Questionnaire for blood donors

Please answer all questions honestly (choosing one of the given options), because they are necessary to protect your health, as well as for maximum safety of the person who receives your blood. Hopefully these questions will help you in making a decision about donation and eventually to self-exclusion. Department of Transfusion Medicine guarantees the confidentiality of given data!

Name and surname
Address
Phone
e-mail

Do you feel healthy today?
Do you have a cold today, flu, sore throat, fever, infection or allergy?

Have you in the last 3 days taken certain medications (including aspirin)?
Have you in the last 3 days treated your teeth?

Have you in the last 3 months received any vaccine or serum?

Have you in the last 6 months you had surgery?

Have you from the last blood donation or in the past 12 had:
– operation or some serious medical tests?
– piercing or tattoo on the skin, acupuncture (by unauthorized person)?
– Accidental injury (sting) with a needle and / or contact of the mucous membrane with somebody’s blood?
– a transfusion?
– vaccination against rabies?
– exposure to hepatitis (in the family or at work)?

Women: Have you been pregnant in the last year?

Have you taken any medicines containing izotretinoin (Roaccutane), etretinat, (Tegison R), aciretin (Neotigason), finastridom (Proscar R, Proprecia)?
Have you been treated with human pituitary extract?
Have you had a transplantation of the brain hard shell?
Have you had a transplantation of the eye corneal?

Do you suffer from any serious illness such as:
jaundice, malaria, tuberculosis, rheumatic fever
heart disease, high / low blood pressure
allergy, asthma
convulsions (seizures) or nerve diseases
chronic diseases such as: diabetes (insulin dependent), chronic bronchitis, cancer or stomach ulcer
toxoplasmosis
brucellosis

Are you well informed about HIV / AIDS, The gold B, C?
Are you receiving / receiving drug into a vein?
Are you receiving / receiving money or drugs for sex?
Do you have hemophilia or have had sexual intercourse with a person who has hemophilia?
Men: Have you ever had a relationship with another man?
Women: According to your knowledge, has any man that you had sexual intercourse with in the past 12 months had a relationship with another man?
Whether in the past 12 months you have had sexual contact with someone who:
– is HIV positive or had jaundice?
– receives of received venous drugs?
– Accepting or receiving money or drugs for sex?
Do you know someone who had Creutzfeldt-Jokob-disease (mad cow disease or spongiform encephalopathy?
Have you had a sexually transmitted disease?

Comments
(Your suggestions, opinions or comments for improvement of blood donation) – optional. If you want make an appointment state the date and the time
All questions that I understood completely.

I am aware that giving false response is a serious matter and can not harm anyone.

I agree not to donate blood if there is a chance my blood to transmit the AIDS virus.

I agree my blood to be tested for AIDS, hepatitis and syphilis in order to ensure the recipient.

If a positive result, I agree to be communicated confidentially and will be reported in accordance with the law on infectious diseases.

I agree to call in the National Institute of Blood Transfusion, if after donating to solve my blood to be used for treatment.

I agree to voluntarily donate blood.