Blood Centre Management

Location *

Donor type

New donor Existing

Personal details

Aadhar Scan

Name *

Gender *

Male Female

Marital status

Single Married

Date of birth

Age *

Blood Group

Father Husband name

Occupation

Anniversary

Weight *

min 45

Address Details

Address *

PO Location

City

State

Country

Mobile Number

Donation Details

Have you donated previously

Yes No

Occasions

When Last

Would you like to be a regular donor?

Yes No

Did you have any discomfort after donation?

Yes No

Would you like to be contacted during emergency requirement of blood?

Yes No

Questinnaire

1. Do you feel well today?

Yes No

2. Did you have something to eat in the last 4 hours?

Yes No

3. Did you sleep well last night?

Yes No

4. Have you any reason to believe that you may be infected by either Hepatities, Malaria, HIV/AIDS and / or venereal diseases?

No Yes

5. ln the last 6 months have you had any history of the following

● Unexplained weight loss
● Repeated Diarrhoea

● Continuous Low-grade fever
● Swollen Glands

Yes No

6. ln the last 6 months have you had any

● Tattooing & Ear Piercing
● Dental Extraction

● Blood Transfusion
● Minor Surgery

Yes No

7. Are you taking or have taken any of these in the past 72 hours?

● Antibiotics ● Steroids ● Aspirin

Yes No

8. Are you under the influence of Alcohol?

Yes No

9. Are you suffering from any of the following diseases?

● Cancer/Malignant Disease
● Heart Disease
● Abnormal bleeding tendency
● Unexplained weight loss
● Diabetes controlled on insulin
● Hepatitis B/C

● Chronic Nepehritis
● Sexually trans diesease
● Liver Disease
● Tuberculosis
● Polycythemia vera
● Asthma

● Epilepsy
● Leprosy
● Schizophrenia
● Endocrine disorders
● Allergic disease
● Hypo/Hyper tension

Yes No

10. If there any history of the following mentioned in past 1 year?

● Hepatitis in family or close contact
● Major surgery

● Typhoid
● Immunoglobulin

● Dog bite/Rabies vaccine
● Jaundice

Yes No

11. ln the past 15 days have been Vaccinated for ?

● Cholera ● Typoid ● Diphtheria ● Tetanus ● Plague ● Gammaglobulin

Yes No

12. ls there history of malaria & Duly Treated

Yes No

13. Have you come from abroad in the last 28 days / from the area declared as Covid-19 infected by the Ministry of Health & Family Welfare/Have You come in contact with any person from this area? Have you suffered from Covid- 19 infection? lf so, Have you completed 28 days of home isolation?

Yes No

14 For Women Donors, are you in the following state :

● Are you pregnant
● Are you having your periods today?

● Have you had an abortion in the last 6 months
● Do you have a child less than one year old

Yes No NA

15 I have read and understood all the information presented and answered all the questions truthfully. I have acknowledged that any incorrect statement or concealment may affect my health or may harm the recipient.

Yes No

Note:

Donor shall not be inmates of Jail, Persons having multiple sex partners and Drug addicts.The Interval between Blood donation shall be 3 months. Donor shall not be betow 18 years of age or above 65 years & weighing lessthan 45 kgs.
As perthe guidelines, Donor weighing between 45,55 kg can give 35O ml of blood and those weighing 55 kg and above can give 45O ml of blood.

I understand that

a) Blood donation is totally voluntary act and no inducement or remuneration has been offered.
b) Donation of blood/components is a medical procedure and that by donating voluntarily, I accept the risk associated with this procedure.
c) The surplus plasma component will be utilised for fractionation and derivation of essential plasma derived medicines.
d) My blood will be tested for Hepatitis B, Hepatities C, Malaria Parasite, HIV/AIDS and venereal diseases in addition to any other screening tests required to ensure blood saftey.
e) Any abnormal tests results will be informed at the address furnished.

I prohibit any information provided by me or about my donation to be disclosed to any individual or government agency without my prior permission.

I would wish to collect the Appreciation Certificate via Email HardCopy

I have read and understood all the information presented and answered all the questions truthfully. I have acknowledged that any incorrect statement or concealment may affect my health or may harm the recipient.

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