Blood Donation Health Screening Questionnaire Form
Please complete this form to help us assess your eligibility and readiness for blood donation. All information is confidential and used for health screening purposes only.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Have you donated blood in the past 3 months?
*
Yes
No
Are you currently feeling healthy and well?
*
Yes
No
Have you had any illness, fever, or infection in the past 14 days?
*
Yes
No
Are you currently taking any medications?
*
Yes
No
Have you traveled outside the country in the past 4 weeks?
*
Yes
No
For female donors: Are you currently pregnant or have you been pregnant in the past 6 months?
*
Not Applicable
Yes
No
Submit Screening
Should be Empty: