BLOOD DONOR QUESTIONNAIRE
***Please answer the following questions correctly. This will help to protect you and the patient who receives your blood.
For women donors:
General Physician Examination:
Weight:___________ Pulse:__________ Hb__________
My blood will be tested for Hepatitis B/C, Malaria parasite, HIV/AIDS and venereal diseases in addition to any other screening tests required to ensure blood safety.
Signature of Medical Officer: _______________________
BLOOD SAFETY BEGINS WITH A HEALTHY DONOR