DONOR HISTORY QUESTIONNAIRE

(adapted from AABB and NVBS)

Date: August 18, 2021

PERSONAL DATA:
Family Name First Name Middle Name
SPEARS BRITNEY JEAN

Date of Birth: 12/2/1997 Age: 23 Sex: ( ) Male (  ) Female Civil Status: SINGLE Nationality: FILIPINO Contact Number: 09551469696 E-mail Address:
[email protected] Occupation: CASHIER ID Presented & ID Number: PHILHEALTH PIN NO: 120269210669
Current Address: STA.FE, BANTAYAN ISLAND, CEBU CITY
House Number, Street, Subdivision Barangay Municipality / City ZIP CODE
F.ROSKA STREET STA. FE BANTAYAN ISLAND 6052

DONORS INFORMED CONSENT

DONATION HISTORY: (  ) NEW DONOR ( ) REPEAT DONOR YES NO RATIONALE
Have you read the educational materials today?  To assure that the donor fully read and understand the collection procedure and
risks involved in donating blood

PRE-DONATION PREPARATIONS
Slept at least 6 hours?  To avoid fainting as a result of a lack of sleep
Have you had any alcoholic drink in the past 12 to 24 hours?  To ensure that the donor is in great health to donate blood as alcohol increases the
risk of dehydration
Have you smoked in the past 3-4 hours?  To ensure that the donor is in great health to donate blood as smoking increases the
risk of fainting
Have you had a meal within the past 4 hours?  To avoid fainting due to not having eaten yet

ARE YOU
Feeling healthy today?  To ensure that the donor feels they are in relatively good health to donate blood
Currently taking an antibiotic?  To assure that the donor do not carry bacterial infections transmittable by blood
 DONOR HISTORY QUESTIONNAIRE
(adapted from AABB and NVBS)

Currently taking any other medications for an infection?  To assure that the donor do not carry bacterial infections transmittable by blood
Have you taken any medications on the Medication Deferral List in the  To avoid negative repercussions for the donor and/or the patient
time frames indicated? Refer to MDL reference

IN THE PAST 48 HOURS

Have you taken aspirin or anything that has aspirin in it?  To avoid undesirable consequences such as excessive bleeding or bruising following a
blood donation as these medications inhibit platelet function

IN THE PAST 8 WEEKS

Donated blood, platelet, or plasma? Date of last donation: ___________ 
To avoid anemia and/or iron deficiency as a result of significant blood loss
Past donation untoward symptoms: _____________________________
Had any vaccinations or other shots?  To avoid undesirable effects as some vaccines contain live virus

IN THE PAST 3 MONTHS?

Had a blood transfusion?  To assess if the donor contracted any infectious illnesses as a result of the
transfusion
Had a transplant such as organ, tissue, or bone marrow?  To assess if the donor contracted any infectious illnesses as a result of the transplant
Had a graft such as bone or skin?  To assess if the donor contracted any infectious illnesses as a result of the graft.
Come into contact with someone else’s blood?  To avoid the spread of infectious diseases
Had an accidental needle-stick?  To rule out TTIs for the safety of both the donor and the patient.
Had sexual contact with anyone who has ever had HIV/AIDS or has ever 
To prevent the transmission of HIV
had a positive test for the HIV/AIDS virus?
Male donors: Had sexual contact with another male? To determine the risk of STD infection
Female donors: Had sexual contact with a male who had sexual contact 
To determine the risk of STD infection
with another male in the past 3 months?
Had sexual contact with a prostitute or anyone else who has ever taken 
To determine the risk of STD infection
money or drugs or other payment for sex?
Had sexual contact with anyone who has ever used needles to take 
To determine the risk of STD infection
drugs or steroids, or anything not prescribed by their doctor?
Had a tattoo?  To prevent the transmission of infectious diseases caused by contaminated needles
 DONOR HISTORY QUESTIONNAIRE
(adapted from AABB and NVBS)
Had ear or body piercing?  To prevent the transmission of infectious diseases caused by contaminated needles
Had or been treated for syphilis or gonorrhea?  To stop these certain STDs from spreading
Used needles to take drugs, steroids, or anything not prescribed by your 
To prevent the transmission of infectious diseases caused by contaminated needles
doctor?
Received money, drugs, or other payment for sex?  To determine the risk of STD infection
Taken any medication to prevent an HIV infection?  To determine the likelihood of HIV infection

IN THE PAST 16 WEEKS,

Have you donated a double unit of red cells using an apheresis 
To avoid anemia and/or iron deficiency as a result of significant blood loss
machine?

