Title Page
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Hospital Name
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Conducted on
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Prepared by
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Location
Blood Donation
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Instructions:
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1. Fill out the details needed and answer "Yes", "No" for the questions below.
2. Add photos and notes by clicking on the paperclip icon.
3. Complete audit by providing digital signature.
Blood Donor Information
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Donor's Name:
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Date of Birth:
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Email:
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Phone:
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Home Address:
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Occupation:
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Blood Type:
- O+
- O-
- A+
- A-
- B+
- B-
- AB+
- AB-
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Did you ever donate blood before?
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When was the last time you have donated blood?
Health Security Check
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Do you suffer of any diseases?
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Please specify disease(s):
- Hepatitis
- Agranulocytosis
- Asthma
- Cholesterol
- Diabetes
- Osteoporosis
- Thyroid Disorders
- Kidney Disease
- Flu
- Anxiety Disorders
- Tendonitis
- Bursitis
- Depression
- Other
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Other diseases:
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Do you have allergies?
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Please specify allergies:
- Aspirin
- Cetuximab
- Pollen
- Nickel
- House dust
- Amoxicillin
- Ibuprofen
- Lamotrigine
- Mold
- Chromium
- Formaldehyde
- Penicillin
- Sulfa
- Dilantin
- Latex
- Fungicide
- Cosmetics
- Other
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Other allergies:
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Have you ever had positive Blood test for HbsAg, Hcv, HIV?
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Please specify:
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Do you have any cardiac problems?
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Do you suffer any bleeding disorders?
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Please specify:
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Do you take medication?
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Please describe the medication you take:
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I want to donate blood voluntarily and will not be entitled to claim any exchange for my donation. I guarantee that all the provided information is true. I understand the questions, which are for my protection as well as to protect the recipient of my blood. Donor's Signature:
