Udhq

Full-Length Donor History Questionnaire
Yes

No

Are you
1. Feeling healthy and well today?
2. Currently taking an antibiotic?
3. Currently taking any other medication for an infection?
Please read the Medication Deferral List.
4. Are you now taking or have you ever taken any medications on the
Medication Deferral List?
5. Have you read the educational materials?
In the past 48 hours
6. Have you taken aspirin or anything that has aspirin in it?
In the past 6 weeks
7. Female donors: Have you been pregnant or are you pregnant now?
(Males: check “I am male.”)

I am
male

In the past 8 weeks have you
8. Donated blood, platelets or plasma?
9. Had any vaccinations or other shots?
10. Had contact with someone who had a smallpox vaccination?
In the past 16 weeks
11. Have you donated a double unit of red cells using an apheresis
machine?
In the past 12 months have you
12. Had a blood transfusion?
13. Had a transplant such as organ, tissue, or bone marrow?
14. Had a graft such as bone or skin?
15. Come into contact with someone else’s blood?
16. Had an accidental needle-stick?
17. Had sexual contact with anyone who has HIV/AIDS or has had a
positive test for the HIV/AIDS virus?
18. Had sexual contact with a prostitute or anyone else who takes money
or drugs or other payment for sex?
19. Had sexual contact with anyone who has ever used needles to take
drugs or steroids, or anything not prescribed by their doctor?
20. Had sexual contact with anyone who has hemophilia or has used
clotting factor concentrates?
21. Female donors: Had sexual contact with a male who has ever had
sexual contact with another male? (Males: check “I am male.”)
22. Had sexual contact with a person who has hepatitis?
23. Lived with a person who has hepatitis?
24. Had a tattoo?
25. Had ear or body piercing?
v. 1.2

I am
male

eff February 2007

Full-Length Donor History Questionnaire
Yes

No

26. Had or been treated for syphilis or gonorrhea?
27. Been in juvenile detention, lockup, jail, or prison for more than 72
hours?
In the past three years have you
28. Been outside the United States or Canada?
From 1980 through 1996,
29. Did you spend time that adds up to three (3) months or more in the
United Kingdom? (Review list of countries in the UK)
30. Were you a member of the U.S. military, a civilian military employee,
or a dependent of a member of the U.S. military?
From 1980 to the present, did you
31. Spend time that adds up to five (5) years or more in Europe? (Review
list of countries in Europe.)
32. Receive a blood transfusion in the United Kingdom or France?
(Review list of countries in the UK.)
From 1977 to the present, have you
33. Received money, drugs, or other payment for sex?
34. Male donors: had sexual contact with another male, even once?
(Females: check “I am female.”)

I am
female

Have you EVER
35. Had a positive test for the HIV/AIDS virus?
36. Used needles to take drugs, steroids, or anything not prescribed by
your doctor?
37. Used clotting factor concentrates?
38. Had hepatitis?
39. Had malaria?
40. Had Chagas’ disease?
41. Had babesiosis?
42. Received a dura mater (or brain covering) graft?
43. Had any type of cancer, including leukemia?
44. Had any problems with your heart or lungs?
45. Had a bleeding condition or a blood disease?
46. Had sexual contact with anyone who was born in or lived in Africa?
47. Been in Africa?
48. Have any of your relatives had Creutzfeldt-Jakob disease?

v. 1.2

eff February 2007

Full-Length Donor History Questionnaire
Use this area for additional questions

v. 1.2

Yes

No

eff February 2007