Blood Donation Questionnaire Form

May 5, 2011 | By formform | Reply More

A Blood donation questionnaire form is used by hospitals to get detailed information about those people who want to donate blood. This form requires information regarding blood group, dieses etc. Below shown is a sample blood donation questionnaire form.

Sample Blood Donation questionnaire Form

Name______________

Age ___________ Sex__________ Weight__________ Height__________

Blood Group______________

Address______________________

Phone Number_______________ Email-ID______________
Have you previously donated blood? If yes than how many times and when?

____________________________________________________

Did you experience any discomfort/trouble while donating blood/after donation?

______________________________________________________

Have you even been infected by any inflectional dieses or chronic illness such as hepatitis/HIV/Malaria? _______________________________________

In last 6 months did you had any piercing/tattooing/dental extraction done? ______________

Have you taken alcohol/antibiotic/asteroid in past 72 hours? _____________________

List those dieses from which you suffered in past or still taking treatment for those? ___________________________________________________________________

Did you sleep well last night and feeling well today? _________________________

Have you read the instructions and conditions properly? ________________________

Do you agree with them? ____________________________

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