Your name

Your Address

Your Age

Pincode

Date Of Birth

Telephone No.

Mobile No.

Email Id

Married :Unmarried :Business :Service :House Wife :Student :

Have you donated previously : Yes / No, If Yes, Last Date of Blood Donation

Did you have any ailment, difficulty or discomfort during / after Donation ?
YesNo

What was difficulty ?
YesNo

Have you ever been advised not to donate blood ?
YesNo

2. Are you feeling well today ?
YesNo

3. Have you eaten anything in the last 4 hours ?
YesNo

4. After Donating Blood do you have to engage in heavy work, driving heavy vehicles, or work at heights today?
YesNo

5. Have you had / have any of the following ? if yes, discuss with the doctor present :
YesNo

5.1 Allergy5.2 Kidney Disease5.3 Endocrine Disease5.4 Cancer5.5 Mental illness5.6 Diabetes5.7 Leprosy5.8 Epilepsy5.9 Fainting Attacks5.10 Amoebiasis5.11 Syphilis5.12 Blood / Bleeding Disorder5.13 Heart Disease5.14 Cold / Cough5.15 Gonorrhoea5.16 Tuberculosis5.17 Lung Disease5.18 Liver Disease5.19 Skin Disease5.20 Polycythemia5.21 Asthma5.22 Fever5.23 High / Low BP5.24 G.6 PD deficiency

6. During past 12 months have you had any of the following

6.1 Received blood or blood components ?
YesNo

6.2 Any accidents or operations ?
YesNo

6.3 Received any vaccinationss ?
YesNo

6.4 Bitten by any animal, which can result in rabies ?
YesNo

6.5 Had tattooing / ear piercing or acupuncture treatment ?
YesNo

6.6 Have you been imprisoned for any reason ?
YesNo

7 Have you had jaundice in the last 1 year ?
YesNo

7.1 Have your blood ever tested positive for hepatitis B or C ?
YesNo

7.2 Have you had close contact with anyone (family / others) suffering from jaundice in the last 1 year ?
YesNo

8 Have you had tuberculosis or typhoid during in the last year ?
YesNo

9 Have you had malaria or taken antimalarial drugs in the last 3 years ?
YesNo

10. Have you had any of the following in the last 6 months ?

Dental ProcedureMeaslesChicken PoxDengue

11. Have you taken any medicine in the last 7 days especially or antibiotic ?
YesNo

12. Do you know that you should not give blood in the following condition ?
YesNo

• If you were found to be HIV positve, Hepatitis B, C or Syphilis infection

• If you are having multiple sex partner or have engaged in male to male sexual activity

• If you have ever worked as a sex worker or had sex with a sex worker.

• If You have ever injected any drug (Esp. Narcotics) not prescribed

• If you suspectthat you or your partner may have HIV or any other sexually trasmitted dieases

13. Do you or your sexual partner belong to any of the above or below categories ?
YesNo

14. Do you have any reason to believe that you have been infected by the virus that causes Aids ?
YesNo

15. In the last 6 month have you had :

15.1. Night Sweats ?
YesNo

15.2. Persistent Diarrhoea ?
YesNo

15.3. Unexpailned Weight loss ?
YesNo

15.4. Swollen Glands ?
YesNo

15.5. Persistent Diarrhoea ?
YesNo

16 In case you are woman ?

16.1. Are you pregnant or have you had an abortion in the last 6 months ?
YesNo

16.2. Have you a child less than 1 year of age ? Are you breast feeding ?
YesNo

16.3. Having periods today ?
YesNo

Consent

I understand that:

• Blood donation is a totally voluntary act and no inducement or remuneration has been offered.

• Donation of blood / Components is medical procedure and that by donating voluntary. I accept the risk associated with this procedure.

• My donated blood, blood and plasma recovered from my donated blood may be sent for _a! plasma tractionation for preparation of plasma derived medicinal products, all of which may be used for larger patient population and not just this blood bank.

• My blood will be tested for Hepatitis B. Hepatitis C, Malaria Parasite, HIV / AIDS and diseases in addition to any other screening tests required ensuring blood safety.

• I would like to be informed about any abnormal test result done on my donated blood YesNo

Date:

Time: