Mpox Vaccine Assessment Form
Mpox Vaccine Assessment Form
Please complete the fields below to ensure a comprehensive evaluation.
Patient Information
Name
Date of Birth
Address
Phone number
Medical History
Have you ever been diagnosed with Mpox?
Are you currently experiencing any symptoms consistent with Mpox?
Have you received a previous Mpox vaccine?
Do you have any of the following medical conditions?
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Immunocompromised
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Pregnancy
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Severe allergies
Vaccination Assessment
Have you had any adverse reactions to vaccines in the past?
Do you have a known allergy to any components of the Mpox vaccine?
Consent and Acknowledgement
I acknowledge that I have been provided with information about the Mpox vaccine, including its benefits, risks, and potential side effects. I understand the information and voluntarily consent to receive the vaccine.
Date:
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