|
|
Yes |
No |
|
|
Are you |
|||
|
1.
Feeling healthy and well today? |
q |
q |
|
|
2.
Currently taking an antibiotic? |
q |
q |
|
|
3.
Currently taking any other medication for an infection? |
q |
q |
|
|
|
|||
|
Please read the Medication Deferral List. |
|||
|
4.
Are you now taking or have you ever taken any medications on the
Medication Deferral List? |
q |
q |
|
|
|
|||
|
5.
Have you read the educational materials? |
q |
q |
|
|
|
|||
|
In the past 48 hours |
|||
|
6.
Have you taken aspirin or anything that has aspirin in it? |
q |
q |
|
|
|
|||
|
In the past week |
|||
|
q |
q |
|
|
|
|||
|
In the past 6 weeks |
|||
|
8.
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 |
|||
|
9.
Donated blood, platelets or plasma? |
q |
q |
|
|
10.
Had any vaccinations or other shots? |
q |
q |
|
|
11.
Had contact with someone who had a smallpox vaccination? |
q |
q |
|
|
|
|||
|
In the past 16 weeks |
|||
|
12.
Have you donated a double unit of red cells using an apheresis
machine? |
q |
q |
|
|
|
|||
|
In the past 12 months have you |
|||
|
13.
Had a blood transfusion? |
q |
q |
|
|
14.
Had a transplant such as organ, tissue, or bone marrow? |
q |
q |
|
|
15.
Had a graft such as bone or skin? |
q |
q |
|
|
16.
Come into contact with someone else’s blood? |
q |
q |
|
|
17.
Had an accidental needle-stick? |
q |
q |
|
|
18.
Had sexual contact with anyone who has HIV/AIDS or has had a positive
test for the HIV/AIDS virus? |
q |
q |
|
|
19.
Had sexual contact with a prostitute or anyone else who takes money
or drugs or other payment for sex? |
q |
q |
|
|
20.
Had sexual contact with anyone who has ever used needles to take
drugs or steroids, or anything not prescribed by their doctor? |
q |
q |
|
|
21.
Had sexual contact with anyone who has hemophilia or has used
clotting factor concentrates? |
q |
q |
|
|
22.
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 |
|
|
Yes |
No |
|
|
23.
Had sexual contact with a person who has hepatitis? |
q |
q |
|
|
24.
Lived with a person who has hepatitis? |
q |
q |
|
|
25.
Had a tattoo? |
q |
q |
|
|
26.
Had ear or body piercing? |
q |
q |
|
|
27.
Had or been treated for syphilis or gonorrhea? |
q |
q |
|
|
28.
Been in juvenile detention, lockup, jail, or prison for more than 72
hours? |
q |
q |
|
|
|
|||
|
In the past three years have you |
|||
|
29.
Been outside the United States or Canada? |
q |
q |
|
|
|
|||
|
From 1980 through 1996, |
|||
|
30.
Did you spend time that adds up to three (3) months or more in the
United Kingdom? (Review list of countries in the UK) |
q |
q |
|
|
31.
Were you a member of the U.S. military, a civilian military employee,
or a dependent of a member of the U.S. military? |
q |
q |
|
|
|
|||
|
From 1980 to the present, did you |
|||
|
32.
Spend time that adds up to five (5) years or more in Europe? (Review list of countries in Europe.) |
q |
q |
|
|
33.
Receive a blood transfusion in the United Kingdom ? (Review list of
countries in the UK.) |
q |
q |
|
|
|
|||
|
From 1977 to the present, have you |
|||
|
34.
Received money, drugs, or other payment for sex? |
q |
q |
|
|
35.
Male donors: had sexual contact with another male, even once? (Females: check “I am female.”) |
q |
q |
q I am
female |
|
|
|
||
|
Have you EVER |
|||
|
36.
Had a positive test for the HIV/AIDS virus? |
q |
q |
|
|
37.
Used needles to take drugs, steroids, or anything not
prescribed by your doctor? |
q |
q |
|
|
38.
Used clotting factor concentrates? |
q |
q |
|
|
39.
Had hepatitis? |
q |
q |
|
|
40.
Had malaria? |
q |
q |
|
|
41.
Had Chagas’ disease? |
q |
q |
|
|
42.
Had babesiosis? |
q |
q |
|
|
43.
Received a dura mater (or brain covering) graft? |
q |
q |
|
|
44.
Had any type of cancer, including leukemia? |
q |
q |
|
|
45.
Had any problems with your heart or lungs? |
q |
q |
|
|
46.
Had a bleeding condition or a blood disease? |
q |
q |
|
|
47.
Had sexual contact with anyone who was born in or lived in Africa? |
q |
q |
|
|
48.
Been in Africa? |
q |
q |
|
|
|
|||
|
49.
Have any of your relatives had Creutzfeldt-Jakob disease? |
q |
q |
|
|
|
|
||
|
Use
this area for additional questions |
Yes |
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|