• Blood Donor Questionnaire and Consent Form

    All information protected

  • Confidential

    Please answer the following questions correctly. This will help to protect you and the patient who receives your blood. 
  • Gender
  • Format: (000) 000-0000.
  • What is your preferred contact method?
  • Would you like your name to included in donor’s website?
  • Have you donated previously?
  • What was the last time you donated blood?
     - -
  • Did you have any discomfort during/after donation?
  • What is your blood type?
  • Do you feel well today?
  • Did you sleep well last night ?
  • Have you any reason to believe that you may be infected : By Hepatitis, Malaria, HIV and/or venereal disease (virinjay)?
  • In the last 6 months have you had any history of the following?
  • In the last six months have you had any of the following?
  • Do you suffer from or have suffered from any of the following diseases?
  • Are you taking or have you taken any of these in the past 72 hours?
  • Is there any history of surgery or blood transfusion in the past six months?
  • For women donors:
  • Have you had an abortion in the last three months ?
  • Do you have a child less than one year old?
  • Would you like to be informed about any abnormal test result at the address furnished by you ?
  • Have you read and understood all the information presented and answered all the questions truthfully, as any incorrect statement or concealment may affect your health or may harm the recipient?
  • Are you pregnant?

  • General Physician Examination

    This area should be filled by the physician
  • Clear
  • Clear
  • Should be Empty:
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