Initial Questionnaire

1Contact Information
2Personal Information
3Pregnancy History
4Menstrual History
5Donor Pre-Screening
6Additional Questions

First Name

Last Name

Today's Date

Sun Mon Tue Wed Thu Fri Sat

Date of Birth

Sun Mon Tue Wed Thu Fri Sat

Cell Phone

Country

Street Address

Street Address 2

City

State

Zip Code

Height

Weight

lbs

Race

Ethnicity

Ethnicity #1

Education Level/Study Focus

University/College

Current Employment

Please provide current job roles and if full-time or part-time

Partner/Relationship Status

Have you ever had a live birth?

Have you ever had a miscarriage?

Have you ever had a termination (surgical/medical abortion)?

Have you ever had an ectopic pregnancy?

What was the first day of your most recent menstrual period?

Sun Mon Tue Wed Thu Fri Sat

What is your cycle length (number of days from the start of one period to the start of the next period)?

Example every 28 days or 30 days.

Please describe problems you may experience during your menstrual cycle (severe menstrual cramps, excessive bleeding, bleeding between periods, etc.)

Have you injected drugs for non-medical reason in the preceding 5 years, including intravenous, intramuscular, or subcutaneous injections?

Do you have hemophilia or other related clotting disorders and have received human-derived clotting factor concentrates in the preceding 5 years?

Have you engaged in sex in exchange for money or drugs in the preceding 5 years?

Have you had sex in the preceding 12 months with any person described in question 1 through 4 or with any person who has HIV infection, including a positive or reactive test for HIV virus, hepatitis B infection, or clinically active (symptomatic) hepatitis C infection?

Have you been exposed in the preceding 12 months to known or suspected HIV, Hepatitis B virus, and / or Hepatitis C virus –infected blood through percutaneous inoculation (e.g., needle stick) or through contact with an open wound, non-intact skin, or mucous membrane?

Have you had sex in the last 12 months with a man who had sex with another man or with someone known or suspected to have an HIV, Hepatitis B, or Hepatitis C?

Have you been in juvenile detention, lock up, jail or prison for more than 72 consecutive hours in the preceding 12 months?

Have you lived with (resided in the same dwelling) another person who has hepatitis B or clinically active (symptomatic) hepatitis C infection in the preceding 12 months?

Have you undergone tattooing, ear piercing or body piercing in the preceding 12 months, in which sterile procedures were not used, e.g., contaminated instruments and/or ink were used, or shared instruments that had not been sterilized between uses were used?

Have you had a past diagnosis of clinical, symptomatic viral hepatitis after your 11th birthday, unless evidence from the time of illness documents that the hepatitis was identified as being caused by hepatitis A virus. Epstein-Barr Virus (EBV), or cytomegalovirus (CMV)?

Have you ever been diagnosed with sepsis (a systemic infection involving your entire body)?

Have you had smallpox vaccination in the preceding 8 weeks?

Have you acquired a clinically recognizable vaccinia virus infection and developed skin lesions or scabs as a result of contact with someone who received the smallpox vaccine (i.e., touching the vaccination area or the scab, including the covering bandages, or touching clothing, towels, or bedding that might have come into contact with an unbandaged vaccination area or scab) and the vaccinia scab separated spontaneously?

Have you acquired a clinically recognizable vaccinia virus infection and developed complications of vaccinia infection as a result of contact with someone who received the smallpox vaccine (i.e., touching the vaccination area or the scab, including the covering bandages, or touching clothing, towels, or bedding that might have come into contact with an unbandaged vaccination area or scab)?

Have you had a diagnosis of West Nile Virus Infection or told that you might have it?

Have you had a medical diagnosis or suspicion of West Nile Virus infection (based on symptoms and/or laboratory results, or confirmed West Nile Virus viremia) in the preceding 120 days?

Have you tested positive or reactive for West Nile Virus infection using an FDA-licensed or investigational West Nile Virus NAT donor screening test in the preceding 120 days?

Have you been treated for or had syphilis within the preceding 12 months?

Have you been treated for or had Chlamydia trachomatis or Neisseria gonorrhea infection in the preceding 12 months?

Have you been diagnosed with variant Creutzfeldt-Jakob Disease (CJD) or any other form of CJD?

Have you been diagnosed with dementia or any degenerative or demyelinating disease of the central nervous system or any other neurological disease of unknown etiology?

Have you received a non-synthetic dura mater (brain covering) transplant, human pituitary-derived growth hormone, or have one or more blood relatives diagnosed with CJD?

Have you had a history of CJD in a blood relative?

Have you spent three months or more cumulatively in the United Kingdom (England, Northern Ireland, Scotland, Wales, the Isle of Man, the Channel Islands, Gibraltar, and the Falkland Islands) from the beginning of 1980 through the end of 1996?

Are you a current or former US military member, civilian military employee or dependent of a military member or civilian employee who resided at U.S. military bases in Northern Europe (Germany, Belgium, and the Netherlands) for 6 months or more cumulatively from 1980 through 1990, or elsewhere in Europe (Greece, Turkey, Spain, Portugal, and Italy) for 6 months or more cumulatively from 1980 through 1996?

Have you spent 5 years or more cumulatively in Europe (Albania, Austria, Belgium, Bosnia-Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Liechtenstein, Luxembourg, Macedonia, Netherlands, Norway, Poland, Portugal, Romania, Slovak Republic, Slovenia, Spain, Sweden, Switzerland, England, Northern Ireland, Scotland, Wales, the Isle of Man, the Channel Islands, Gibraltar, the Falkland Islands, and Yugoslavia) from 1980 until the present?

Have you received any transfusion of blood or blood components in the United Kingdom or France between 1980 and the present?

Were you or any of your sexual partners born or lived in certain countries in Africa (Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger, or Nigeria) after 1977?

Have you received a blood transfusion or any medical treatment that involved blood in Cameroon, Central African Republic, Chad, Congo, Equatorial Guinea, Gabon, Niger, or Nigeria after 1977?

In the past 12 months have you had a blood transfusion, an organ, tissue or bone marrow transplant, or bone or skin graft?

Have you or your sexual partner or any member of your household has ever had a transplant or other medical procedure that involved being exposed to live cells, tissues, or organs from an animal?

If this is a repeat donation within 6 months of your last full medical history interview, have the answers to the above questions changed?