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Monkeypox Self Screening Questionnaire

Monkeypox Self-Screening Questionnaire

A medical form used by medical facilities to screen patients for monkeypox - a disease with symptoms similar to those of smallpox

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Please answer the following questions to help us determine if you may have been exposed to monkeypox.

Email*

What is your full name?*

What is your date of birth?*

What is your current address?*

What is your phone number?*

Do you have any recent histo...

Have you been in contact wit...*

Monkeys

Squirrels

Rats

Other

Have you been in contact wit...

Yes

Please upload any relevant m...

Drop a file here or click the button below to load the file

Choose file

Max Combine file size: 10MB

Description:Screen for monkeypox symptoms with our self-screening questionnaire. This medical form helps medical facilities quickly identify potential cases of monkeypox.

A monkeypox self-screening questionnaire is a medical form used by medical facilities to screen patients for monkeypox - a rare disease caused by a virus that can cause fever, headache, muscle aches, and a rash. The symptoms are similar to those of smallpox, but less severe. The questionnaire helps medical professionals quickly identify potential cases of monkeypox and take appropriate action to prevent the spread of the virus.

Full Name*

Date of Birth*

Address*

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Patient's Last Name*

Patient's Date of Birth*

Select date

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Full Name*

Date of Birth*

Address*

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