Yes

No

 

1.       Are you feeling healthy and well today?

q

q

 

2.       Have you read the educational materials?

q

q

 

In the past 48 hours

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

q

q

 

In the past week

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

 

 

In the past 8 weeks have you

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

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

q

q

 

Since your last donation have you

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 elses 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