Donor Health Check Form (Sample) (NATF 155 19 – HTML)

Donor Health Check. Medical – in confidence

Check and complete this side at session

DO NOT USE AFTER

Read and sign at session

• Name
• Address
• Postcode
• E-mail
• Date of Birth
• No. Home
• No. Mobile
• Registration No.
• Linked Venues
• Total Donations & Badge Award
• Date:
• Venue:
• Blood
• Group
• Ethnicity

Signature …………………………………………………………

DONOR DECLARATION

1. I have read and understood the Donor Information Leaflet, the information overleaf, and the current Health Check Questionnaire which I have completed. I have been given the opportunity to ask questions and they have been answered to my satisfaction.
2. I affirm that, to the best of my knowledge, all the information I have given is correct, and I am not at risk of any of the infections listed in the Donor Information Leaflet.
3. I agree that my blood will be tested for HIV and other conditions listed in the Donor Information Leaflet. I understand that if my blood gives a positive result for any of these tests, I will be informed, and given further advice.
4. I agree to my blood being blood-typed, and a small sample of it being stored.
5. I understand the nature of the donation process and the possible risks involved as explained in the Donor Information Leaflet.
6. I understand SNBTS will hold information about me, my health, my attendances and my donations and will use it for the purposes explained in the Donor Information Leaflet.
7. I agree to donate, and thereby give my blood to SNBTS, to be used for the benefit of patients. This may be by direct transfusion to a patient, or indirectly as explained in the Donor Information Leaflet.

 

• Aged 17-19
• H
• W
• AED Code
• Requires F/U Yes No
• Notes
• Initials
• Date
• eProgesa update
• Initials
• Date
• NATF 155 19
• Last Att & Status
• Reg/H.S.
• Accept / Defer
• Recall Date
• Code
• Donation No.
• Hb Pass/Fail
• 2nd Hb P/F
• Issue
• Scale/Machine
• Label 1
• Label 2
• Conclude
• Volume
• Hb analyser
• Hb analyser VS
• Fluids Y / N
• AMT Y / N
• P.
• P. start
• P. stop
• Sealer
• Seal/Check
• Antiplatelet
• WNV
• MAT
• cruzi
• Hep B
• HTLV
• Linked
• Discard
• Donation Medication
• Test required
• Test
• Core
• Test
• By
• Hold
• Test
• Profile
• WB/Serum
• Platelet/Leuco
• CMV
• RC/OAS
• 18060
• FFP
• Cryo
• Apheresis
• Collection Comments:
• Donation No.
• Notes:

PLEASE READ THIS IMPORTANT INFORMATION BEFORE COMPLETING THE HEALTH CHECK

Blood Safety starts with you. By answering our questions accurately, you’ll be helping to ensure that we’ll not harm you by taking your blood, nor harm anyone else by giving your blood to them.

Each time you give blood, please read each question very carefully. Your health or our questions could have changed since your last visit.

If you weigh less than 50kg, please let staff know.

HELP US KEEP BLOOD TRANSFUSION SAFE

Never give blood just to get a test. If you do, you risk infecting other people. If at any time after you have given blood you have doubts about whether your donation should be used, please let us know.

If you want to leave the session without giving blood, that’s OK. You don’t have to explain why. The Scottish National Blood Transfusion Service (SNBTS) is a Division of NHS National Services Scotland.

DONATION SAFETY CHECK – IN CONFIDENCE. TO BE COMPLETED BY DONOR

All donors (Yes/No)

1. Are you fit and well?
2. Have you seen a doctor, dentist or any other healthcare professional in the last 7 days or are you waiting to see one?
3. Are you taking any medicine or other treatment prescribed by a health care professional? (except HRT for the menopause, the pill or other birth control)
4. Have you taken any other medicine or tablets in the last 7 days?
5. Do you have any unhealed wounds or broken skin?
6. Has anyone in your family had CJD (Creutzfeldt-Jakob Disease)?
7. Have you had symptoms of any infections in the past 2 weeks?
8. Have you been in contact with anyone with an infectious disease in the last 4 weeks?
9. Have you had any vaccinations in the last 8 weeks?
10. Do you work for the emergency services or drive a bus, train or HGV? Will you be working at depth or height in the next 24 hours?
11. What is your job?
12. Are you pregnant, or have you been in the last 6 months? (if not applicable, please tick No)

Only New Donors Or Donors Who Have Not Given In 2 Years

(Do not complete this section of you have given in the last 2 years)

13. Have you ever had a serious illness or medical condition?
14. Have you ever seen a doctor about your heart?
15. Have you ever had an operation, or any medical investigations or tests (including endoscopy)?
16. Have you ever had jaundice or hepatitis?
17. Have you ever received a blood transfusion (including Covid-19 plasma)?If Yes – where and when?
18. Have you ever been treated by a skin specialist?
19. Do you have any allergies?
20. Are you prone to fainting or dizzy spells?
21. Were you treated with growth hormone before 1986?
22. Did you have brain or spinal surgery before August 1992?
23. Were you or your mother born in South America, Central America or Mexico?
24. Have you ever had sex with someone who has HTLV?
25. Have you ever received fertility treatment for you to become pregnant?

Donors who have given in the last two years

26. Since you last gave blood have you had sex with someone who has HTLV?
27. Since you last gave blood have you had a:

• Serious illness or infection
• Medical test or investigation
• Operation
• Blood Transfusion (including Covid-19 plasma)

All Donors – Your Travel History

28. Were you born outside the UK? If Yes – where? ………………………………………………………………..
29. Have you ever been outside the UK for a continuous period of 6 months or more?
30. Have you ever had malaria or an unexplained fever during or after travel?
31. Have you ever visited South America, Central America or Mexico for 4 weeks or more?
32. Have you been outside the UK (including business) in the last 12 months?If Yes – where and when?

All Donors – Blood Safety

33. Have you ever been diagnosed with:

• HIV
• Hepatitis B
• Syphilis
• HTLV
• Hepatitis C

34. Have you ever injected, or been injected with illegal or non-prescribed drugs? This includes bodybuilding drugs, injectable tanning agents and injected chemsex drugs.
35. Have you ever had sex with someone who had previously had a viral haemorrhagic fever (e.g. Ebola Fever, Lassa Fever)?
36. In the last 4 months, have you had:

• Acupuncture, a tattoo or a piercing
• Cosmetic treatments that involve piercing your skin

37. In the last 4 months, have you had an injury which could have put you at risk of hepatitis or HIV?
38. In the last 3 months, have you received payment for sex, e.g. money or drugs?
39. In the last 3 months, have you or anyone you have had sex with been diagnosed or treated for a sexually transmitted infection? (except chlamydia, genital herpes or genital warts)
40. In the last 3 months have you taken Pre- or Post-Exposure Prophylaxis (PrEP/PEP) to prevent HIV infection?
41. In the last 3 months have you had chemsex i.e. use of drugs solely to enhance sexual experience?
42. In the last 3 months, have you had sex with:

• Anyone who has hepatitis B, hepatitis C, or HIV
• Anyone who has ever received payment for sex, e.g. money or drugs
• Anyone who has ever injected drugs

43. In the last 3 months, have you had more than one sexual partner, or had a new sexual partner? If yes, did you have anal sex?