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|
Yes |
No |
|
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1.
Are you feeling healthy and well today? |
q |
q |
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|
||||
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2.
Have you read the educational materials? |
q |
q |
||
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|
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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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|
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In the past week |
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4.
Have you had a headache and fever at the same time? |
q |
q |
||
|
|
||||
|
In the past 6 weeks |
||||
|
5.
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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6.
Donated blood, platelets or plasma? |
q |
q |
||
|
7.
Had any vaccinations or other shots? |
q |
q |
||
|
8.
Had contact with someone who
had a smallpox vaccination? |
q |
q |
||
|
|
||||
|
In the past 16 weeks |
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|
9.
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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|
10.
Had any new medical problems or diagnoses? |
q |
q |
||
|
11.
Had any new medical treatments? |
q |
q |
||
|
12.
Taken any of the medications on the Medication Deferral List? |
q |
q |
||
|
13.
Been outside the United States or Canada? |
q |
q |
||
|
14.
Come into contact with someone else’s blood? |
q |
q |
||
|
15.
Had an accidental needle-stick? |
q |
q |
||
|
16.
Had sexual contact with anyone who has HIV/AIDS or has had a positive
test for the HIV/AIDS virus? |
q |
q |
||
|
17.
Had sexual contact with a prostitute or anyone else who takes money
or drugs or other payment for sex? |
q |
q |
||
|
18.
Had sexual contact with anyone who has ever used needles to take
drugs or steroids, or anything not prescribed by their doctor? |
q |
q |
||
|
19.
Had sexual contact with anyone who has hemophilia or has used
clotting factor concentrates? |
q |
q |
||
|
20.
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 |
|
|
21.
Had sexual contact with anyone who was born in or lived in Africa? |
q |
q |
|
|
|
22.
Had sexual contact with a person who has hepatitis? |
q |
q |
||
|
23.
Lived with a person who has hepatitis? |
q |
q |
||
|
24.
Received money, drugs, or other payment for sex? |
q |
q |
||
|
25.
Male donors: had sexual contact with another male, even once?
(Females: check “I am female.”) |
q |
q |
q I am
female |
|
|
26.
Had a tattoo? |
q |
q |
|
|
|
27.
Had ear or body piercing? |
q |
q |
||
|
|
Yes |
No |
|
28.
Been in juvenile detention, lockup, jail, or prison for more than 72
hours? |
q |
q |
|
29.
Used needles to take drugs, steroids, or anything not
prescribed by your doctor? |
q |
q |
|
30.
Have any of your relatives had Creutzfeldt-Jakob disease |
q |
q |