Blood Donor Health Questionnaire

Full Name Date of Birth Gender Female Male Other Phone Email Yes No

Have you donated blood in the last 8 weeks?

Yes No

Have you ever had any of the following? (check all that apply)

Heart disease Cancer Diabetes Hepatitis Other serious illness

In the past 12 months, have you had:

Tattoo or piercing Major surgery Blood transfusion None of the above

List any medications you are currently taking Do you have any allergies? Additional Comments