Donor History Questionnaire
YES NO
Are you
___ ___ 1. Feeling well today? When was your last
meal? ___________
___ ___ 2. Are you between the ages of 17 and 70?
(Donation on bus must be between ages 17-66)
___ ___ 3. Currently taking an antibiotic?
___ ___ 4. Currently taking any other medication for
an infection?
Please read the Medication Deferral List
___ ___ 5. Are you now taking or have you ever taken any
medications on the Medication Deferral List?
___ ___ 6. Have you read the educational materials ?
In the past 48 hours
___ ___ 7. Have you taken aspirin or anything that has aspirin in it?
In the past 4 weeks
___ ___ 8. Have you taken any other medications?
In the past 6 weeks
___ ___ 9. Female Donors: Have you been pregnant or
are you pregnant now? (Males: check NO)
In the past 8 weeks
___ ___ 10. Have you donated blood, platelets, or plasma?
___ ___ 11. Have you had any vaccinations or other shots?
___ ___ 12. Had contact with someone who had a smallpox
vaccination?
In the past 16 weeks
___ ___ 13. Have you donated a double unit of red cells
using an apheresis machine?
In the past 12 months have you
___ ___ 14. Had a blood transfusion?
___ ___ 15. Had a transplant such as organ, tissue, or bone
marrow?
___ ___ 16. Had a graft such as bone or skin?
___ ___ 17. Come in contact with someone else’s blood?
___ ___ 18. Had an accidental needle-stick?
___ ___ 19. Had sexual contact with anyone who has HIV/
AIDS or has had a positive test for the HIV/AIDS
virus?
___ ___ 20. Had sexual contact with a prostitute or anyone
else who takes money or drugs or other payment
for sex?
___ ___ 21. Had sexual contact with anyone who has ever used
needles to take drugs or steroids, or anything
else not prescribed by their doctor?
___ ___ 22. Had sexual contact with anyone who has
hemophilia or has used clotting factor
concentrates?
___ ___ 23. Female donors: had sexual contact with a male
who has ever had sexual contact with another
male?
___ ___ 24. Had sexual contact with a person who has
hepatitis?
___ ___ 25. Lived with a person who has hepatitis?
___ ___ 26. Had a tattoo?
___ ___ 27. Had ear or body piercing?
YES NO
___ ___ 28. Had or been treated for syphilis or gonorrhea?
___ ___ 29. Been in juvenile detention, lockup, jail, or prison or
for more than 72 hours?
___ ___ 30. Have you been under a doctor’s care or had a major
illness or surgery?
In the Past 3 years have you
___ ___ 31. Been outside the United States or Canada?
From 1980 through 1996,
___ ___ 32. Did you spend time that adds up to three (3) months
or more in the United Kingdom? (Review list of
countries in the U.K.)
___ ___ 33. Were you a member of the U.S. military, a civilian
military employee, or a dependent of a member of
the U.S. military?
Between 1980 and the present, did you
___ ___ 34. Spend time that adds up to five (5) years or more
in Europe? (Review list of countries in Europe).
___ ___ 35. Receive a blood transfusion in the United
Kingdom? (Review list of countries in UK)
Since 1977 have you
___ ___ 36. Received money, drugs, or other payment for sex?
___ ___ 37. Male donors: had sexual contact with another
male, even once? (Females: check NO)
Have you EVER
___ ___ 38. Had a positive test for the HIV/AIDS virus?
___ ___ 39. Used needles to take drugs, steroids, or anything
not prescribed by your doctor?
___ ___ 40. Used clotting factor concentrates?
___ ___ 41. Had hepatitis?
___ ___ 42. Had malaria?
___ ___ 43. Had Chagas’ disease?
___ ___ 44. Had babesiosis?
___ ___ 45. Received a dura mater (or brain covering graft?)
___ ___ 46. Had any type of cancer, including leukemia?
___ ___ 47. Had any problem with your heart or lungs?
___ ___ 48. Had a bleeding condition or blood disease?
___ ___ 49. Had sexual contact with anyone who was born in
or lived in Africa?
___ ___ 50. Been in Africa?
___ ___ 51. Had any relatives that had Creutzfeldt-Jakob
disease?
___ ___ 52. Donated or attempted to donate using another
name?
___ ___ 53. Have all your questions been answered?
HISTORIAN: _____________________________________
COMMENTS: ______________________________________
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Revised7-8-06