Mumps Diagnostic Evaluation Form
Complete this form to assist in the evaluation of a possible mumps case. Please provide accurate and relevant information for clinical review.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Symptom Onset
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Select all symptoms present
*
Parotid gland swelling
Jaw pain
Fever
Headache
Fatigue
Loss of appetite
Other
Has the patient had known exposure to a confirmed or suspected mumps case in the past 25 days?
*
Yes
No
Unknown
Mumps vaccination status
Fully vaccinated (2 doses)
Partially vaccinated (1 dose)
Not vaccinated
Unknown
Relevant medical history (e.g., immunodeficiency, pregnancy, chronic illness)
Provider's clinical notes or recommended next steps
Submit Evaluation
Should be Empty: