Donor questionnaire for blood, platelets and plasma


The donor questionnaire captures relevant information about you and your donation. It is a confidential questionnaire that helps decide if you are eligible to give blood.

If there is a question you do not understand, or would like to discuss eligibility based on your responses, contact 1 888 2 DONATE (1-888-236-6283). This could prevent an unnecessary visit to one of our donor centres. Please note that final eligibility is determined by staff at the donor centre.

Blood, platelets and plasma questionnaire

Wellness

The following questions ask about your wellness today.
  1. Are you feeling well today?
  2. Do you have a _________?
    • flu
    • sore throat
    • fever
    • infection

Drugs, vaccines

The following questions ask about medications and shots you may have taken.
  1. In the last 3 days have you taken medication, including Aspirin?(vitamins and birth control are excluded)
  2. In the last month have you taken any of the following medications? (Click for more info)
    • Accutane
    • Epuris
    • Clarus
    • Isotretinoin
    • Toctino
    • Hanzema
    • Alitretinoin
    • Proscar
    • Propecia
    • Finasteride
  3. In the last 3 months have you had a vaccination?
  4. In the last 4 months have you taken any medication to prevent HIV infection such as pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP)?
  5. In the last 6 months have you taken any of the following medications?
    • Avodart
    • Jalyn
    • Dutasteride
  6. In the last 12 months have you had a rabies shot or a shot for exposure to hepatitis B?
  7. Have you ever taken any of the following medications?
    • Tegison
    • Soriatane
    • Human pituitary growth hormone

General Medical

The following questions are about your medical history
  1. Do you have diabetes?
  2. In the last 3 days have you had dental work?
  3. In the last 14 days have you been exposed to someone with suspected or confirmed COVID-19?
  4. In the last 28 days have you had COVID-19? 
  5. In the last 6 months have you consulted a doctor for a health problem, had surgery or medical treatment?
  6. In the last 6 months have you been pregnant? (female donors)
  7. In the last 6 months have you had hepatitis?
  8. In the last 6 months have you received blood or blood products?
  9. In the last 12 months have you had a graft?
  10. In the last 12 months have you had close contact with a person who has had hepatitis or yellow jaundice?
  11. Since 1980, did you receive a blood transfusion or blood product in the United Kingdom, France or elsewhere in Europe?
  12. Have you ever had malaria?
  13. Have you ever been pregnant, miscarried or had an abortion? (female plasma/platelet donors)
  14. Have you ever had a positive test for the HIV/AIDS virus?
  15. Have you ever had epilepsy or fainting?
  16. Have you ever had a coma or stroke?
  17. Have you ever had problems with your heart or lungs?
  18. Have you ever had kidney or blood problems?
  19. Have you ever had cancer?
  20. Have you ever had Crohn’s disease?
  21. Have you ever received a dura mater (brain covering) graft?
  22. Have you ever had Chagas' disease, Babesiosis or Leishmaniasis?
  23. Do you have a biological (blood relative) parent, child or sibling diagnosed with Creutzfeldt-Jakob Disease (CJD)?

Travel

The following questions are about your travel history
  1. In the last 3 months, did you return from a stay of less than 6 months outside Canada and the U.S.?
  2. In the last 8 weeks have you travelled outside Canada?
  3. In the last three and a half years have you spent more than 6 months in a continuous period outside Canada or the U.S.
  4. From January 1, 1980 through December 31, 1996 have you spent a total of 3 months or more in the United Kingdom (England, Northern Ireland, Scotland, Wales, the Isle of Man, or the Channel Islands)?
  5. Have you spent a total of 3 months or more in France from January 1, 1980 through December 31, 1996?
  6. Have you spent a total of 5 years or more in Europe from January 1, 1980 through December 31, 2007?
  7. Have you spent a total of 6 months or more in Saudi Arabia from January 1, 1980 through December 31, 1996?
  8. Have you spent a total of 6 months or more in a continuous period in Mexico, Central America or South America?
  9. Were you born in Mexico, Central America or South America?
  10. Was your mother or maternal grandmother born in Mexico, Central America or South America?

Additional questions

  1. In the last 3 months have you had a tattoo?
  2. In the last 3 months have you had skin or ear piercing?
  3. In the last 3 months have you had sex with a man who, in the last 12 months, had sex with another man? (Female)
  4. In the last 3 months, have you had sex with a man? (Male)
  5. In the last 6 months have you had acupuncture?
  6. In the last 6 months have you had electrolysis?
  7. In the last 6 months have you had an injury from a needle or come in contact with someone else's blood?
  8. In the last 12 months have you taken illegal steroids with a needle?
  9. In the last 12 months have you had or been treated for syphilis or gonorrhea?
  10. In the last 12 months have you been in jail or prison?
  11. In the last 12 months have you used cocaine?
  12. In the last 12 months have you had sex with a sex trade worker or anyone else who has taken money or drugs for sex?
  13. In the last 12 months have you had sex with anyone who has ever taken illegal drugs with a needle?
  14. In the last 12 months, have you had sex with anyone who has HIV/AIDS or has tested positive for HIV/AIDS virus?
  15. At any time since 1977 have you taken money or drugs for sex?
  16. Have you ever taken illegal drugs with a needle even one time?
  17. Have you, in your past or present job, taken care of or handled monkeys or their body fluids?
  18. Did you make your last donation or last attempted donation at Héma-Québec?
Questionnaire for donation at Sudbury (900 Lasalle Boulevard), Lethbridge (3735 Mayor Magrath Drive South), Kelowna (2271 Harvey Avenue – Orchard Park Mall)

Wellness

The following questions ask about your wellness today.
  1. Are you feeling well today?
  2. Do you have a _________?
    1. flu
    2. sore throat
    3. fever
    4. infection

Drugs, vaccines

The following questions ask about medications and shots you may have taken.
  1. In the last 3 days have you taken medication, including Aspirin?(vitamins and birth control are excluded)
  2. In the last month have you taken any of the following medications? (Click for more info)
    • Accutane
    • Epuris
    • Clarus
    • Isotretinoin
    • Toctino
    • Hanzema
    • Alitretinoin
    • Proscar
    • Propecia
    • Finasteride
  3. In the last 3 months have you had a vaccination?
  4. In the last 4 months have you taken any medication to prevent HIV infection such as pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP)?   
  5. In the last 6 months have you taken any of the following medications?
    • Avodart
    • Jalyn
    • Dutasteride
  6. In the last 12 months have you had a rabies shot or a shot for exposure to hepatitis B?
  7. Have you ever taken any of the following medications?
    • Tegison
    • Soriatane
    • Human pituitary growth hormone

General Medical

The following questions are about your medical history
  1. Do you have diabetes?
  2. In the last 14 days have you been exposed to someone with suspected or confirmed COVID-19?
  3. In the last 28 days have you had COVID-19? 
  4. In the last 6 months have you consulted a doctor for a health problem, had surgery or medical treatment?
  5. In the last 6 months have you been pregnant? (female donors)
  6. In the last 6 months have you had hepatitis?
  7. In the last 6 months have you received blood or blood products?
  8. In the last 12 months have you had a graft?
  9. In the last 12 months have you had close contact with a person who has had hepatitis or yellow jaundice?
  10. Since 1980, did you receive a blood transfusion or blood product in the United Kingdom, France or elsewhere in Europe?
  11. Have you ever had a positive test for the HIV/AIDS virus?
  12. Have you ever had epilepsy or fainting?
  13. Have you ever had a coma or stroke?
  14. Have you ever had problems with your heart or lungs?
  15. Have you ever had kidney or blood problems?
  16. Have you ever had cancer?
  17. Have you ever had Crohn’s disease?
  18. Have you ever received a dura mater (brain covering) graft?
  19. Do you have a biological (blood relative) parent, child or sibling diagnosed with Creutzfeldt-Jakob Disease (CJD)?

Travel

The following questions are about your travel history
  1. In the last thee weeks, have you travelled outside Canada?
  2. From January 1, 1980 through December 31, 1996 have you spent a total of 3 months or more in the United Kingdom (England, Northern Ireland, Scotland, Wales, the Isle of Man, or the Channel Islands)?
  3. Have you spent a total of 3 months or more in France from January 1, 1980 through December 31, 1996?
  4. Have you spent a total of 5 years or more in Europe from January 1, 1980 through December 31, 2007?
  5. Have you spent a total of 6 months or more in Saudi Arabia from January 1, 1980 through December 31, 1996?

Additional questions

  1. In the last 3 months have you had a tattoo?
  2. In the last 3 months have you had skin or ear piercing?
  3. In the last 3 months have you had sex with a man who, in the last 12 months, had sex with another man? (Female)
  4. In the last 3 months, have you had sex with a man? (Male)
  5. In the last 6 months have you had acupuncture?
  6. In the last 6 months have you had electrolysis?
  7. In the last 6 months have you had an injury from a needle or come in contact with someone else's blood?
  8. In the last 12 months have you taken illegal steroids with a needle?
  9. In the last 12 months have you had or been treated for syphilis or gonorrhea?
  10. In the last 12 months have you been in jail or prison?
  11. In the last 12 months have you had sex with a sex trade worker or anyone else who has taken money or drugs for sex?
  12. In the last 12 months have you had sex with anyone who has ever taken illegal drugs with a needle?
  13. In the last 12 months, have you had sex with anyone who has HIV/AIDS or has tested positive for HIV/AIDS virus?
  14. At any time since 1977 have you taken money or drugs for sex?
  15. Have you ever taken illegal drugs with a needle even one time?
  16. Have you, in your past or present job, taken care of or handled monkeys or their body fluids?
  17. Did you make your last donation or last attempted donation at Héma-Québec?