Blood Donor Consent

Submission Date:  [Submission Date]
Donor ID / Reference No.:  [Submission Reference]
Blood Unit No: [Field 3]
License No: [Field 4]

👤 Donor Personal Details

Full Name: [Field 6]

Date of Birth: [Field 7]

Gender: [Field 8]

Occupation: [Field 9]

Email: [Field 10]

Phone Number: [Field 11]

Preferred Contact Method: [Field 16]

Would you like your name included in the donor website?: [Field 17]

Address: [Field 12], [Field 13], [Field 14], [Field 15]

🩺 Donation History & Consent

Have you donated previously?: [Field 18]

If yes, how many occasions?: [Field 19]

Last donation date: [Field 20]

Any discomfort during/after previous donation?: [Field 21]

Blood Type: [Field 22]

Time of last meal: [Field 23]

Do you feel well today?: [Field 24]

Did you sleep well last night?: [Field 25]

🧬 Health & Risk Assessment

Any belief of infection (Hepatitis, Malaria, HIV, STDs)?: [Field 26]

History in last 6 months (Specify): [Field 27]

Diseases you have or had: [Field 29]

Medications taken in the past 72 hours?: [Field 30]

History of surgery/blood transfusion in past 6 months?: [Field 31]

👩‍⚕️ For Women Donors

Abortion in the last three months?: [Field 33]

Child under 1 year old?: [Field 34]

Are you pregnant?: [Field 37]

Additional Consent

Would you like to be informed about abnormal test results?: [Field 35]

Acknowledgement of accurate and truthful answers provided?: [Field 36]

General Physician Examination (To be filled by medical officer)

Weight: [Field 40]

Pulse: [Field 41]

Hemoglobin (Hb): [Field 42]

Blood Pressure (BP): [Field 43]

Temperature: [Field 44]

This document contains sensitive health and identification data. All responses are confidential and used solely for the safety and eligibility evaluation of the donor and recipients.