| 1 |
Feeling healthy and well today? |
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| 2 |
Currently taking an antibiotic? |
|
| 3 |
Currently taking any other medication for an infection? |
|
| 4 |
Are you over 22 years of Age? |
|
| 5 |
Please read the Medication Deferral List.
Are you now taking or have you ever taken any medications on the Medication Deferral List?
|
|
| 6 |
Have you read the educational materials? |
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| In past 48 hours |
| 7 |
Have you taken aspirin or anything that has aspirin in it? |
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| In past 6 weeks |
| 8 |
Female donors: Have you been pregnant or are you pregnant now? |
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| In past 8 weeks have you |
| 9 |
Donated blood, platelets or plasma? |
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| 10 |
Had any vaccinations or other shots? |
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| 11 |
Had any vaccinations or other shots? |
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| In past 16 weeks |
| 12 |
Have you donated a double unit of red cells using an apheresis machine? |
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| In past 12 months have you |
| 13 |
Had a blood transfusion? |
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| 14 |
Had a organ failure/transplant such as organ, tissue, or bone marrow? |
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| 15 |
Had a graft such as bone, Skin, Orthopedic, Dental Implants? |
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| 16 |
Come into contact with someone else’s blood? |
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| 17 |
Had an accidental needle-stick? |
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| 18 |
Had sexual contact with anyone who has HIV/AIDS or has had a positive test for the HIV/AIDS virus? |
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| 19 |
Had sexual contact with a prostitute or anyone else who takes money or drugs or other payment for sex? |
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| 20 |
Had sexual contact with anyone who has ever used needles to take drugs or steroids, or anything not prescribed by their doctor? |
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| 21 |
Had sexual contact with anyone who has hemophilia or has used clotting factor concentrates? |
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| 22 |
Female donors: Had sexual contact with a male who has ever had sexual contact with another male? |
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| 23 |
Had sexual contact with a person who has hepatitis? |
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| 24 |
Lived with a person who has hepatitis? |
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| 25 |
Had a tattoo? |
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| 26 |
Had ear or body piercing? |
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| 27 |
Had or been treated for syphilis or gonorrhea? |
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| 28 |
Been in juvenile detention, lockup, jail, or prison for more than 72 hours? |
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| In past 3 years have you |
| 29 |
Been outside the Pakistan? |
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| 30 |
Did you spend time that adds up to three (3) months or more outside Pakistan? |
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| 31 |
Were you a member of the Armed Forces (Army, Navy, Airforce, Police)? |
|
| 32 |
Receive a blood transfusion outside Pakistan? |
|
| Have you ever |
| 33 |
Had a positive test for the HIV/AIDS virus? |
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| 34 |
Used needles to take drugs, steroids, or anything not prescribed by your doctor? |
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| 35 |
Used needles to take drugs, steroids, or anything not prescribed by your doctor? |
|
| 36 |
Had hepatitis? |
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| 37 |
Had diabetes? |
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| 38 |
Had malaria? |
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| 39 |
Had any type of cancer, including leukemia? |
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| 40 |
Had any problems with your heart or lungs? |
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| 41 |
Had a bleeding condition or a blood disease? |
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| 42 |
Had any co-oglation disorder? |
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