Mpox Case Questionnaire

Mpox Case Questionnaire
Please fill out this questionnaire to help us gather information regarding potential Mpox cases.
Full Name*
First NameLast Name
Date of Birth*
MonthDayYear
Date
Contact Number*
Please enter a valid phone number.
Email Address*
example@example.com
Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Have you experienced any symptoms?*
YesNo
If yes, please specify the symptoms you have experienced.
Date of symptom onset
MonthDayYear
Date
Have you had any known exposure to a confirmed Mpox case?*
YesNo
If yes, please provide details about the exposure.
Have you traveled internationally in the last 30 days?*
YesNo
If yes, please list the countries visited.
Have you received the Mpox vaccine?*
YesNo
If yes, please provide the date of vaccination.
MonthDayYear
Date
Additional Comments or Concerns
Should be Empty: