Blood Donation Form
Confidential - Please answer the following questions correctly. This will help to protect you and the patient who receives your blood.
What is your blood type?
0 Rh+
0 Rh-
A Rh +
A Rh -
B Rh+
B Rh -
AB Rh +
AB Rh -
Full Name
First Name
Last Name
Birth Date
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
Male
Female
Occupation
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Weight
Pulse
Hb
BP
Temparature
Have you donated previously?
Yes
No
What was the last time you donated blood?
-
Month
-
Day
Year
Date
In the last six months have you had any of the following?
Tattooing
Ear piercing
Dental extraction
Do you suffer from or have suffered from any of the following diseases?
Heart Disease
Cancer/Malignant Disease
Diabetes
Hepatitis B/C
Sexually Transmitted Diseases
Typhoid ( last on year) (Antay joro)
Lung Disease
Tuberculosis
Allergic Disease
Kidney Disease
Epilepsy (Charay rog)
abnormal Bleeding tendency.
Jaundice (last one year).
Malaria (six months)
Fainting spells.
Are you taking or have you taken any of these in the past 72 hours?
Antibiotics
Steroids
Aspirin
Vaccinations
Alcohol
Dog bite Rabies vaccine (1 year)
Is there any history of surgery or blood transfusion in the past six months?
Major
Minor
Blood Transfusion
Submit
Should be Empty: