Blood Donation Questionnaire Uk Form PDF Details

For individuals who are interested in donating blood, there is a questionnaire that needs to be filled out. This questionnaire helps to determine eligibility of blood donation. The Blood Donation Questionnaire UK Form is an online form that can be filled out by those interested in donating blood in the United Kingdom (UK). By filling out this form, you will help to ensure that potential donors meet the eligibility requirements for donating blood in the UK. The questionnaire asks a series of questions about your health and travel history. Donating blood can save lives, so please consider filling out this form if you are eligible to donate!

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

How to Edit Blood Donation Questionnaire Uk Form Online for Free

blood donor questionnaire uk can be completed online without difficulty. Simply make use of FormsPal PDF editing tool to perform the job without delay. To maintain our tool on the forefront of efficiency, we strive to put into operation user-oriented features and enhancements on a regular basis. We're at all times grateful for any feedback - join us in reshaping how we work with PDF forms. This is what you'd need to do to start:

Step 1: First, access the tool by pressing the "Get Form Button" in the top section of this webpage.

Step 2: With the help of this handy PDF file editor, you can do more than merely fill out forms. Edit away and make your forms appear faultless with custom textual content put in, or adjust the original input to perfection - all that comes along with an ability to add any pictures and sign the PDF off.

As for the blank fields of this particular document, this is what you want to do:

1. Complete your blood donor questionnaire uk with a group of major blanks. Gather all of the information you need and ensure there is nothing missed!

Filling out segment 1 of donor healthcheck form

2. Right after filling in the last step, head on to the subsequent part and fill in the essential details in all these blank fields - Yes No, Staff, In the last months have you been, Have you ever had malaria or an, Were you or your mother born in, A Female donors only In the last , has ever had oral or anal sex with, B Your health B, Have you ever been told that you, Have you ever had a serious, Have you ever had any hospital, Are you taking any prescribed, IN CAPITALS ForenameSurname Your, IN CAPITALS, and B In the last days have you taken.

IN CAPITALS, Have you ever had malaria or an, and Have you ever had a serious in donor healthcheck form

3. The following segment is about PostcodeHome noWork no DD MM YYYY, Withdrawsuspend until , Attention Clinical Support Team, Medical Referal Form attached, Date, Set medical bar, CSTDonor Records signa ture, Additional notes label, and Page of FRM - fill out each of these blank fields.

Attention Clinical Support Team, Set medical bar, and Date in donor healthcheck form

Concerning Attention Clinical Support Team and Set medical bar, be certain that you get them right in this current part. These could be the key fields in the page.

Step 3: Immediately after going through the fields you have filled in, hit "Done" and you are good to go! Join FormsPal right now and instantly access blood donor questionnaire uk, ready for download. All modifications made by you are kept , making it possible to change the document later on if needed. FormsPal offers safe form completion with no personal data record-keeping or distributing. Feel safe knowing that your information is safe here!

Blood Donation Questionnaire Uk Form isn’t the one you’re looking for?

Related Documents