Mpox Exposure Risk Assessment Form Template

About this template

An Mpox (formerly Monkeypox) Exposure Risk Assessment Form is a form template designed to gather information about an individual's potential exposure to Mpox, a contagious virus. This form includes questions about recent travel history, contact with known or suspected Mpox cases, participation in activities that might increase exposure risk (such as attending large gatherings), and symptoms consistent with Mpox. The purpose of this form is to identify individuals at risk, guide testing and isolation decisions, and prevent further spread of the virus. Public Health Agencies, Hospitals and Healthcare Providers, Occupational Health Departments, Telehealth Providers, Non-Governmental Organizations (NGOs), Research Institutions, Schools, and Universities can benefit from using this form to assess and manage the risk of Mpox exposure.

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