Collin County - Person Under Investigation - Monkeypox
Patient Demographics
Name
First Name
Last Name
Patient DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Residency
US Resident
Non-US Resident
Please list residency
Gender Identity
Please Select
Male
Female
Non-Binary
Transgender Male
Transgender Female
Intersex
Patient Race
White
Black
Asian
Pacific Islander
Native American/Alaskan
Unknown
Patient Ethnicity
Hispanic
Not Hispanic
Unknown
Patient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Clinical Presentation
First Symptom Onset (could be rash, fever, headache, chills, exhaustion, backache, swollen lymph nodes, or muscle aches)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Rash Onset Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
At what site(s) is the rash currently located?
Face
Hands
Neck
Mouth, Lips, Oral Mucosa
Trunk
Arms
Legs
Palms of Hands
Soles of Feet
Genitals
Perianal
Other
Current lesion development stage(s):
Macules
Papules
Vesicles
Pustules
Scab
Are all the lesions at the same stage?
Yes
No
Unknown
Please describe how rash started and the look of the rash. Refer to CDC Key Characteristics for Identifying Monkeypox: https://www.cdc.gov/poxvirus/monkeypox/clinicians/clinical-recognition.html
File Upload (Picture of rash if applicable)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Type of Monkeypox Testing to Occur?
Commercial Lab Option (i.e. LabCorp, Quest, Mayo Clinic)
Public Health Lab (must call 972-548-4707 for prior approval)
Please explain why commercial lab testing cannot occur. Collin County physician will provide a consultation on this patient that is based on the limited information and images provided by your organization. If you have a strong clinical suspicion of monkeypox, it is recommended that your organization proceeds with testing at a commercial laboratory.
Please check all other symptoms associated with this illness
Fever
Chills
Headache
Backache
Myalgia (muscle aches)
Malaise (general feeling of weakness)
Swollen lymph nodes
Cough
Eye Lesions
Conjunctivitis
Pruritis (itching)
Vomiting/Nausea
Tenesmus (urgency to defecate)
Rectal Pain
Rectal Bleeding
Pus of Blood in Stool
Other
Medical Record Upload (please upload patient file if available)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Epidemiology Factors
In the past 21 days has the patient had contact with a known monkeypox case?
Yes
No
Unknown
In the past 21 days has the patient had contact with one or more persons with similar symptoms?
Yes
No
Unknown
In the past 21 days has the patient had travel?
Yes
No
Unknown
Please list country visited and dates
In the past 21 days did the patient have any sexual encounters?
Yes, Male(s)
Yes, Female (s)
Yes, Non-binary Person(s)
No Sexual Contacts
Physician Information
Physician Name
First Name
Last Name
Facility Name
Physician Contact
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: