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.
Save Time and Skip the Line!
You may fill out your medical history questionnaire ahead of time on the day of your donation by using SBC preCheck™.
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 | Have you taken any medications on the Medication Deferral List in the time frames indicated? (Review the Medication Deferral List.) | Y | N |
| 5 | Have you read the educational materials today? | Y | N |
IN THE PAST 48 HOURS
| 6 | Have you taken aspirin or anything that has aspirin in it? | Y | N |
IN THE PAST 8 WEEKS, HAVE YOU
| 7 | Donated blood, platelets or plasma? | Y | N |
| 8 | Had any vaccinations or other shots? | Y | N |
| 9 | Had contact with someone who was vaccinated for smallpox in the past 8 weeks? | Y | N |
IN THE PAST 3 MONTHS, HAVE YOU
| 10 | Had a blood transfusion? | Y | N |
| 11 | Had a transplant such as organ, tissue, or bone marrow? | Y | N |
| 12 | Had a graft such as bone or skin? | Y | N |
| 13 | Come into contact with someone else’s blood? | Y | N |
| 14 | Had an accidental needle-stick? | Y | N |
| 15 | Had sexual contact with anyone who has ever had HIV/AIDS or has ever had a positive test for the HIV/AIDS virus? | Y | N |
| 16 | Had sexual contact with a prostitute or anyone else who has ever taken money or drugs or other payment for sex? | Y | N |
| 17 | Had sexual contact with anyone who has ever used needles to take drugs or steroids, or anything not prescribed by their doctor? | Y | N |
| 18 | Male donors: Had sexual contact with another male? | Y | N |
| 19 | Female donors: Had sexual contact with a male who had sexual contact with another male in the past 3 months? | Y | N |
| 20 | Had a tattoo? | Y | N |
| 21 | Had ear or body piercing? | Y | N |
| 22 | Had or been treated for syphilis or gonorrhea? | Y | N |
| 23 | Used needles to take drugs, steroids, or anything not prescribed by your doctor? | Y | N |
| 24 | Received money, drugs, or other payment for sex? | Y | N |
IN THE PAST 16 WEEKS,
| 25 | Have you donated a double unit of red cells using an apheresis machine? | Y | N |
IN THE PAST 12 MONTHS, HAVE YOU
| 26 | Had sexual contact with a person who has hepatitis? | Y | N |
| 27 | Lived with a person who has hepatitis? | Y | N |
| 28 | Been in juvenile detention, lockup, jail, or prison for 72 hours or more consecutively? | Y | N |
IN THE PAST THREE YEARS, HAVE YOU
| 29 | Been outside the United States or Canada? | Y | N |
FROM 1980 THROUGH 1996,
| 30 | Did you spend time that adds up to 3 months or more in the United Kingdom countries of England, Northern Ireland, Scotland, Wales, the Isle of Man, the Channel Islands, Gibraltar, or the Falkland Islands? | Y | N |
FROM 1980 THROUGH 2001, DID YOU
| 31 | Spend time that adds up to 5 years or more in France or Ireland? Time spent in Ireland does not include time spent in Northern Ireland which is part of the United Kingdom. | Y | N |
FROM 1980 TO THE PRESENT, DID YOU
| 32 | Receive a blood transfusion in France, Ireland, England, Northern Ireland, Scotland, Wales, the Isle of Man, the Channel Islands, Gibraltar, or the Falkland Islands? | Y | N |
HAVE YOU EVER
| 33 | Been pregnant or are you pregnant now? | Y | N |
| If yes, answer sub-questions below: | |||
| 33a. Are you pregnant now or have been pregnant in the last 6 weeks? | Y | N | |
| 33b. Since your last donation, have you been pregnant? | Y | N | |
| 34 | Had a positive test for the HIV/AIDS virus? | Y | N |
| 35 | Had malaria? | Y | N |
| 36 | Received a dura mater (or brain covering) graft or xenotransplantation product? | Y | N |
| 37 | Had any type of cancer, including leukemia? | Y | N |
| 38 | Had any problems with your heart or lungs? | Y | N |
| 39 | Had a bleeding condition or a blood disease? | Y | N |
| 40 | Had a positive test result for Babesia? | Y | N |
ADDITIONAL QUESTIONS
| 41 | In the past 12 months, have you had Hepatitis? | Y | N |
| 42 | In the last 12 months, have you donated two whole blood donations or one double red blood cell donations? | Y | N |
| 43 | Do you take a multi-vitamin with iron, or an iron supplement, after you donate blood? | Y | N |
| 44 | In the past 28 days, have you traveled outside the United States? | Y | N |
| 45 | In the past 28 days, have you been diagnosed with or suspected of having 2019 Novel Coronavirus infection (COVID- 19)? | Y | N |
| 46 | In the past 14 days, have you had close contact with an individual(s) diagnosed with or suspected of having 2019 Novel Coronavirus infection (COVID-19)? | Y | N |
| 47 | In the past 3 months, have you taken any medication to prevent an HIV infection? | Y | N |
| 48 | Have you EVER taken any medication to treat an HIV infection? | 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.