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Yes |
No |
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1.
Are you feeling healthy and well today? |
q |
q |
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2.
Have you read the educational materials and had your questions
answered? |
q |
q |
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In the past 48 hours |
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3.
Have you taken aspirin or anything that has aspirin in it? |
q |
q |
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In the past 6 weeks |
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4.
Female donors: Have you been pregnant or are you pregnant now?
(Males: check “I am male.”) |
q |
q |
q I am
male |
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In the past 8 weeks have you |
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5.
Donated blood, platelets or plasma? |
q |
q |
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6.
Had any vaccinations or other shots? |
q |
q |
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7.
Had close contact with the smallpox vaccination
site of someone else? |
q |
q |
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In the past 16 weeks |
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8.
Have you donated a double unit of red cells using an apheresis
machine? |
q |
q |
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Since your last donation have you |
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9.
Had any new medical problems or diagnoses? |
q |
q |
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10.
Had any new medical treatments? |
q |
q |
|
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11.
Taken any of the medications on the Medication Deferral List? |
q |
q |
|
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12.
Been outside the United States or Canada? |
q |
q |
|
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13.
Come into contact with someone else’s blood? |
q |
q |
|
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14.
Had an accidental needle-stick? |
q |
q |
|
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15.
Had sexual contact with anyone who has HIV/AIDS or has had a positive
test for the HIV/AIDS virus? |
q |
q |
|
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16.
Had sexual contact with a prostitute or anyone else who takes money
or drugs or other payment for sex? |
q |
q |
|
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17.
Had sexual contact with anyone who has ever used needles to take
drugs or steroids, or anything not prescribed by their doctor? |
q |
q |
|
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18.
Had sexual contact with anyone who has hemophilia or has used
clotting factor concentrates? |
q |
q |
|
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19.
Female donors: had sexual contact with a male who has ever had sexual
contact with another male? (Males:
check “I am male.”)
|
q |
q |
q I am
male |
|
20.
Had sexual contact with anyone who was born in or lived in Africa? |
q |
q |
|
|
21.
Had sexual contact with a person who has hepatitis? |
q |
q |
|
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22.
Lived with a person who has hepatitis? |
q |
q |
|
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23.
Received money, drugs, or other payment for sex? |
q |
q |
|
|
24.
Male donors: had sexual contact with another male, even once?
(Females: check “I am female.”) |
q |
q |
q I am
female |
|
25.
Had a tattoo? |
q |
q |
|
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26.
Had ear or body piercing? |
q |
q |
|
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27.
Been in juvenile detention, lockup, jail, or prison for more than 72
hours? |
q |
q |
|
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28.
Used needles to take drugs, steroids, or anything not
prescribed by your doctor? |
q |
q |
|
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29.
Have any of your relatives had Creutzfeldt-Jakob disease? |
q |
q |
|