| Are you |
- Feeling healthy and well today?
- Currently taking an antibiotic?
- Currently taking any other medication for an infection?
- Pregnant now?
|
| Have you |
- Taken any medications on the Medication Deferral List in the time frames indicated? (Review the Medication Deferral List.)
- Read the blood donor educational materials today?
|
| In the past 48 hours, have you |
- Taken aspirin or anything that has aspirin in it?
|
| In the past 8 weeks, have you |
- Donated blood, platelets, or plasma?
- Had any vaccinations or other shots?
- Had contact with someone who was vaccinated for smallpox in the past 8 weeks?
|
| In the past 3 months, have you |
- Taken any medication by mouth (oral) to prevent HIV infection? (ie, PrEP or PEP)
- Had sexual contact with a new partner? (Refer to the examples of "new partner" in the Blood Donor Educational Material)
- Had sexual contact with more than one partner?
- Had sexual contact with anyone who has ever had a positive test for HIV infection?
- Received money, drugs, or other payment for sex?
- Had sexual contact with anyone who has, in the past 3 months, received money, drugs, or other payment for sex?
- Used needles to inject drugs, steroids, or anything not prescribed by your doctor?
- Had sexual contact with anyone who has used needles in the past 3 months to inject drugs, steroids, or anything not prescribed by their doctor?
- Had syphilis or gonorrhea or been treated for syphilis or gonorrhea?
- Had sexual contact with a person who has hepatitis?
- Lived with a person who has hepatitis?
- Had an accidental needle-stick?
- Come into contact with someone else's blood?
- Had a tattoo?
- Had ear or body piercing?
- Had a blood transfusion?
- Had a transplant such as organ, tissue, or bone marrow?
- Had a graft such as bone or skin?
|
| In the past 16 weeks, have you |
- Donated a double unit of red blood cells using an apheresis machine?
|
| In the past 12 months, have you |
- Been in juvenile detention, lockup, jail, or prison for 72 hours or more consecutively?
|
| In the past 2 years, have you |
- Received any medication by injection to prevent HIV infection? (ie, long-acting antiviral PrEP or PEP)
|
| In the past 3 years, have you |
- Been outside the United States or Canada?
|
| Have you EVER |
- Had a positive test for HIV infection?
- Taken any medication to treat HIV infection?
- Been pregnant?
- Had malaria?
- Received a dura mater (or brain covering) graft or xenotransplantation product?
- Had any type of cancer, including leukemia?
- Had any problems with your heart or lungs?
- Had a bleeding condition or blood disease?
- Had a positive test result for Babesia?
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| Use this area for additional questions |
| |
