Donor questionnaire example

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Before you donate, you'll be asked to complete a confidential questionnaire in-centre. Some of the questions are personal, but they help us keep everyone safe.

Don't rule yourself out - Answering 'yes' to some questions doesn't mean you won't be eligible to donate - sometimes we just need to ask a few more questions.

If you're unsure about anything, more information on risks and eligibility is available on our website. Or you can chat with us or give us a call anytime.

A PDF version of the questionnaire is available below. Please note that this is a sample only and cannot be used.

Important information for a safe, comfortable donation.

At Lifeblood, your safety is our priority. We have experienced team members at your side to make your donation as safe and comfortable as possible.

This questionnaire helps keep you and patients safe. Each question is important and you must answer honestly. Giving false or misleading information may lead to fines and imprisonment. Some people MUST NOT give blood as it may not be safe for them, or the transfused patient. You can change your mind at any time — just let us know.

Fainting

About 2 in 100 donors feel faint (dizzy, light-headed, hot or sweaty). Symptoms usually resolve quickly. About 1 in 1,000 donors faint (lose consciousness). Feeling faint or fainting is more common in donors who are younger, female or new. Donors over 50 years old are more likely to feel faint after leaving the donor centre.

Reduce the chance of fainting

In the 24 hours before, drink 8 to 10 glasses of fluid.

In the 3 hours before, drink 750 mL of fluids, eat something salty and avoid strenuous exercise.

Afterwards, spend at least 15 minutes in the refreshment area. If you have had any donation reaction or are 70 or older, please stay at least 30 minutes.

For 8 hours after, drink plenty of fluids. Avoid alcohol, as well as standing for long periods or getting overheated.

For 12 hours after, avoid strenuous and hazardous activities, including jobs where public safety may be affected — check with your employer or ask in your interview.

If you feel faint:

  • Lie or sit down with your head between your knees
  • Repeatedly squeeze and release your inner thigh and abdominal muscles
  • Ask for help
  • If you’re driving, pull over, park, lay your seat back and call for assistance. Do not continue driving.

Bruising

Small bruises are very common and larger bruises, which may be uncomfortable, occur about every 1,500 donations. To reduce the risk, keep the bandage on for 2 hours and minimise lifting or carrying with your donation arm for 24 hours.

If you develop a bruise, an ice pack and/or pain reliever may help.

If you bleed, apply pressure and raise your arm.

Reactions requiring outside medical care

About 1 in 1,500 donors experience a side effect that requires outside medical care, including events related to skin disinfection and needle placement (e.g. allergy, local inflammation, infection, piercing an artery, clot or nerve injury).

Iron levels

Donation can cause low iron, particularly in frequent blood donors and women of child-bearing age. This may cause tiredness, poor concentration and low haemoglobin (anaemia).

We recommend a healthy, iron-rich diet, and that women aged 18-45 take iron supplements after each blood donation. In particular, women trying to become pregnant need healthy iron levels for pregnancy.

We check your haemoglobin before every donation and, if you’re donating blood, test your iron (ferritin) periodically. Speak with
your doctor before donating if you’re concerned about iron or how often to donate.

For more information on the risks of donating blood, and our iron recommendations, ask one of our team or visit this page.

Testing your donation

For patient safety, all successful donations are tested for hepatitis A, hepatitis B, hepatitis C, parvovirus B19 and HIV. Some donations are tested for HTLV, syphilis, and genes related to blood groups and iron variants.

We’ll let you know if your results are significantly abnormal.

Please call us immediately on 13 14 95 if you:

  • Develop a cough, cold, diarrhoea or other infection within a week of donating
  • Are diagnosed or hospitalised with a serious infection within 2 months of donating, or
  • Learn of any reason why your blood shouldn’t be used.

If you feel unwell or are concerned after your donation, speak to a team member, call us on 13 14 95, or see your doctor.

A. New and returned donors

You'll be asked these questions if you're a new donor or haven't donated in the last 2 years. All questions are Yes/No answers unless specified.

 

