Create an Account Fast Track Health History Fast Track Health History Questionnaire Thank you for coming to give blood today. Your donation could save and change the lives of the recipients. We sincerely request you to read our blood donation information precisely. To protect your safety in giving blood and the safety of the recipients of your donation, it is vital that we review your suitability to donate today. If you are uncertain about any questions in this form or in need of more blood donation information, please talk to our nurse on duty.After donation, your blood will be stringently tested, inter alia, blood groups and infectious diseases, before processed into blood products. Donations that meet all the quality and safety standards will be issued for patient use in our Blood Center. However, some will be selected for quality assurance testing, academic or medical research. In addition, it may be made available to patients outside our Blood Center for humanitarian considerations or if there is a genuine surplus to local needs. Giving blood is not completely risk-free as adverse reactions may occasionally happen. These include bruising, pain, inflammation, infection or skin allergy around the needle puncture site, dizziness or fainting after donation. They usually are mild and short-lasting. In the event of adverse reactions, our nurse will provide on-site care and arrange referral to hospital, if necessary. We sincerely request you to read and follow our “Post-Donation Advice”. Should you have any queries, please feel free to ask our nurse on duty. SAFE BLOOD SAVE LIVES. NOT ALL BLOOD BORNE INFECTIONS CAN BE DETECTED BY LABORATORY TESTS. PLEASE HELP US ENSURE BLOOD SAFETY AND DO NOT PROCEED TO DONATE IF YOU SUSPECT THAT YOUR BLOOD MAY CARRY A POTENTIAL RISK OF INFECTION OR IF YOU WANT TO HAVE YOUR BLOOD TESTED. I am completing this questionnaire on the day of my donation. I will complete the questionnaire in a confidential setting, free of interruptions. I have read these pre-donation documents and am ready to answer the questions. I will review the Frequently Asked Questions if needed. Your Information Please complete the following required information. To ensure we can accept your Fast Track Ticket, it's important the information you provide below match what we have in our computer system or that it match your legal ID if this is your first time donating with us. First Name Last Name Birth Date Please input date of birth in this order: month/year/date Gender Assigned at Birth Male Female Required fields are indicated with BEGIN QUESTIONNAIRE ×
