Please answer the following question correctly. This will help to protect you and the patient who receive your blood. Tick Yes or No

1. Do you feel well today? Yes No
2. Did you have something to eat in the last 4 hours? Yes No
3. Did you sleep well last night? Yes No
4. Have you donated blood previously? Yes No
5. When did you donate last?
6. Did you have any discomfort during/After blood donation? Yes No
7. Will you drive public transport, heavy duty vehicles, piloting, sky diving, mountaineering or work with machinery after blood donation? Yes No
8. Have you any reason to believe that you may be infected by either Hepatitis B/C ,HIV, Syphilis and MP diseases? Yes No

   In last six months, did you have any history of the following?

   1. Unexplained weight loss? Yes No
   2. Repeated diarrhoea? Yes No
   3. Continuous low grade fever? Yes No
   4. Swollen glands? Yes No

In the last Six Months, have you had any of the following?

1. Tattoo Yes No
2. Dental Extraction Yes No
3. Blood transfusion Yes No
4. Ear piercing Yes No
5. Minor Surgery Yes No

Do you suffer or have been suffering from any of the following diseases ?

1. Heart Disease Yes No
2. Lung Disease Yes No
3. Malignant Diseases/Cancer Yes No
4. Kidney Disease Yes No
5. Epilepsy Yes No
6. Diabetes Yes No
7. Tuberculosis Yes No
8. Hepatitis B/C Yes No
9. Allergy Yes No
10. VD/STD Yes No
11. Malaria Yes No
12. Typhoid Yes No
13. Abnormal bleeding tendency Yes No
14. Fainting spells Yes No
15. Jaundice Yes No

Are you taking or have taken any of these in last 72 hours?

1. Antibiotics Yes No
2. Aspirin Yes No
3. Alcohol Yes No
4. Steroid Yes No
5. Vaccine Yes No

In last one year?

1. Did you take Anti Rabies Vaccine? Yes No
2. Did you have Major Surgery? Yes No

FOR WOMEN DONORS ONLY ?

1. Are you pregnant? Yes No
2. Your child is 1 year of age? Yes No
3. You had abortion in last 3 months? Yes No
4. You have breast feeding child? Yes No
5. You are having menstrual period? Yes No