Yes

No

 

1.       Are you feeling healthy and well today?

q

q

 

2.       Have you read the educational materials and had your questions answered?

q

q

 

In the past 48 hours

3.       Have you taken aspirin or anything that has aspirin in it?

q

q

 

In the past 6 weeks

4.       Female donors: Have you been pregnant or are you pregnant now? (Males: check I am male.)

q

q

q I am male

 

 

In the past 8 weeks have you

5.       Donated blood, platelets or plasma?

q

q

6.       Had any vaccinations or other shots?

q

q

7.       Had close contact with the smallpox vaccination site of someone else?

q

q

 

In the past 16 weeks

8.       Have you donated a double unit of red cells using an apheresis machine?

q

q

 

Since your last donation have you

9.       Had any new medical problems or diagnoses?

q

q

10.   Had any new medical treatments?

q

q

11.   Taken any of the medications on the Medication Deferral List?

q

q

12.   Been outside the United States or Canada?

q

q

13.   Come into contact with someone elses blood?

q

q

14.   Had an accidental needle-stick?

q

q

15.   Had sexual contact with anyone who has HIV/AIDS or has had a positive test for the HIV/AIDS virus?

q

q

16.   Had sexual contact with a prostitute or anyone else who takes money or drugs or other payment for sex?

q

q

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

18.   Had sexual contact with anyone who has hemophilia or has used clotting factor concentrates?

q

q

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

22.   Lived with a person who has hepatitis?

q

q

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

 

26.   Had ear or body piercing?

q

q

27.   Been in juvenile detention, lockup, jail, or prison for more than 72 hours?

q

q

28.   Used needles to take drugs, steroids, or anything not prescribed by your doctor?

q

q

 

29.   Have any of your relatives had Creutzfeldt-Jakob disease?

q

q