ey Poona Modical Rollat & Rosoarch Foundation’s POONA SEROLOGICAL INSTITUTE BLOOD CENTRE C.T.S No, 692 3rd Floor Dhanwantarl Complex, Noar Tarachand Hospital Rasta Poth, Puno = 411.011 Ph, No, 2013 3907/2614 1719 Mob, No, 72496 42613 wre Mig. Lie. No. PD/32 Ht Blood Donor Consent Form For Blood Bank Use o Date. Time: Unit No, Name. Segment No Address, Batch No Company Email typo __[as0z0] spmeneaone] [erDAeon] Mob. No. Hb — 9m% Pedal Oodema Yous No pps uvbing Yes/No Date of Birth age Years | puso_____‘Lymehadenopetny: Yes/No Temp sei rerele. wee ts ‘Venipunciure site : Cubital Vein - Middie / Latorat / Mociarr 1. Ageia: 18106 year_weignt:43 Kgscor Mora Ho>tzgmy | venpeare ole: Cuba Iiefiscfatseicties Rtcrea tive eeaet ct ve slaty Votorstariy Wieck wry | (Kaen or aaa ee ferns ir unl laes providon racked crralion it dota blow (7) This wherever applicabie 4) Do you feel well today? YesINo 2) Did you have something {o eat in the last 4 hours? 3) Did you sleep well last night? YesiNo 4) Have you donated blood in the last three months? 5) Have you donated Platelets in last 28 days ? If Yes, was the Red Cell Rediflusion completed 6) Have you had Malaria or taken Antimalaral drug in the last 3 Months? 7) Have you had Zika Virus / West Nie Virus / during in the last 4 Months, Osteomyolits (2 Years)? 8) Have you had UTI /Acule Infection of Kidney during in the last 6 Months ? 9) Have you had Typhoid during in the last 12 Months? 40) Have you taken medicine Today / Aspirin in last 3 days? 11) Are you Air Crew Member / Long Distance Vehicle Driver / Night Shift Worker 12) Have you taken any medicine in ine last 7 days especially steriads ot antibiotics or Ketoconazole, ‘Antinelminthic and Mebendazoto. 13) Have you taken any medicine in the last 14 days especially Ticlopidine, Ciopidogral, Piroxicam Dipyridamole, 14) Have you taken any medicine in the las! One Month Like Etretinato, Acitretin ar Isotretinoin (Uses for Acno) Finasteride, used to Treal Benign Prostatatic Hyperplas! 15) Alter donating blood do you have to engage in heavy work. YesiNo Driving heavy Vehicle or work at height Today? 46) Did you have any discomfort during prior blood donation? ‘YesiNo 17) Have you consumed Alcohol in last 24 hours ? i 18) Have you blood ever tested Posilive for Hepatitis B or C 7 YesiNo 19) Have you any reason lo believe thal you may be infected by eithter YesiNo f Pt HE YesiNo Hepatitis, Malaria, HIV/AIDS, Vencreal disease? 20) Have you or your's close contact had Jaundice in the last 1 Year? ‘YeaNo 24) Conjunctivitis (il treatmentis over) and migraine (non-savere) : 22) Do you suffer or have suffered from any of the following? (Permanently Defer) —_ yone Conwulsions & Epilepsy Asthmatics aitack or on sterolds Any Heart Disease Leishmanioasis High / Low BP Abnormal Biooding Tendency Kidnoy Disease Leprosy Renal Falluro Faintting Attacks: Lungs Disease ° _Dibotes a22) Ifany Medicine Taken Like, YosiNo ‘AntiArmhythmic, Anil-Convulsions, Anticoagulant, Antl-Thyrold Drugs, Cylotoxle Drugs, Cardiac Failure Drugs (Digitalis), Insulin etc. 23) Have you any immunized or vaccinated in last 28 days, (Live Aitenuated Vaccines) YesiNo Polio Oral Measles (Rubella) Yollow Fever Cholera Typhoid Hepatitis 'A" Mumps Anti Diphtheria Serum: Infuenza Japanese Encephalitis ‘Anti Tetanus Serum AntiVenomSerum Anti Gas Gangrene Serum, 24) In the last 6 months have you had any history of the following? Repeated Diathea Persist Cough Night Sweats General Malaise Pain headache Mumps Chicken Pox Measles Continuous low-grade fevor Swollen Glands Dengue Osteomyelitis Migraine Conjunctivitis Tooth Extration Danial Surgery Prostatic Hyperplasia Minor Surgery Radioactive Contrast with in 8 weoks 25) During past 12 months have you had any of the following? Blood Transfusion Any Accident or Operation Body Piercing _G. |. Endoscopy YesiNo Tattooing Dog Bite/ Anti Rabies Vaccine Scarfication, Cosmetic Procedure YesiNo YesiNo 26) Have you any immunised or vaccinated in last 14 days. (Non-live vaccines) Whooping Cough Tetanus Plague iheria. Hepatitis Swine Flu Covid-19 Typhoid Cholera Palio Influenza Pertussis Papilloama Virus Meningococcal Neumococcal Globulin 27) Are you a Resident of other Counties 7 ‘Accept only afier stay in india for Three years continuous ? YesiNo 28) For Female Donors A)Are you Pregnant? B) Have you had an abortion in the last 6 months? C) Do you have a child less than one year old? D) Are you on breast Feeding? E) Have you donate blood in past 4 months? F) Are you in menses now? Consent : Blood Safety begins with a Healthy Donor J understand that - a) Blood donation Is a totally voluntary act; and no inducement or remuneration has been offered. b) Donation of blood/components is a medical procedure; and that by donating voluntarily. | accept the risks associated with this procedure. ¢)_ Myblood will be tested for Hepatitis B, Hepattis C, Malaria Parasite, HIVIAIDS and Veneral Disease in addition to any other screening tests required to ensure blood safety. d) The blood donated by me will be used in such a manner as the blood center may deem desirable, as per prevaling guidelines / regulations e) Would you like to be informed about any abnormal tost result, Ifyes, Please contact us f) _ Mydonated blood, blood and plasma recovered from my donated blood may be sent for plasma fractionation for preparation of plasma medicinal products, all of which may be used for larger patient population and not just this blood bank. Ihave read and understood all the information presented and answered alll the questions truthfully, as any incorrect statement or concealment may affect my health or may harm the receipient. Reason for Deferral -