Mpox Case Report Form

Patient's Full Name

First NameLast Name

Date of Birth

Date

Gender

MaleFemaleNon-BinaryPrefer Not to Say

Email Address

example@example.com

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Date of Onset of Symptoms

Date

Symptoms Experienced

Have you been tested for Mpox?

YesNoOther

Date of Test

Date

Test Result

PositiveNegativePending

Treatment Received

Countries Visited

Date of Travel

Date

Additional Notes