Download Questionnaire for Donors of Blood, Plasma and/or Blood Cells

Information for the staff
concerning donnation (donnor’s card) :
in force since Jan.1, 2010
Questionnaire for Donors of Blood, Plasma and/or Blood Cells
First name and family name: ...............................................................
weight :
high:
Date of birth: ...................................Phone n:.………………..e- mail :…………………………………………..
Address: ...........................................................................................
male : ○
female : ○
Dear Donor,
Thank you very much for your generosity in donating blood, plasma or blood cells.
Prior to donation, your blood, temperature and blood pressure will be tested and your general physical
conditions will be screened.
From your blood sample your blood type/group will be identified and the following tests will be made for
hepatitis B surface antigen (HBsAg), antibodies to hepatitis C (anti-HCV), antibodies to AIDS/HIV (anti-HIV),
syphilis and ALT liver enzyme. You will be notified of the results of these tests only if your eligibility to donate
has been affected or if any additional examination may be necessary.
All the tests and examinations are made to prevent transmission of infectious diseases via blood donation.
In some cases, particularly in cases of most recent infection, the laboratory results may be negative, yet the
infection can be transmitted from donor to recipient. Therefore, it is imperative that you answer each of the
following questions truly and accurately. If in doubt, please consult a physician from this department. By
concealing any information, you may expose a recipient to serious infection risk.
Please give true answers when filling in the Questionnaire, which is a compulsory part of screening before
blood donation as provided by Regulation of the Ministry of Health of the Slovak Republic No. 333/2005
Z.z. on the requirements and proper procedures for the preparation of transfusion medication.
Circle the correct answers!
Have you ever donated blood, plasma or blood cell in the past?
Have you ever been excluded from blood donation as ineligible?
Health History:
Are you in good health?
Is your weight over 50 kg?
Have you been treated by a dentist in the past 72 hours ?
Have you been using any medication in the past month? Which medication?
Have you suffered from herpes, diarrhea, sucked in tick, animal bite, fever over 38°C in the past month?
Have you been vaccinated in the past month?
Have you ever suffered or are you currently suffering from:
• hepatitis, tuberculosis, boreliosis, toxoplasmosis, brucellosis, infectious mononucleousis?
• malaria, or another tropical disease (babesiosis, Q–fever, leishmaniasis)?
• rheumatic disorders, rheumatic fever?
• heart disease, high or low blood pressure?
• chronic lung or bronchi disease, asthma, allergy, hay fever/pollinosis?
• kidney disease?
• blood disease, bleeding/hemorrhage symptoms?
• nervous system disease, epilepsy?
• metabolism disorders (diabetes, thyroid gland)?
• skin diseases (eczema, psoriasis)?
• digestive system, liver or pancreas diseases?
• tumor disease?
• sexually transmissible disease?
Have you experienced inexplicable weight loss, raised temperature, sweating, behavioral changes,
enlarged lymphatic nods in the past twelve months?
Have you been treated for acne by isotretinoine (RoaccutaneR, AccutaneR), for prostate by finasteride
(ProscarR, AvodartR), and for baldness (PropeciaR) in the past three months?
Have you been treated by acitretin (NeotigasonR) or etretinate (TegisonR ) in the past three years?
yes
yes
no
no
yes
yes
yes
yes
yes
yes
no
no
no
no
no
no
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
no
no
no
no
no
no
no
no
no
no
no
no
no
yes
no
yes
yes
No
No
Risk Factors Questions:
In the past six months have you had
- any operation, medical test or treatment, endoscopy , arterial catheterization?
yes
- any tattooing, piercing, ear-ring application, acupuncture, permanent make – up ?
yes
- any injury during which the wound or mucous membrane came into contact with another person’s
blood, or
yes
- any accidental stick of a used needle?
Have you received a blood component transfusion in the past six months?
yes
Have you spent the past six months in Africa, America, Asia?
yes
In the past six months, have you been in contact with any person suffering from hepatitis or another
yes
infectious disease?
In the past twelve months, have you had any sexual contact with
- anyone who is HIV positive or has hepatitis?
yes
- anyone who has used needles to take drugs?
yes
- anyone who engages in sex for money or drugs?
yes
- any person other than your permanent sexual partner or a person from another country?
yes
Have you ever used needles to take drugs or steroids?
yes
Were you born or have you ever lived in a country/region in which malaria occurs?
yes
Did you spend the time in excess of six moths in the United Kingdom/Ireland during 1980–1996?
yes
Have you had any surgery or have you received transfusion in the United Kingdom or Ireland at any time yes
following 1980?
Have you had any information about Creutzfeldt-Jacob disease or its variant form in your family?
yes
Have you been treated with a growth hormone?
yes
Have you had any human or animal tissue transplant ?
yes
Do you have a risky occupation/hobbies? (professional driver, diver, worker in the height?
yes
Male Donors:
Have you had a sexual contact with a man in the past twelve months?
yes
Female Donors:
yes
Were you been pregnant or a lactating mother in the past six months?
