Blood Donation Questionnaire Uk Form PDF Details

The Blood Donation Questionnaire in the UK, often encountered by both new and recurring donors, marks a crucial step in the pre-donation screening process. This form, demanding to be filled out with either blue or black ballpoint pen, undertakes the significant task of ascertaining a donor's eligibility for blood donation through a series of meticulously crafted questions. Divided into sections that explore lifestyle choices, health status, exposure to risks of infection, additional risk factors, and recent travels outside the UK, the form seeks comprehensive details from the prospective donor. For instance, inquiries about lifestyle habits such as history of drug use or engagement in activities with high HIV risk are paramount to evaluating the safety of the blood supply. Health-related questions probe any conditions or medications that might disqualify someone from donating. Furthermore, the questionnaire delves into recent illnesses, possible contact with infectious diseases, and overseas travel that could introduce additional risks. While mistakes on the form are to be left uncorrected by correction fluid, indicating the seriousness with which the information must be treated, the presence of any uncertainties encourages a confidential discussion with a nurse, thereby ensuring the integrity of the blood donation process. Through this meticulous vetting, the questionnaire plays a pivotal role in safeguarding not only the donor's health but also that of the countless recipients who depend on these vital donations.

QuestionAnswer
Form NameBlood Donation Questionnaire Uk Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesblood donation form, blood donor questionnaire, donor healthcheck form, blood donation questionnaire pdf

Form Preview Example

Donor Health Check for new and returning donors

Please answer the following questions in blue or black ballpoint pen. If you are uncertain of any answer, leave the box blank and speak in confidence to the nurse.

Please do not use correction fluid if you make a mistake on this form.

A Your lifestyle

Yes No Staff

 

 

A1 Have you tested positive for HIV or do you think you may be HIV positive?

A2 Have you ever had hepatitis B or hepatitis C or think you may have hepatitis now?

A3 Have you ever injected yourself or been injected with illegal or non-prescribed drugs including body-building drugs or cosmetics (even if this was only once or a long time ago)?

A4 Have you ever been given money or drugs for sex?

A5 In the last 12 months have you had sex with:

a anyone who is HIV positive;

b anyone with hepatitis B, hepatitis C or HTLV;

c anyone who has ever been given money or drugs for sex;

d anyone who has ever injected drugs; or

eanyone who may ever have had sex in parts of the world where AIDS/HIV is very common (this includes most countries in Africa)?

A6 Male donors only; In the last 12 months have you had oral or anal sex with a man, with or without a condom?

A7 Female donors only; In the last 12 months have you had sex with a man who has ever had oral or anal sex with another man, with or without a condom?

B Your health

Yes No Staff

 

 

B1 Have you ever been told that you should not give blood?

B2 Have you ever had a serious illness or seen a doctor about your heart?

B3 Have you ever had any hospital investigations or tests or operations?

B4 Are you taking any prescribed medicine or tablets or other treatments (except HRT for the menopause, the pill or other birth control)?

B5 In the last 7 days have you taken any additional medicines or tablets includ- ing any you have bought yourself?

B6 In the last 7 days have you seen a doctor, dentist or any other healthcare pro- fessional or are you waiting to see one (except for routine screening appoint- ments)?

Change of details – If we have your details wrong, please give us the correct information below.

Title

Forename

Surname

Address

 

Postcode

Home no

Work no

Mobile

Email

DoB:.......DD /.......MM/............YYYY

 

C Risks of infection

 

 

 

 

 

DT

 

Yes

 

No

 

Staff

 

 

 

 

 

 

CODE

 

 

 

 

 

 

 

 

In the last 2 weeks have you had any illness, infection or fever or do you

 

 

 

 

 

 

 

 

 

 

C1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

think you have one now?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In the last 4 weeks have you been in contact with anyone with an

 

 

 

 

 

 

 

 

 

 

C2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

infectious disease?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C3

 

 

In the last 8 weeks have you had any immunisations, vaccinations or jabs?

 

 

 

 

 

 

 

 

 

 

 

 

 

In the last 12 months...

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C4

 

 

...have you had your ears, face or body pierced, had a tattoo or any cos-

 

S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

metic treatment that involved piercing your skin?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C5

 

 

...have you had acupuncture?

 

 

 

 

 

S

 

 

 

 

 

 

 

 

 

 

 

...

have you been exposed unintentionally to someone else’s blood or

 

 

 

 

 

 

 

 

 

 

C6

 

 

 

S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

body fluids eg through a needle prick or bite or broken skin?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional risks

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C7

 

 

Have you ever had jaundice or hepatitis?

 

 

 

 

 

J

 

 

 

 

 

 

 

 

C8

 

 

Have you received a blood transfusion since 1st January 1980?

 

 

 

 

 

 

 

 

 

 

C9

 

 

Has anyone in your family had CJD?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C10

Were you treated with growth hormone before 1985?

 

 

 

 

 

 

 

 

 

 

C11

Did you have brain surgery or an operation for a tumour or cyst in your

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

spine before August 1992?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C12 Female donors only; Have you ever had treatment for infertility?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D Travel outside the UK

 

 

 

 

 

DT

 

Yes

 

No

 

Staff

 

 

 

 

 

 

CODE

 

 

 

 

D1

 

 

 

In the last 12 months have you been outside the UK (inc. business trips)?

 

R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D2a.

 

Were you born or have you ever lived or stayed outside the UK for a

 

L

 

 

 

 

 

 

 

 

 

 

 

 

continuous period of 6 months or more?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.

 

 

If ‘yes’ have you been outside the UK since then?

 

L

 

 

 

 

 

 

 

D3a.

 

Have you ever had malaria or an unexplained fever which you could

 

M/F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

have picked up while travelling?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.

 

 

If ‘yes’ have you been outside the UK since then?

 

V

 

 

 

 

 

 

 

D4

 

 

Have you ever visited Central America or South America for a continu-

 

R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ous period of 4 weeks or more?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D5

 

 

Were you or your mother born in Central America or South America?

 

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(IN CAPITALS)

 

(IN CAPITALS)

 

 

 

 

 

 

 

 

 

............................................................Forename

 

Surname

 

 

 

 

 

 

 

 

Your Signature

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STAFF USE ONLY

 

CLINICAL NOTES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Suspend until

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Withdraw

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accept

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

/

......../

 

 

Withdraw/suspend until

......../

/

 

 

 

 

 

Additional

 

 

 

 

 

 

Set medical bar

CST/Donor Records signa-

notes

 

 

Attention Clinical

 

 

Medical Referal

 

label

 

 

 

 

 

ture

 

 

 

 

Support Team

 

 

Form attached

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 1 of 2 01/05/12 FRM421/5

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