  • Have you ever donated blood or plasma before? If yes, where and when?
  • Have you ever been advised not to give blood?
  • Have you ever had:
    • Anaemia, any blood disorders, or a serious illness, operation or been admitted to hospital?
    • Stroke or epilepsy, heart or blood pressure problems or chest pain, or rheumatic fever or a heart murmur?
    • Bowel disease, or lung problems including tuberculosis (TB)
    • Diabetes, a thyroid disorder, or an autoimmune disease e.g. rheumatoid arthritis or lupus?
    • Cancer of any kind including melanoma?
    • Jaundice (yellow eyes/skin) or hepatitis?
    • Malaria, Q fever or Chagas’ disease?
    • Syphilis?
  • Have you ever received a transplant or graft (organ, bone marrow, cornea, dura mater, bone, etc.)?
  • Have you ever had treatment with the medication TIGASON (Etretinate) or NEOTIGASON (Acitretin)?
  • Have you had a neurosurgical procedure involving the head, brain or spinal cord between 1972 and 1989?
  • Have you received injections of human growth hormone for short stature or human pituitary hormone for infertility prior to 1986?
  • What was your country of birth?
  • Have you ever been outside Australia, including being born overseas? If no, you don't need to answer any further questions in this section.
  • Have you ever spent a continuous period of 6 months or more outside Australia at any stage of your life?
  • Have you been outside Australia in the last 3 years? If yes, have you been in Papua New Guinea (PNG) in the last 3 years?
  • Have you ever received a transfusion or injection of blood or blood products in Mexico, Central America or South America?

B. Medical questionnaire

All donors will be asked these questions. All questions are Yes/No answers unless specified.

 

  • Are you feeling healthy and well?
  • If this isn't your first donation, did you have any side effects after leaving the donor centre after your last donation? If yes, did you report this to Lifeblood?
  • Are you allergic to the antiseptic chlorhexidine?
  • What is your weight in kilograms? If you're unsure there are scales provided
  • In the next 3 days, do you intend to participate in any activity which would place you or others at risk of injury if you were to become unwell after donating, such as driving public transport, operating heavy machinery, underwater diving, piloting a plane or other activities?
  • In the last week, have you:
    • Had dental work, cleaning, fillings or extractions?
    • Taken any aspirin, pain killers or anti-inflammatory preparations?
    • Had any cuts, abrasions, sores or rashes?
    • Had a gastric upset, diarrhoea, abdominal pain or vomiting?
  • Since your last donation, have you – or if you’re a new donor, have you in the last 12 months:
    • Been unwell?
    • Seen a doctor or any health care practitioner?
    • Undergone any tests/investigations?
    • Had an operation/surgical procedure?
    • Had chest pain/angina or an irregular heartbeat?
    • Had shingles or chickenpox?
    • Had any immunisations/vaccinations (including as part of a clinical trial) other than influenza vaccine in Australia (e.g. fluvax)?
    • Had a sexually transmitted infection e.g. syphilis, gonorrhoea or genital herpes?
  • Since your last donation, have you – or if you’re a new donor, have you in the last 12 months – taken or used any medication, including:
    • Regular medication?
    • Clinical trial medication?
    • Acne or other skin condition medications?
  • Since your last donation, have you – or if you’re a new donor, have you in the last 12 months – taken or used:
    • PrEP (pre-exposure prophylaxis) to prevent HIV infection?
    • Injectable medications?
  • Do you know anyone in your family who had or has:
    • Creutzfeldt-Jakob disease (CJD)?
    • Gerstmann-Sträussler-Scheinker syndrome (GSS)?
    • Fatal familial insomnia (FFI)?
  • Since your last donation, have you - or if you’re a new donor, have you in the last 12 months - been pregnant (including miscarriage and termination of pregnancy)? If yes, have you been pregnant in the last 9 months?

Donors who have not completed Section A. New and returned donors will also be asked the following questions:

  • Have you been in Papua New Guinea in the last 3 years?
  • Since your last donation, have you been outside Australia?
  • Since your last donation, have you received a transfusion or injection of blood or blood products?

C. Donor declaration

All donors will need to complete this section. All questions are Yes/No answers unless specified.

 

  • To the best of your knowledge, have you EVER 
    • Thought you could be infected with HIV or have AIDS?
    • Had a test which showed you had hepatitis B, hepatitis C, HIV or HTLV?
  • To the best of your knowledge, in the last 5 years have you “used drugs” by injection or been injected with drugs not prescribed by a doctor or dentist?
  • In the last 12 months have you 
    • Had an illness with both a rash AND swollen glands, with or without a fever?
    • Been imprisoned in a prison or been held in a lock-up or detention centre?
    • Had (yellow) jaundice or hepatitis or been in contact with someone who has?
  • In the last 6 months have you had sex, excluding oral sex, with :
    • Someone new? If yes, have you had anal sex in the last 3 months?
    • More than one person? If yes, have you had anal sex in the last 3 months?
  • In the last 4 months have you:
    • Been injured with a used needle (needlestick)?
    • Had a blood splash to eyes, mouth, nose or to broken skin?
    • Had a tattoo, body and/or ear piercing or acupuncture?
    • Had a blood transfusion?
  • In the last 3 months have you engaged in sexual activity with someone who:
    • Had a test which showed they had hepatitis B, hepatitis C, HIV or HTLV?
    • Has ever “used drugs” by injection or been injected, even once, with drugs not prescribed by a doctor or dentist?