Mpox Exposure Risk Assessment Form
Please fill out this form to assess your exposure risk related to Mpox.
Full Name
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Have you traveled to any areas with reported Mpox cases in the last 30 days?
Yes
No
Have you had any contact with animals that are known to carry Mpox?
Yes
No
If yes, please specify the locations:
If yes, please provide details about the contact:
Have you had close contact with anyone diagnosed with Mpox in the last 30 days?
Yes
No
Have you been in close contact with anyone who has traveled to a country with reported Mpox cases?
Yes
No
If yes, please provide details of the contact:
If yes, please provide details of the contact:
Are you experiencing any symptoms related to Mpox? (e.g., rash, fever, fatigue)
Yes
No
Have you experienced any recent travel to areas with reported Mpox cases?
Yes
No
If yes, please describe your symptoms:
If yes, please specify the locations and dates of travel:
Have you been vaccinated against Mpox?
Yes
No
If yes, please provide the date of your last vaccination:
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Comments or Concerns:
Submit
Should be Empty: