Mpox survey template is designed to collect information on mpox (formerly monkeypox) from the public, patients, and healthcare providers. Use this free template to measure awareness, symptoms, vaccination coverage, risk factors, and access to care.

The template includes demographic items such as age group and gender, medical history questions about diagnosis and vaccination, symptom checklists, and open fields for diagnosis date and additional comments. Questions are concise and suitable for online, clinic, or community outreach settings. It includes multiple choice and open-text fields.

Ideal users include public health agencies, researchers, hospitals, and NGOs conducting surveillance, vaccine uptake studies, or community awareness campaigns. The form supports privacy-sensitive data collection and can be customized in SurveyMars for integrations, e-signatures, and reporting. Administrators can export results and generate summary reports for rapid decision-making.

Click "Use This Template" to open, modify, and deploy the mpox survey template quickly, securely, and begin collecting actionable data.