disinfected or laundered)
Have you been in contact with an exposed individual’s clothing with the person with mpox skin lesions, bodily fluids, or their soiled linens or dressings in the last 14 days? (e.g., during turning, bathing, or assisting with transfer)
Name
First Name
Last Name
Email
example@example.com
Signature
Submit
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