Medical History Questionnaire

Prior to completing the medical history questionnaire, donors MUST FIRST READ Blood Donor Educational Material. The questions below will be answered YES or NO. If you are trying to determine your eligibility to donate and answer “yes” to one of the questions (excluding #1 and #5) please call 650-723-7831 to clarify. A “yes” response does not necessarily make you ineligible to donate.

The following is included in the medical history questionnaire:

I certify that I am 17 years of age or older (unless separate consent is signed), and I am voluntarily donating my blood to the Stanford Blood Center for use as it deems advisable. I have read and understood the donor information given to me, the donation process has been explained to me, and all of my questions have been answered to my satisfaction.

I understand that my blood will be tested for evidence of exposure to infectious agents that can be transmitted through transfusion including, but not limited to, hepatitis B and C, HIV (the AIDS virus), HTLV, syphilis, and West Nile Virus. I will be notified of test results that are important to my health or that affect my eligibility to donate. Blood with a positive test result will not be used for transfusion. The Blood Center will retain records of all donors with abnormal test results. I understand that the Blood Center may be required to report certain positive tests to the public health service.

I understand and agree that my blood and stored samples may be used for transfusion, further manufacturing, investigational testing, training, research, and other uses as needed. I also understand and agree that my health information may be used in a confidential manner for blood center operations and research.

I agree not to donate blood or plasma for transfusion to another person or for further manufacture if I know that I am infected with HIV (the AIDS virus), if I have tested positive for HIV or antibody to HIV, or if I believe that I may have been exposed to HIV. I understand that starting 2018 it is a misdemeanor in California for persons to donate blood when they know they have AIDS or have tested positive for HIV or antibodies to HIV.

I understand that the most common side effects of blood donation are bruising at the donation site, light-headedness, and rarely, fainting, inflammation of the vein, infection of the skin, or nerve injury.

I certify that I have read the materials and that I have answered all questions truthfully and to the best of my knowledge, to provide protection for me as a donor and for the safety of the recipient of my blood.

DONOR SIGNATURE X__________________________

 

ARE YOU

1	Feeling healthy and well today?	Y	N
2	Currently taking an antibiotic?	Y	N
3	Currently taking any other medication for an infection?	Y	N
4	Pregnant now?	Y	N
5	Have you taken any medications on the Medication Deferral List in the time frames indicated? (Review the Medication Deferral List.)	Y	N
6	Have you read the blood donor educational materials today?	Y	N

IN THE PAST 48 HOURS

7

Have you taken aspirin or anything that has aspirin in it?

Y

N

IN THE PAST 8 WEEKS, HAVE YOU

8	Donated blood, platelets or plasma?	Y	N
9	Had any vaccinations or other shots?	Y	N
10	Had contact with someone who was vaccinated for smallpox in the past 8 weeks?	Y	N

IN THE PAST 3 MONTHS, HAVE YOU

11	Taken any medication by mouth (oral) to prevent an HIV infection? (i.e., PrEP or PEP)	Y	N
12	Had sexual contact with a new partner? (refer to the examples of “new partner” in the Blood Donor Educational Material)?	Y	N
13	Had sexual contact with more than one partner?	Y	N
14	Had sexual contact with anyone who has ever had a positive test for HIV infection?	Y	N
15	Received money, drugs, or other payment for sex?	Y	N
16	Had sexual contact with anyone who has, in the past 3 months, received money, drugs or other payment for sex?	Y	N
17	Used needles to inject drugs, steroids, or anything not prescribed by your doctor?	Y	N
18	Had sexual contact with anyone who has used needles in the past 3 months to inject drugs, steroids, or anything not prescribed by their doctor?	Y	N
19	Had syphilis or gonorrhea or been treated for syphilis or gonorrhea?	Y	N
20	Had sexual contact with a person who has hepatitis?	Y	N
21	Lived with a person who has hepatitis?	Y	N
22	Had an accidental needle-stick?	Y	N
23	Come into contact with someone else’s blood?	Y	N
24	Had a tattoo?	Y	N
25	Had ear or body piercing?	Y	N
26	Had a blood transfusion?	Y	N
27	Had a transplant such as organ, tissue, or bone marrow?	Y	N
28	Had a graft such as bone or skin?	Y	N

IN THE PAST 16 WEEKS, HAVE YOU

29

Donated a double unit of red blood cells using an apheresis machine?

Y

N

IN THE PAST 12 MONTHS, HAVE YOU

30

Been in juvenile detention, lockup, jail, or prison for 72 hours or more consecutively?

Y

N

IN THE PAST TWO YEARS, HAVE YOU

31

Received any medication by injection to prevent HIV infection? (i.e., long-acting antiviral PrEP or PEP)

Y

N

IN THE PAST THREE YEARS, HAVE YOU

32

Been outside the United States or Canada?

Y

N

HAVE YOU EVER

33	Had a positive test for the HIV infection?	Y	N
34	Taken any medication to treat HIV infection?	Y	N
35	Been pregnant?	Y	N
36	Had malaria?	Y	N
37	Received a dura mater (or brain covering) graft or xenotransplantation product?	Y	N
38	Had any type of cancer, including leukemia?	Y	N
39	Had any problems with your heart or lungs?	Y	N
40	Had a bleeding condition or a blood disease?	Y	N
41	Had a positive test result for Babesia?	Y	N

ADDITIONAL QUESTIONS

42	In the past 28 days, have you traveled outside the United States?	Y	N
43	In the past 14 days, have you had symptoms of a confirmed or suspected COVID-19 infection or have you had a positive COVID-19 test?	Y	N

 

Additional restrictions may apply. Please call 888-723-7831 to make an appointment and to inquire about your eligibility. Appointments can also be made online at sbcdonor.org.

For more information regarding medication or travel deferral, please review Form 05-F36, Donor Education Materials.