Download Information on contagious diseases for Blood Donors

Załączniki do rozporządzenia Ministra Obrony Narodowej ………………
Załącznik Nr 1
Questionnaire for Blood Donor
Name and family name ....................................................... Donation no. ...............................
Date of birth ..................................................................
Identification no ………………………………………
Information on infectious diseases for Blood Donors
What you should know before donating blood
Your blood will be tested for syphilis, AIDS (HIV infection), HBV and HCV. If the
results are positive your blood will not be transfused. However, with every infection,
there is always a certain time lapse between the moment of infection and the possibility
of determining this infection in laboratory tests. Within this period it is absolutely
forbidden to donate blood as it may be the source of infection for others.
Do not donate blood if you have had any of the following hazardous contacts that have
put your blood at risk:
-
sexual contacts with many partners (men or women) known only for a short time,
sexual contacts with persons drug shots used,
sexual contacts for money,
drug shots used at present or in the past
sexual contacts with partners with positive tests for syphilis, HIV, HCV and HBV,
sexual contacts with a partner receiving coagulation factor concentrates due to
illness.
We are fully aware that by referring to these issues we intrude on very private spheres
of life. However, the already small risk of transmitting infectious diseases by blood
transfusion can be reduced even further only if before donating blood, you carefully
analize the above situations and provides acurate information. The answers remain
confidential. If test results are positive ( this means infection) you will be informed by
the doctor.
Thank you for your cooperation.
Have you ever donated blood? If yes, when was the last time? .………….. Yes ; No 
Do you feel healthy at the present time ?
Yes ; No 
In the last 7 days have you had any dental procedures ?
Yes ; No 
In the past 4 weeks have you been ill, had:
 to visit a doctor
Yes ; No 
 any temperature over 38 °C ?
Yes ; No 
5. In the last 4 weeks have you had any vaccination ?
Yes ; No 
If so, what ? ............................................. When ? .....................................................
6. Have you had any of the following diseases or do you feel or felt any of the following
symptoms ? (write “yes” or “no”)
a) circulatory diseases (hypertension), .......................... heart disease ................................
If so, when ? ................................................
1.
2.
3.
4.
b) skin diseases, ................ rash, exanthema ...............allergy ............
If so, when ? .................................................
c) diabetes
If so, when ? ............................................................
d) syphilis ,............gonorrhea, ..............toxoplasmosis, ............
If so, when ? .......................................................................
7. In the past 6 months have you had gastroscopy, biopsy
or other diagnostic procedure ?
8. Have you ever had a blood transfusion ?
If so, when ? ................................................
9. Have you ever had malaria or any other tropical diseases ?
If yes, what disease ........................................
10. In the past 6 months have you had:
 a tattoo
 perforation of the ears or any other part of the body ?
If yes, when ? …........................................................
11. In the past 6 months or since the last blood donation
have you been in contact with human blood
or blood stained equipment ?
12. Have you ever had jaundice ?
If yes, when ........................................?
13. In the past 6 months has your life or sexual partner had jaundice ?
14. In the past 12 months have you been in contact with anyone
suffering from an infectious disease ?
a) have you read and understood the
„ information on infectious diseases for blood donors”
b) have you been exposed to the risk of infection
(see „information on infectious diseases for blood donors” )
15. Have you ever been advised not to donate blood ?
Yes ; No 
Yes ; No 
Yes ; No 
Yes ; No 
Yes ; No 
Yes ; No 
Yes ; No 
Yes ; No 
Yes ; No 
Yes ; No 
Yes ; No 
Yes ; No 
Only for women
16. Are you pregnant or have you been pregnant in the past 12 months
or since you last donated blood ?
Yes ; No 
If yes, when ? .................................. Give the date of delivery……………………..
17. Do you menstruate ?
Yes ; No 
When was your last period ? ...........................................
18. Have you had hormone injections or any infertility
therapy between 1965 and 1985 ?
Yes ; No 
I hereby give my consent to:
- donate whole blood
as well as to use my blood or its components if necessary for any appropriate medical
purposes
I have received information on the procedure of blood collection and forseen consequences
of blood donating for my health.
I have read the information on AIDS and other infectious blood transmitted diseases.
I ascertain with good conscience that according to my best knowledge I have supplied true
and accurate information on the past diseases and the present state of my health. I understand
that this information is necessary for protecting my health as the donor and also the health of
the future recepient of my blood.
I ascertain that I have never been treated with blood and I believe that my blood is suitable for
medical purposes.
.........................................
Date and donor’s signature
If you have changed your address within 3 months of donating blood please inform the Military Blood
Service in ………………………………………………………………………………………………………
Please inform us of any disturbing symptoms that may occur within 48 hours of blood
donation.
……………………………..
Date and signature of doctor
…………………………….
Date and donor’s signature