IN THE PAST 12 MONTHS,

Had sexual contact with a person who has hepatitis?  To determine the possibility of hepatitis infection
Lived with a person who has hepatitis?  To determine the possibility of hepatitis infection
Been in juvenile detention, lockup, jail, or prison for 72 hours or more  To determine the likelihood of contracting infectious illnesses as a result of an
consecutively? increased risk

FROM 1980 THROUGH 1996,

Did you spend time that adds up to 3 months or more in the United 
To determine the likelihood of contracting infectious illnesses as a result of an
Kingdom countries of England, Northern Ireland, Scotland, Wales, the
increased risk from these places
Isle of Man, the Channel Islands, Gibraltar, or the Falkland Islands?

FROM 1980 THROUGH 2001, DID YOU

Spend time that adds up to 5 years or more in France or Ireland? 
To determine the likelihood of contracting infectious illnesses as a result of an
Time spent in Ireland does not include time spent in Northern Ireland
increased risk from these places
which is part of the United Kingdom.

HAVE YOU EVER

Lived outside your place of residence?  To see whether there is a higher risk of contracting infectious illnesses in specific
areas
 DONOR HISTORY QUESTIONNAIRE
(adapted from AABB and NVBS)
Lived outside the Philippines?  To see whether there is a higher risk of contracting infectious illnesses in specific
areas
Female donors: Been pregnant or are you pregnant now?  To avoid any unfavorable consequences for the mother or the baby
Had a positive test for the HIV/AIDS virus?  To stop the transmission of HIV
Had malaria?  To stop the transmission of malaria
Received a dura mater (or brain covering) graft or xenotransplantation  To assess if the donor has contracted any infectious illnesses as a result of the
product? transplant.
Had any type of cancer, including leukemia?  To identify the possibility of being immunocompromised
Had any problems with your heart or lungs?  To identify the possibility of being immunocompromised
Had a bleeding condition or a blood disease?  To avoid undesirable consequences such as excessive bleeding or bruising following a
blood donation
Had a positive test result for Babesia?  To prevent the transmission of Babesia
Taken any medication to treat an HIV infection?  To determine the likelihood of HIV infection

Are you giving blood because you wanted to be tested for HIV or 
To ascertain the reason for the blood donation
Hepatitis virus?
Would you be willing to be called again to donate blood at the hospital 
To identify potential blood donors on a regular basis
facility should the need arise?
“I certify that I am the person referred to in all the entries, which were read and well understood by me. It is my free and voluntary act to donate my blood, aware of its risks during and
after extraction. The same have been explained to me in understandable language and dialect that I speak.”

“I am voluntarily giving my blood through Primo Health Medical Hospital. I understand that my blood will be tested for my blood type, hemoglobin, and the NVBSP required tests for the
5 transfusion transmissible infections (including HIV), and no official result will be released to me. If found reactive, I agree to have my blood submitted to the National Reference
Laboratory for confirmatory testing. When confirmed to have the disease, I agree to be referred to the appropriate facility for counseling and other management.

I certify that I have to the best of my knowledge, truthfully answered the above questions.

______________________________________
DONOR’S SIGNATURE
 DONOR HISTORY QUESTIONNAIRE
(adapted from AABB and NVBS)

PHYSICAL EXAMINATION PRELIMINARY BLOOD TYPING RESULT: Blood Type “O+”

ACCEPTED VALUES ACCEPTED VALUES ACCEPTED VALUES

BODY WEIGHT 55kg BLOOD PRESSURE 100/80 mmHg PULSE RATE: 90bpm
The donor has good turgor and Examined the donor conscious,
mobility and no rashes noted. responsive, coherent, afebrile,
Inspection reveals evenly colored eupneic and with the vital signs of
skin tone without unusual or BP= 100/80, PR = 90. Temperature
prominent discolorations. The skin is of 36.6 °C and weight is 55 kg
TEMPERATURE: 36.6 °C SKIN also intact and there are no GEN. APPEARANCE which is considered normal.
reddened areas. Skin is warm and
smooth without any lesions noted.
And skin rebounds and does not
remain indented when pressure is
released.

( ) Temporarily Deferred ( ) Permanently Deferred Deferral Reasons: The donor had a contact with a person who is a high risk individual.

Medically Assessed by: Melrose Faye C. Arcenal, RMT Blood Bank Officer: Kang Song, RMT