This questionnaire is the means by which first time donors are screened. The questions are usually asked in a phone interview. Additionally KEMH policy requires that each donor read this questionnaire before each donation he or she makes.

Donors are required to inform the nurse if they respond ‘yes’ to any of the questions.

1. Have you visited or lived in the UK, Republic of Ireland, or in Europe for a cumulative total of six months or more from 1980 through 1996?

2. Do you have any health problems?

3. Are you:

Under 18 or over 70 years of age?

Under 110lbs in weight?

Having any medical investigations?

Taking medications - either prescription or over-the-counter?

Suffering from diabetes, epilepsy, bleeding conditions, heart or chest disease?

Suffering from swellings in the neck, armpits, or groin?

Suffering from a fever, cough, flu - are you feeling generally unwell? Please let us know if you develop any flu-like symptoms in the next few days.

4. In the last twelve months, have you had:

Major surgery, a tattoo, skin piercing including electrolysis, acupuncture, chirpody, an accidental needle stick injury, a transfusion of blood or blood components, or have you received an organ donation or tissue graft, or used recreational drugs?

5. Have you recently had:

An immunization, vaccination or any other injection?

Any medical treatments?

6. In the past three days, have you had:

A tetanus shot, antibiotics by mouth or dental treatments?

7. Have you:

Been deferred or refused as a blood donor for any reason?

Ever been diagnosed with, or treated for cancer?

Ever taken Tigason, Soriatane, pituitary growth hormone, or anabolic steroids.

Ever had Chagas disease, babesiosis, malaria, or have you been in a malaria area in the past 12 months?

Ever had hepatitis or any other sexually transmitted diseases?

Done more than your usual amount of exercise today?

Failed to eat a meal before coming to the clinic today?

8. Ladies: Have you been pregnant within the last six months.

After donating blood, please do not smoke for at least one hour. Do not do any vigorous exercise for the rest of the day and evening.

Please do not donate blood if you are having - or have ever had - intimate contact with a homosexual, a bi-sexual, an intravenous drug user, a haemophiliac, anyone with a positive HIV test anyone with a positive Hepatitis B or C test, or if you had paid or unprotected sex.

Have you read and understood everything on this questionnaire? Do you have any questions or comments? Thank you for being a blood donor.