Have you been treated with hormonal injection for sterility before 1986 ?
yes
Declaration
I declare that I have read the above questions and answered them all truthfully. I am aware that by knowingly
concealing any information, I may cause health problems or death to another person and I may be prosecuted
under Criminal Code of the Slovak Republic. I have been informed of the possibility to exclude myself from
donation, if necessary. I consider myself to be a suitable blood donor, whose blood will not jeopardize
recipient’s health .In case of any indications or symptoms of an infectious disease. I shall inform the transfusion
unit without any delay.
I declare that I am willing to donate blood (plasma, blood cells) voluntarily and free of charge, agreeing that the
blood may be used for medical purposes. I agree with the above laboratory tests to be made. And I give my
consent to the National Blood Transfusion Service, the operator, to process my personal information in
conformity with § 7 of Act 428/2002 Z.z. (Protection of Personal Information Act) as amended to the extent
specified in the Questionnaire, and results of the tests, too. I have given my consent to the operator especially to
collect, assemble and record, maintain, organize, search for and use this personal information for keeping the
Register of Blood Donors and using it in conformity with the general statutory regulations. I have taken notice
of the fact that in relation to processing the personal information I have the rights stipulated in Act 428/2002 Z.z.
(Protection of Personal Information Act) as amended. I have given my consent voluntarily and for indefinite
period of time. Prior to donation of blood and its components I have been orally informed of the protection of
personal information and the measures to prevent unauthorized publication of my identity, the information
concerning my conditions of health and the test results.
In................................................ Date :
Donor’s signature :
Thank you for your filling in the questionnaire, now you will be called for physical examination.
Doctor’s observations:
Hb
Conclusion:
g/l
TT
°C
legible for donation
Record of blood taking:
Duration < 10 min. > 10 min.
TK
mmHg
illegible for donation
Responsible staff:
amount taken
ml
no
no
no
no
no
no
no
no
no
no
no
no
no
no
no
no
no
no
no
no
no
collapse
blood vessel complication
(rupture
hematoma
bleeding
Performed by (Name of the nurse)
reaction
)
Information for Donors
Please read the following information carefully.
Before Donation:
Consume light meals the day before donation, drink at least 0,5 l non-alcoholic beverage and have a
light breakfast (bread, jam, honey, fruit, vegetable), avoid dairy products, smoked meats and the like.
You should not come after some physical or psychological effort or strain. And blood donation is not
recommended during, immediately before or after menstruation.
Donation Procedure:
1. filling in the Questionnaire for Donors of Blood, Plasma and Blood Cells
2. registration of the donor
3. taking blood sample for testing (blood count, hemoglobin) or blood group
4. physical check-up
5. donation (duration approx. 7-10 min., volume of blood taken: 400-500 ml)
No donor can be infected. For donation only disposable materials are used.
Blood donor must be in good health, aged 18-60, and of at least 50 kg in weight.
Permanently excluded from blood donation is anyone:
1. who is AIDS (HIV),hepatitis B or C and syphilis positive
2. who is a drug addict on intravenous or muscular drugs
3. who changes sexual partners in a promiscuous way
4. who gets paid for sexual services
5. who is on medically not-indicated anabolic steroids or hormones
6. who has a history of coagulation disorders (e.g. hemophilia) by blood preparations/medications
Temporarily deferred from blood donation is anyone:
7. who has visited regions with endemic malaria in the past six months, or who has had malaria
8. who has had a history of gonorhea or another sexually transmitted disease in the past twelve
months
9. who has visited, in the past twelve months, a region with high rates of AIDS or hepatitis
10. who has visited, in the past month, a region in which bird flu occurred
11. whose sexual behavior may expose you to a risk of contracting serious blood transmitted diseases
(intimate contact in the past twelve months with a person meeting the criteria shown in 1 – 6
above )
12. who has a history of surgical or other treatments (operation, endoscopy, arterial catheterization,
blood transfusion, tattooing, piercing, ear-rings application, acupuncture) in the last six months
13. who suffers from allergy, any health disorders or who is on medication
14. who has been on some medication
After donation you are advised to make up for the loss of the body liquids and to take a snack. Avoid
any strenuous physical or psychological activity in the following twelve hours. Driving immediately
after donation is strictly to be avoided, and you should drive very carefully also at some later time
Possible post-donation complications:
In about 1-3 % of donations, some complications can occur, such as hematomas (bruises) or temporary
weakness, dizziness or sickness.
You are encouraged to ask any question concerning blood donation and blood components.
Our doctors will be pleased to answer them all.
Thank you for your cooperation.
National Blood Transfusion Service staff