Female Donor Eligibility Screening Form
Full Name
Date of Birth
Contact Number
Address
Are you currently pregnant?
Yes
No
Date of Last Menstrual Period
Are you currently breastfeeding?
Yes
No
Have you ever been diagnosed with any of the following? (check all that apply)
Anemia
Hypertension
Diabetes
Other
Have you donated blood in the past 3 months?
Yes
No
Are you currently taking any medication?
Yes
No
If yes, please specify
Do you feel well and healthy today?
Yes
No
Comments / Additional Information