SAFE BLOOD SAVE LIVES
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- Myra Ashley Simpson
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1 DIN BLOOD DONATION REGISTRATION FORM PART I: PRE-DONATION INFORMATION 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 Hong Kong. However, some will be selected for quality assurance testing, academic or medical research. In addition, it may be made available to patients outside Hong Kong 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". We would use your contact information (name, address, telephone and ) provided in this form to keep you informed of blood donation activities. In addition, if your blood is tested positive for any of the infection, we shall inform you accordingly. 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. FOR FREE HIV TESTING, PLEASE CONSULT YOUR DOCTOR OR CALL If you find this blood donation registration form, please contact our staff at
2 PART II: HEALTH SCREENING AND INFECTION RISK ASSESSMENT You are required to answer the following questions honestly by putting a " " in the correct box. If you do not understand any questions in this form or not certain how to respond, please leave the question blank and seek clarification from our nursing staff later. Our nurse will review your responses, answer your questions and discuss with you IN CONFIDENCE to determine if you can donate today. The information you disclose will be kept in strict confidence. Thank you. General Health Screening YES NO Use A1. Are you feeling well enough to give blood today? A2. Are you currently under a doctor's treatment, taking any medication (including herbal medicine) or awaiting test result? A3. Have you ever been diagnosed of the following illnesses? cardiovascular diseases (e.g. chest pain, hypertension) respiratory diseases (e.g. asthma) gastrointestinal or liver diseases ( e.g. inflammatory bowel disease, hepatitis) blood diseases (e.g. bleeding problem) cancers endocrine or metabolic diseases (e.g. diabetes, thyroid diseases) neurological diseases (e.g. loss of consciousness, epilepsy) mental disorders kidney or urogenital diseases (e.g. nephritis, kidney or bladder stones) autoimmune or rheumatological diseases (e.g. SLE, rheumatoid arthritis) A4. Have you ever been diagnosed of G6PD deficiency? A5. Have you ever taken the following drugs? aspirin or any drugs containing aspirin non-steroidal anti-inflammatory drugs drugs for hair loss drugs for benign prostatic hypertrophy drugs for acne A6. Have you ever had drug allergy? If yes, please specify: A7. If you are male, please continue the questionnaire on the next page. If you are female, Are you pregnant? Have you given birth/ had an abortion in the last 12 months? Are you still breast-feeding? Have you ever received treatment for infertility?
3 HIV/ AIDS, Hepatitis B and Hepatitis C Infection Risk Assessment (Some of the questions below are related to your sexual life. Sexual contact in this Form refers to oral, vaginal or anal sex, with or without the use of condom.) YES NO Use B1. Have you been diagnosed of or suspected to have the following? HIV infection/ AIDS Hepatitis B infection Hepatitis C infection B2. Have you ever had sex for money? B3. Have you ever used or injected yourself with narcotics or non-prescribed medication? B4. Have you ever received clotting factor concentrates? B5. Are you aware of your sexual partner(s) has been diagnosed of HIV infection/ AIDS? has ever been a sex worker? has ever used or injected narcotics or non-prescribed medication? has ever received clotting factor concentrates? B6. If you are male, have you ever had oral or anal sex with a man? If you are female, have you ever had sexual contact with a bisexual man (one who has had oral or anal sex with another man)? CJD and vcjd (Mad-cow Disease) Infection Risk Assessment YES NO Use C1. Between 1 January 1980 and 31 December 1996, have you spent a total of three or more months in the UK? have you worked or lived for a total of six or more months at US Military bases in Europe? C2. Between 1 January 1980 and the present, have you spent a total of five or more years in Europe? have you received blood transfusion in the UK or France? have you received bovine insulin injection? C3. Have you ever received pituitary derived human growth hormone or human gonadotrophin? organ or tissue transplant? C4. Have any of your blood relatives been diagnosed of Creutzfeldt- Jakob Disease (CJD)?
4 Other Recent Infection or Vaccination Risk Assessment YES NO Use D1. In the past 1 week, have you had any dental procedure (including scaling, dental extraction, etc.), open wounds or skin lesions? D2. In the past 2 weeks, have you had symptoms of flu, fever, headache,eye pain, muscle or joint pain, vomiting, enlarged lymph nodes or skin rash? D3. In the past 4 weeks, have you had contact with someone with an infectious disease e.g. chickenpox, rubella, tuberculosis (TB)? have you had any vaccinations e.g. vaccination against Hepatitis A, Hepatitis B or tetanus? have you had diarrhea? D4. In the past 12 months, have you travelled outside Hong Kong? Destination(s): Date of return to HK (DD/MM/YY): have you had tattoo, acupuncture, ear or body piercing, or accidental needle stick injury? have you been given Hepatitis B Immune Globulin? have you been bitten by any animal? have you undergone surgical operation (including endoscopic examination, treatment involving the use of catheters)? have you received blood transfusion? D5. Have you been diagnosed of the following infectious diseases? Malaria Venereal disease Tuberculosis (TB) Glandular fever SARS Dengue Fever West Nile Virus infection Chikungunya Others, please specify:
5 Other Risk Factors Assessment YES NO Use E1. Have you ever donated blood under another name? E2. Have you ever been informed not to donate blood permanently by us or other blood service? E3. Have you resided outside Hong Kong consecutively for 6 months or longer during the past three years? If yes, your previous country of residence: E4. Will you be undertaking any hazardous sport today? e.g. rock climbing, diving or flying E5. Will you be driving a heavy vehicle or working at hazardous depths or heights today? e.g. fireman, train or lorry driver, or scaffolding worker Supplementary Question YES NO Use F1. Are you aware of your sexual partner(s) Has been diagnosed of Zika infection? Has been resided or returned from the Zika virus affected areas in the past 3 months? PART III: DECLARATION I solemnly and sincerely declare that I have read, understood and agreed with 'Part I: PRE-DONATION INFORMATION' and the staff on duty has answered all my queries. I solemnly and sincerely declare that all information which I have provided in 'Part II: HEALTH SCREENING AND INFECTION RISK ASSESSMENT' is true. I also consent to have my blood tested for infectious diseases (including HIV) by the Hong Kong Red Cross Blood Transfusion Service and to be informed if my blood is tested positive. Donor Signature: (Please sign in front of screening nurse) Date: Verified by Screening nurse Signature:
6 PART IV : PERSONAL INFORMATION (Corresponds to Personal Identity Document ) (Remark: Photocopy of form is not accepted ) If there is no change of contact details, previous donors are required to fill in items with * asterisk only. DIN *Name Surname Other Name Name in Chinese (if applicable) Telegraph code ( )( )( )( ) (if applicable) *HK ID. No. ( ) *Date of Birth (DD) (MM) (YY) *Sex *Weight (kg) *Height (cm) Blood Group (if known) Donor ID. Have you donated blood in HK Yes No *Last Donation Date Corresponding Address (Please provide accurate address for future correspondence) Daytime Tel. No. *Mobile No. Address I do not wish to receive information relating to the publicity and promotion of blood donation activities. For Office Use Only (Please where appropriate) Donor Examination Hb Test Performed By Hb/Counter Reading (Highlight heading when out of range) Hb/Counter Eq. No. Blood Flow Start Time : hr.:min. End Time : hr.:min. Duration min. Health Screened By : Special Message : H.K. KLN. N.T. EIHMC: Nighttime Tel. No. g/dl EIAUA: Time Hb tested : hr.:min. Blood Unit Weigher Equipment No. : EIMIX Hand Held Sealer Equipment No. : EITCS No. of DIN Labels Used / Destroyed : / Blood Pack Lot No. /EIBAL Apheresis Plasma only Plasma & Platelet Platelet only Blood Pack (WB Donation) Quadruple 450 Volume Collected Over Collection ml Quadruple 350 Low Volume Unit ml Single Inadequate Collection ml Fail ml Access for Venepuncture: Accepted for Donation and Venepuncture By: Venepuncture Completed By: Deferral Hold Remark : Deferral Duration : Comment : / /EICPP Drive ID : BP mmhg P /min. Temp o C Lt / Rt (1 st ) Donor Label Remarks Require new card Aspirin Stain/Mark Small Vein Autologous Donation Directed Donation Lignocaine Yes No Ferrous Sulphate 300mg/tablet (14 tablets for 14 days) One tablet daily Fortifer FA 300mg/tablet (16 tablets for 16 days) One tablet daily Dispensed By Lt / Rt (2 nd ) (1 st ) (2 nd )
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MEDICAL HISTORY FORM ADMINISTRATION INSTRUCTIONS
ADMINISTRATION INSTRUCTIONS CONFIRM THE STUDY BAR CODE ON PAGES 1 THROUGH 6 OF THIS FORM DO NOT PLACE A STUDY BAR CODE LABEL ON THIS INSTRUCTION PAGE. Interview Instructions The interview should be conducted
PRE-EMPLOYMENT PHYSICAL - INALFA
Page 1 of 5 PRE-EMPLOYMENT PHYSICAL - INALFA Patient Name Date of Birth Please Circle: Gender Male Female Marital Status: Single Married Divorced Widowed Address City State Zip Code Home Phone Cell Phone
Abatacept. What is abatacept?
