Print Form Donation Number CTS – SS DONOR SESSION SLIP
Date of Birth: ____ /____ / ____ Place of Birth:
Type of ID：¨B.I.R. ¨H.K. ID ¨Worker Permit ¨China Identification Document ¨Other
Profession: Which way would you prefer to be reminded donation if you don’t mind ? ¨ by SMS ¨ by E-mail
I declare that all the information provided is accurate. I give the permission to
Signature:_______________________ Date:____________________ ◎ OFFICAL USE ONLY RECEPTION SELECTION & COLLECTION
BP: _______ mmHg Normal C. Ausc. ¨ Suspended ¨
Treatment: Physician:
¨ Abandon venepuncture ¨ 2nd venepuncture ¨
Lot no.: 1. ____________________ 2. ____________________
Data Input by: CTS -F7r12Rc-E/pg 1 Effective Date:05/08/2004 HEALTH ENQUIRY ============================================================================================================== During the early stages of infection, the laboratory may not be able to detect the infectious agents. For this reason the safety of the blood cannot be relied entirely on the results of laboratory tests. In order to help us to provide high quality blood and blood components to the patients, please read carefully the leaflet “PLEASE DON’T GIVE BLOOD WITHOUT READING THIS LEAFLET” and truthfully answer the following questions: TODAY/NOW
1. Are you feeling well enough to give blood?
2. Are you currently undergoing a treatment, taking any medication or waiting for test results?
3. After blood donation, are you going to take part in any vigorous sports activities, such as mountain climbing,
4. After blood donation, will you be driving a heavy vehicle or work at hazardous depths or heights today?
IN THE PAST 3 DAYS, HAVE YOU
7. taken aspirin or any medication with aspirin in it?
IN THE PAST 10 DAYS, HAVE YOU IN THE PAST 4 WEEKS, HAVE YOU
9. had any vaccinations, e.g. polio , tetanus, rubella, Hepatitis B …?
IN THE PAST 3 MONTHS (PAST 4 MONTHS IF FEMALES), HAVE YOU IN THE PAST 12 MONTHS, HAVE YOU
11. had tattoo, acupuncture, ear or skin piercing?
12. any history of venereal diseases or sexual activity with prostitutes or multiple sexual partners?
After returning to Macau, did you have any discomfort such as fever, diarrhoea, weight loss, etc?
14. had blood transfusion, or any major surgery?
HAVE YOU EVER
16. had a serious illness e.g. chest pain, hypertension, heart disease, diabetes, hepatitis, lung disease, epilepsy,
17. been deferred as a blood donor or told not to donate blood?
18. suffered from an infectious disease, such as dengue fever, malaria or SARS?
20. received hormones treatment or immunotherapy?
21. (or your family) had Creuzfelt-Jacob disease?
22. stayed 3 months or more in UK, Ireland or France between 1980 and 1996?
23. stayed 5 years or more in European countries or had blood transfusion in England since 1980?
24. Do you belong to any group of people who is advised not to donate blood as mentioned in the “PLEASE
DON’T GIVE BLOOD WITHOUT READING THIS LEAFLET”?
The information provided will be kept in strict CONFIDENCE ! CTS -F7r12Rc-E/pg 2 Effcective Date: 05/08/2004
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