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• Blood Donor Registration Form

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• Last Name, First Name, MI, Suffix*
• Birthdate*
• Address*

  Street Address 1

  Street Address 2

  City

  State/Province/Region

  Postal/Zip Code

  Country
• Phone*

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• Email*
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• Blood Type* Select A A- B B- AB AB- O O- I don't know
• Height*
• Weight*
• Have you donated blood before?*

  Yes No
• When was the last time you donated?* Select 1-3 months 3-6 months 6-12 months More than a year ago
• Have you ever suffered any of the following effects during/after donation?* Select Dizzy/Light-headed Headache Disoriented Nausea/Vomiting Pain at the Needle Site Body Pain or Discomfort Fainting
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• Health Information

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• In the last seven days have you suffered any of the following:* Select Severe Headache Unexplained Cough Sore Throat Swollen Glands Fall Continuous low-grade fever
• Do you have any of the following conditions* Select Hypertension Diabetes Blood-clotting disorder Kidney disease Liver disease Cancer Tuberculosis Lung disease Sexually transmitted disease Epilepsy/seizures Hepatitis
• Are you pregnant?*

  Yes No
• Have you given birth within the last three months?*

  Yes No
• Have you had any of the following procedures in the past three months?*

  Major Surgery Minor Surgery Blood Transfusion
• Have you taken any of the following within the past 72 hours?*

  Aspirin Antibiotics Nsaids Steroids Vaccinations
• Have you had any of the following substances within the last 24 hours?*

  Alcohol Marijuana Narcotic Drugs
• What time did you last eat ?*

  :AMPM
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• For Office Use Only

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• Donor

  Height	Weight	Blood Pressure	Pulse	Temperature

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• Donor Signature*
• Date*
• Medical Officer Signature*
• Date*
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