Mpox Exposure and Symptoms Survey Form
Please answer the following questions to help us understand possible exposure to mpox and any symptoms you may be experiencing. This survey does not collect sensitive personal information.
What is your age group?
*
Please Select
Under 18
18-24
25-34
35-44
45-54
55-64
65 or older
Prefer not to say
What is your current region or country?
*
Have you had close contact with someone diagnosed with mpox in the last 21 days?
*
Yes
No
Not sure
Have you attended any large gatherings, events, or venues in the past 21 days?
*
Yes
No
In the past 21 days, have you traveled outside your usual area?
*
Yes
No
Are you currently experiencing any of the following symptoms? (Select all that apply)
*
Fever or chills
Headache
Muscle aches
Swollen lymph nodes
Rash or skin lesions
Fatigue
No symptoms
Other
When did your symptoms begin? (If applicable)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you sought medical advice for your symptoms?
*
Yes
No
Not applicable
Is there anything else you would like to share about your exposure or symptoms?
Would you like to be contacted for follow-up (no personal identifiers will be collected)?
Yes
No
Submit Survey
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