Mpox Screening Form
Please fill out this form to help us assess your risk and provide appropriate guidance.
Full Name
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you experienced any of the following symptoms? (Select all that apply)
Fever
Chills
Rash
Fatigue
Headache
Muscle aches
Swollen lymph nodes
None of the above
Other
Have you had close contact with someone diagnosed with Mpox?
Yes
No
Other
Have you traveled to areas with reported Mpox cases in the last 30 days?
Yes
No
Other
Do you have any underlying health conditions? (If yes, please specify)
Are you currently vaccinated against Mpox?
Yes
No
Other
If you have any additional comments or concerns, please specify:
Submit
Should be Empty: