Blood Donor Screening Form Template

Full name

Date of birth

Occupation

Phone number

Email address

Home address

The clinic will fill in anything you do not know.

Weight (kg)

Pulse (bpm)

Temperature (C)

Haemoglobin (g/dL)

Blood pressure

Have you given blood before?

YesNo

When did you last give blood?

In the last six months, have you had any of these?

A tattooA piercingA tooth taken outNone of these

In the last six months, have you had any of these?

Major surgeryMinor surgeryA blood transfusionNone of these

Anything else the clinician should know?0 / 500 characters

The answers I have given are true as far as I know, and I consent to donating blood today. I have read the donor information.

Blood donor questionnaire