BLOOD DONOR INTERVIEW INFORMATION FORM
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THIS PAGE PRESENTS A SAMPLE OF A TYPICAL BLOOD DONOR PRE-DONATION INTERVIEW FORM, TO BE FILLED OUT BEFORE ALL BLOOD DONATIONS.

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This form is typical of Blood donor interview forms that we have seen. This form, to be filled out pre-donation, is to be used to determine the suitability and quality of your Blood donation. It asks detailed questions about your health and recent travel history. The form that you are asked to read, answer and sign may be slightly different.

   PART A.   FOR ALL BLOOD DONORS

CIRCLE ONE
1. Do you feel well today? YES NO
2. At this time, do you have a cold, flu or any other illness or infection? YES NO
3. In the past week have you visited a doctor or dentist? YES NO
4. In the past three days have you taken any product containing aspirin and/or anti-inflammatory medication? YES NO
5. Have you had any skin piercing treatment in the last 12 months? This includes ear and body piercing, acupuncture, electrolysis and tattooing. YES NO
6. Have you ever had hepatitis or close contact with anyone with hepatitis? YES NO
7. Have you ever had a tissue transplant? That is kidney, cornea, bone, skin graft. YES NO
8. Did you have any head or brain surgery between 1968 and 1999? YES NO
9. Is it possible that any member of your family has suffered from any form of Creutzfeldt-Jakob Disease (CJD)? YES NO
10. Did you receive injections of human growth hormone for short stature or human pituitary hormones for infertility between 1968 and 1999? YES NO
11. Have you traveled out of the United States in the past 12 months? YES NO
12. Have you lived out of the United States in the past 3 years? YES NO
13. Were you born in, lived in or had sex with anyone who lived in for more than 3 months, or received Blood products in Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger or Nigeria since 1977 YES NO
14. Have you ever spent more than 3 months in Central or South America, Thailand, Tobago, or Curacao? YES NO
   PART B.   FOR NEW BLOOD DONORS ONLY

CIRCLE ONE

14.

 Have you ever had any of the following:
   a serious illness or accident? YES NO
   an operation/investigative procedure? YES NO
   tablets, medications, or vaccinations? YES NO
   a pregnancy? YES NO
   yellow jaundice or hepatitis? YES NO
   tuberculosis? YES NO
   malaria? YES NO
   a tattoo? YES NO
   a blood transfusion? YES NO
   contact with any infectious disease? YES NO
   heart disease? YES NO
   high blood pressure? YES NO
   asthma? YES NO
   kidney disease? YES NO
   diabetes? YES NO
   a stomach ulcer? YES NO
   PART C.   FOR PREVIOUS BLOOD DONORS ONLY

CIRCLE ONE

14.

 Since your last donation have you:
   had an illness? YES NO
   had injections/vaccinations? YES NO
   taken tablets/medication? YES NO
   had any pregnancies? YES NO
   had or expect to have an operation or procedure YES NO
   been in contact with anyone with any infectious disease YES NO
   had cancer or a tumor? YES NO
   had any bleeding disorder? YES NO
   had any fainting episodes? YES NO
   shown signs of epilepsy? YES NO

BLOOD DONATION STATEMENT

I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE ALL OF MY
ANSWERS TO THE FOLLOWING QUESTIONS ARE TRUE.

NOTE: The word Partner is defined as any person, either male or female, with
whom you have had any type or form of sexual contact in the past 12 months.

CIRCLE ONE
1. Have you or your partner any reason to believe that either of you have been infected with or exposed to HIV, the AIDS causing virus? YES NO
2. In the past 6 months, have you had:
   persistent night sweats, for even a few continuous nights? YES NO
   unexplained weight loss? YES NO
   persistent fever? YES NO
   persistent diarrhea? YES NO
   persistent swollen glands? YES NO
3. Have you or your partner had sexual activity in the past 5 years with any person whom you know to have been exposed to HIV, the virus that causes AIDS? YES NO
4. Have you had sexual activity with a person with hemophilia in the last 5 years? YES NO
5. Have you or your partner been a male or female sex worker (prostitute) in the United States or in another country in the last 5 years? YES NO
6. Have you had sexual activity with a male or female sex worker (prostitute) in the United States or in another country in the last 5 years? YES NO
7. Have you had male to male sexual activity in the last 5 years? YES NO
8. Have you had any sexual activity with a male in the last 12 months, who has had sexual activity with another male in the last 5 years? YES NO
9. Have you or your partner ever injected yourself, or been injected with any drug not prescribed for you by a doctor? YES NO
10. Have you or your partner ever shared needles and / or syringes at any time? YES NO
11. Have you been injured in any way with a used needle in the last 12 months? YES NO
12. Have you been tattooed in the last 12 months? YES NO

13.

 Have you received a blood transfusion or been treated in any way with human blood products in the last 12 months? YES NO
 

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   last updated 11/10/2004   bloodbook.com