Donor | My Website

Donor Questionnaire & Consent Form

Donor Category*

Existing Donor New Donor

Company Location*

Donor Details

Donor Name*

Gender*

Blood Group*

Address*

Date of birth*

Mobile*

Parent / Husband Name

Occupation

IDcard Type*

IDcard No*

General Information

Have you Donated Previously?*

Did you had any discomfort during / after blood donation?

Donor Questionnaire

Choose the appropriate answer

Are you in good health today?

Time of Breakfast / Lunch

Did you have 6-8 hours of sleep last night?

Did you take any medicine in last 3 days?

Have you or anyone staying with you had fever in the last one week?

Have you any reason to believe that you are infected with

In the last one month have you had Immunization / Dental Extraction / Root Canal Treatment Immunization (Cholera, Typhoid, Diptheria, Tetanus, Plague, Gammaglobulin)

In the last 6 months did you suffer / had

In the last 1 year have you had any

Do you suffer from or have suffered from any of following diseases? Heart / Lung / Kidney / Cancer / Fits / Jaundice / Tuberculosis / Abnormal Bleeding Tendency / Allergic diseases / Sexually Transmitted Diseases / Malaria(3months) / Fainting Spells / Diabetes

Did you consume alcohol in last 24 hours?

Would you like to donate blood again? If yes, at what interval

For Women donor only

Are you married?

Are you pregnant?

Have you had an abortion in the last 6 months?

Do you have a child less than 1 year old?

Are you Breastfeeding?

For Understanding

Have you understood all the information presented and answered all the questions truthfully?

Do you wish to register yourself as stem cell donor?

I understand that
a) Blood donation is totally voluntary and no inducement of renumeration is offered.
b) Donation of blood is a medical procedure and that by donating voluntarity, I accept the risks associated with it.
c) My blood will be tested for HIV, Hepatitis B, Hepatitis C, Malaria Parasite, Venereal diseases and any other test(s) required to ensure blood safety.
d) Information provided by me will not be disclosed to any one without my consent.
e) I was provided an opportunity not to donate blood for reasons that might affect blood safety. (Form given)
f) Plasma recovered from my donated blood may be sent for preparation of plasma derived medicinal products for human use.