Medical History Questionnaire

Prior to completing the medical history questionnaire, donors MUST FIRST READ general blood donation material and a medication deferral list. The questions below will be answered YES or NO. If you are trying to determine your eligibility to donate and answer “yes” to one of the questions (excluding #1 and #5) please call 650-723-7831 to clarify.

A “yes” response does not necessarily make you ineligible to donate.

The following questions are included in the medical history:

Are you
1.	Feeling healthy and well today?
2.	Currently taking an antibiotic?
3.	Currently taking any other medication for an infection?
4.	Have you taken any medications on the Medication Deferral List in the time frames indicated? (Review the Medication Deferral List.)
5.	Have you read the educational materials today?
In the past 48 hours
6.	Have you taken aspirin or anything that has aspirin in it?
In the past 8 weeks, have you
7.	Donated blood, platelets or plasma?
8.	Had any vaccinations or other shots?
9.	Had contact with someone who was vaccinated for smallpox in the past 8 weeks?
In the past 16 weeks
10.	Have you donated a double unit of red cells using an apheresis machine?
In the past 12 months, have you
11.	Had a blood transfusion?
12.	Had a transplant such as organ, tissue, or bone marrow?
13.	Had a graft such as bone or skin?
14.	Come into contact with someone else’s blood?
15.	Had an accidental needle-stick?
16.	Had sexual contact with anyone who has HIV/AIDS or has had a positive test for the HIV/AIDS virus?
17.	Had sexual contact with a prostitute or anyone else who takes money or drugs or other payment for sex?
18.	Had sexual contact with anyone who has ever used needles to take drugs or steroids, or anything not prescribed by their doctor?
19.	Male donors: Had sexual contact with another male?
20.	Female donors: Had sexual contact with a male who had sexual contact with another male in the past 12 months?
21.	Had sexual contact with a person who has hepatitis?
22.	Lived with a person who has hepatitis?
23.	Had a tattoo?
24.	Had ear or body piercing?
25.	Had or been treated for syphilis or gonorrhea?
26.	Been in juvenile detention, lockup, jail, or prison for more than 72 hours?
In the past three years, have you
27.	Been outside the United States or Canada?
From 1980 through 1996
28.	Did you spend time that adds up to three (3) months or more in the United Kingdom? (Review list of countries in the UK.)
29.	Were you a member of the U.S. military, a civilian military employee, or a dependent of a member of the U.S. military?
From 1980 to the present, did you
30.	Spend time that adds up to five (5) years or more in Europe? (Review list of countries in Europe.)
31.	Receive a blood transfusion in the United Kingdom or France? (Review country lists.)
Have you EVER
32.	Female donors: Been pregnant or are you pregnant now?
If yes	Answer sub-questions below:
	32a.	Are you pregnant now or have been pregnant in the last 6 weeks?
	32b.	Since your last donation, have you been pregnant?
33.	Had a positive test for HIV/AIDS virus?
34.	Used needles to take drugs, steroids, or anything not prescribed by your doctor?
35.	Received money, drugs, or other payment for sex?
36.	Had malaria?
37.	Had Chagas disease?
38.	Had babesiosis?
39.	Received a dura mater (or brain covering) graft or xenotransplantation product?
40.	Had any type of cancer, including leukemia?
41.	Had any problems with your heart or lungs?
42.	Had a bleeding condition or a blood disease?
43.	Have any of your relatives had Creutzfeldt-Jakob disease?
44.	Have you ever been diagnosed with Zika virus infection?
45.	In the past 12 months, have you had Hepatitis?

Additional restrictions may apply. Please call 1-888-723-7831 to make an appointment, and to inquire about your eligibility.

For more information regarding medication or travel deferral, please review Form 05-F36, Donor Education Materials.