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.

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 questions are included in the medical history questionnaire:

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 56 days, have you been diagnosed with or suspected of having 2019 Novel Coronavirus infection (COVID- 19)? Y N
46 In the past 28 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.