What is abatacept? Abatacept (trade name Orencia) is a type of drug called a biological therapy. It works by stopping the function of a particular cell in the immune system (called a T-cell). This prevents
CJD (Creutzfeldt-Jakob disease)
CJD - lyodura and the risk of exposure during healthcare - frequently asked questions We would like to reassure all our patients that tight regulations govern all infection control processes at Addenbrooke's,
PATIENT REGISTRATION
PATIENT REGISTRATION Patient Information Whom may we thank for referring you to our office? _ Date Preferred Name (Circle) Patient Name Age Birthdate M or F First M.I. Last Residence & Mailing Address
NEW PATIENT QUESTIONNAIRE Spine pt acct #
NEW PATIENT QUESTIONNAIRE Spine pt acct # Name: Date of Visit: Male Female (please fill in the circles) Date of Birth: Height: Weight: Age Today: What studies have been done on your spine? Where/When?
John Wayne Cancer Institute Dr. Foshag Dr. Faries Dr. Bilchik Dr. Leuchter
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PRE-ADMISSION MEDICAL EXAMINATION FORM (HIGHER NITEC IN EARLY CHILDHOOD EDUCATION) (SERVICE CODE FOR SATA: ITE-HS/EC/SS)
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www.blutspendezurich.ch EDV-Eingabe: Kontrolle Datum: : ja The recent questionnaire is available on www.blutspendezurich.ch Formulare & Dokumente. Please print and fill out clearly before donating! New
The Orthopedic Center of St. Louis John O. Krause, M.D. Orthopedic Surgery; Surgery of the Foot & Ankle NEW PATIENT INFORMATION
The Orthopedic Center of St. Louis John O. Krause, M.D. Orthopedic Surgery; Surgery of the Foot & Ankle NEW PATIENT INFORMATION Name: Email: Daytime Phone Number: Date of Birth: / / Age: How did you hear
DEPARTMENT OF MEDICINE Outpatient Intake Form
NAME: Last First Middle Initial Date of Birth: ADDRESS: HOME PHONE: WORK PHONE: Did someone refer you here? Yes No If yes, please give name: Main reason for your visit today: MEDICAL HISTORY: (Please check
Initial History Form
William C. Gorospe, M.D., Ph.D. Sebastian R. Stanciu, M.D. Christina L. Bailey, M.D. Initial History Form Welcome to First Coast Infectious Disease Consultants, LLC. In order for us to get to know you
REDDY & ASSOCIATES LLC D/B/A Reddy Medical Group D/B/A Reddy Urgent Care. Reddy Urgent Care Pre-Employment Physical Form
REDDY & ASSOCIATES LLC D/B/A Reddy Medical Group D/B/A Reddy Urgent Care 132 Franklin Springs St. 1061 Dowdy Road STE 100 280 General Daniels Ave. Royston, GA 30662 Athens, GA 30606 Danielsville, GA 30633
Donor Eggs Australia Summary of Male Patient Information Introduction
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Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.
Dear You are scheduled for an appointment with Dr. Manoj Kohli at Christie Clinic in the Department of Rheumatology on at. Please check in on the first floor. The office is located on the 2 nd floor of
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
HIV/AIDS. Kuna High School Mr. Stanley
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Student Health Services
MEDICAL RECDS of birth Home address City State ZIP Home phone number Gender identity: Pronouns: Chosen Name Class status (circle): First year Sophomore Junior Senior Graduate Postbac Premed IN CASE OF
Who is filling out this intake form? Self Spouse Parent Guardian
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Our staff will need to make a photocopy of the following: Insurance Card (front and back) Driver's License or picture identification
Long Island Pulmonary and Sleep Medicine Associates, PLLC Louis Saffran, MD FCCP Frank S. Coletta, MD FCCP Karen Mrejen-Shakin, MD FCCP Aviva Kamath, MD FCCP Sepideh Sedgh DO 200 North Village Avenue Suite
Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:
Patient Medical Information Name: First Middle Last Sex: M / F Age: Date of Birth: Social Security # Driver s License # Home Address: City: State: Zip Code: Home Phone: Occupation: Cell: Employer: Business
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: First Name: Address: City Postal Code: Home Phone: Work Phone: Age: Birth date (dd/mm/yr): Sex: M / F Height Weight Occupation: Alberta Health Care #: PLEASE CHECK