Mpox Case Investigation
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Autocompleted Address
Email
example@example.com
Date-of-birth
-
Month
-
Day
Year
Date
Sex
Male
Female
Gender
Sexual Orientation
Do you work in healthcare?
Yes
No
Facility Name
Medical History (select all that apply)
Pregnant
Immunosuppressed
HIV positive
Other
List conditions:
Have you ever received the smallpox vaccine?
Yes
No
Unknown
When did you receive the vaccine?
(enter exact date or year)
Symptoms (select all that apply)
Rash
Bumps
Blisters
Headache
Fever
Swollen lymph nodes
Exhaustion
Chills
Respiratory symptoms (i.e. cough)
Other
Symptom onset date:
-
Month
-
Day
Year
Date
Exposure (select all that apply)
Close contact with confirmed case
Sexual contact
Traveled out of Montana in the last 14 days
Other
Where did you travel?
List close contacts
Name, phone number
List sexual partners
Name, phone number
Submit
Should be Empty: