Health history reference

Gulf Coast Regional Blood Center
SOP 3320 series
1400 La Concha Lane, Houston, TX 77054
Phone: (713) 790-1200 Fax: (713) 790-1007
Page 1 of 2
Health History Reference
Please tell us if you are now taking or if you have EVER taken any of these medications:
Proscar (finasteride) – usually given for prostate gland enlargement
Avodart, Jalyn (dutasteride) – usually given for prostate enlargement
Propecia (finasteride) – usually given for baldness
Accutane, Absorica, Amnesteem, Claravis, Myorisan, Sotret, and Zenatane (isotretinoin) – usually given
for severe acne
Soriatane (acitretin) – usually given for severe psoriasis
Tegison (etretinate) – usually given for severe psoriasis
Growth Hormone from Human Pituitary Glands – used usually for children with delayed or impaired growth
Insulin from Cows (Bovine, or Beef, Insulin) – used to treat diabetes
Hepatitis B Immune Globulin – given following an exposure to hepatitis B.
NOTE: This is different from the hepatitis B vaccine which is a series of 3 injections given over a 6 month period
to prevent future infection from exposures to hepatitis B.
Plavix (clopidogrel) and Ticlid (ticlopidine) – inhibits platelet function; used to reduce the chance for heart
attack and stroke.
Feldene – given for mild to moderate arthritis pain
Experimental Medication or Unlicensed (Experimental) Vaccine – usually associated with a research protocol
CellCept® (mycophenolate mofetil) – Normally used to lower the immune system in transplant patients
Coumadin® (Jantoven®, warfarin) and Pradaxa® (dabigatran etexilate) – usually given to prevent blood clots
Lovenox® (heparin) – an injection usually given to prevent the formation of blood clots
Brilinta® (ticagrelor) and Effient® (prasugrel) – inhibit platelet function; usually given to reduce the chance for
heart attack and stroke
Piroxicam – usually given to patients with arthritis
IF YOU WOULD LIKE TO KNOW WHY THESE MEDICINES AFFECT YOU AS A BLOOD DONOR, PLEASE
KEEP READING:
If you have taken or are taking Proscar, Avodart, Jalyn, Propecia, Accutane, Absorica, Amnesteem,
Claravis, Myorisan, Sotret, Zenatane, Soriatane, or Tegison, these medications can cause birth defects. Your
donated blood could contain high enough levels to damage the unborn baby if transfused to a pregnant woman.
Once the medication has been cleared from your blood, you may donate again. Following the last dose, the
deferral period is one month for Proscar, Propecia, Accutane, Absorica, Amnesteem, Claravis, Myorisan, Sotret,
and Zenatane, six months for Avodart and Jalyn, and three years for Soriatane. Tegison is a permanent deferral.
Growth hormone from human pituitary glands was prescribed for children with delayed or impaired growth.
The hormone was obtained from human pituitary glands, which are found in the brain. Some people who took this
hormone developed a rare nervous system condition called Creutzfeldt-Jakob Disease (CJD, for short). The
deferral is permanent.
Insulin from cows (bovine, or beef, insulin) is an injected material used to treat diabetes. If this insulin was
imported into the US from countries in which “Mad Cow Disease” has been found, it could contain material from
infected cattle. There is concern that “Mad Cow Disease” is transmitted by transfusion. The deferral is indefinite.
Hepatitis B Immune Globulin (HBIG) is an injected material used to prevent infection following an exposure to
hepatitis B. HBIG does not prevent hepatitis B infection in every case, therefore persons who have received HBIG
must wait 12 months to donate blood to be sure they were not infected since hepatitis B can be transmitted
through transfusion to a patient.
Feldene is a non-steroidal anti-inflammatory drug that can affect platelet function. A donor taking Feldene will not
be able to donate platelets for 3 days; however, its use will not affect whole blood donations.
Plavix and Ticlid are medications that can decrease the chance of a heart attack or stroke in individuals at risk
for these conditions. Since these medications can affect platelets, anyone taking Plavix or Ticlid will not be able to
donate platelets for 14 days after the last dose. Use of either medication will not prohibit whole blood donations.
Experimental Medication or Unlicensed (Experimental) Vaccine is usually associated with a research protocol
and the effect on blood donation is unknown. Deferral is one year unless otherwise indicated by Medical Director.
Brilinta and Effient are medications that can decrease the chance of a heart attack or stroke in individuals at risk
for these conditions. Since these medications can affect platelets, anyone taking Brilinta or Effient will not be able
to donate platelets for 14 days after the last dose. Use of either medication will not prohibit whole blood donations.
Gulf Coast Regional Blood Center
SOP 3320 series
1400 La Concha Lane, Houston, TX 77054
Phone: (713) 790-1200 Fax: (713) 790-1007
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List of States with Licensed Tattoo / Piercing Facilities List of Countries in the United Kingdom (UK) Contact with a person who has had smallpox vaccination – Touching the vaccination area or the scab that
forms on the skin, including the bandages covering the vaccination area or scab; touching/handling materials
that might have come into contact with an unbandaged vaccination area or scab including clothing, towels, and
bedding.
Contact with blood – (1) a needlestick or other sharps injury from an instrument that has been used on any
individual or patient; (2) exposure to non-intact skin (e.g., skin that is chapped, abraded, or afflicted with
dermatitis); (3) a human bite that breaks the skin; (4) exposure to eye, nose, or mouth i.e., the mucous
membranes.
Lived with – Residing in the same dwelling. EXAMPLES: house, dormitory, or apartment.
Severe complications include the following: rash (resembling blisters) covering a small or large area of the
body; necrosis (tissue death) in the area of exposure; encephalitis (inflammation of the brain); infection of the
cornea (eye); and localized or systemic skin reaction in someone with eczema or other chronic skin condition.
Sexual contact – The meaning of the words “sexual contact with” and “sex” are identical, and apply to any of
the following activities, whether or not a condom or other protection was used: (1) Vaginal sex (contact
between penis and vagina); (2) Oral sex (mouth or tongue on someone’s vagina, penis, or anus); (3) Anal sex
(contact between penis and anus).
Tattoos include tattoo "touch ups", tattoos applied by oneself, and those applied by others.
Viral hepatitis – Inflammation of the liver. Symptoms may include fever, malaise, weakness, anorexia,
nausea, and abdominal distress. The most common types of viral hepatitis are A, B, and C, CMV, and
mononucleosis (caused by Epstein-Barr virus).

Source: http://www.giveblood.org/doclib/GC%20Form%201657.pdf