Donor questionnaire
Wellness
The following questions ask about your wellness today.
- Are you feeling well today?
- Do you have a _________?
- flu
- sore throat
- fever
- infection
Drugs, vaccines
The following questions ask about medications and shots you may have taken.
- In the last 3 days have you taken medication, including Aspirin?(vitamins and birth control are excluded)
- 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
- In the last 3 months have you had a vaccination?
- 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)?
- In the last 6 months have you taken any of the following medications?
- Avodart
- Jalyn
- Dutasteride
- In the last 12 months have you had a rabies shot or a shot for exposure to hepatitis B?
- 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
- Do you have diabetes?
- In the last 3 days have you had dental work?
- In the last 14 days have you been exposed to someone with suspected or confirmed COVID-19?
- In the last 28 days have you had COVID-19?
- In the last 6 months have you consulted a doctor for a health problem, had surgery or medical treatment?
- In the last 6 months have you been pregnant? (female donors)
- In the last 6 months have you had hepatitis?
- In the last 6 months have you received blood or blood products?
- In the last 12 months have you had a graft?
- In the last 12 months have you had close contact with a person who has had hepatitis or yellow jaundice?
- Since 1980, did you receive a blood transfusion or blood product in the United Kingdom, France or elsewhere in Europe?
- Have you ever had malaria?
- Have you ever been pregnant, miscarried or had an abortion? (female plasma/platelet donors)
- Have you ever had a positive test for the HIV/AIDS virus?
- Have you ever had epilepsy or fainting?
- Have you ever had a coma or stroke?
- Have you ever had problems with your heart or lungs?
- Have you ever had kidney or blood problems?
- Have you ever had cancer?
- Have you ever had Crohn’s disease?
- Have you ever received a dura mater (brain covering) graft?
- Have you ever had Chagas' disease, Babesiosis or Leishmaniasis?
- 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
- In the last 3 months, did you return from a stay of less than 6 months outside Canada and the U.S.?
- In the last 8 weeks have you travelled outside Canada?
- 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.
- 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)?
- Have you spent a total of 3 months or more in France from January 1, 1980 through December 31, 1996?
- Have you spent a total of 5 years or more in Europe from January 1, 1980 through December 31, 2007?
- Have you spent a total of 6 months or more in Saudi Arabia from January 1, 1980 through December 31, 1996?
- Have you spent a total of 6 months or more in a continuous period in Mexico, Central America or South America?
- Were you born in Mexico, Central America or South America?
- Was your mother or maternal grandmother born in Mexico, Central America or South America?
Lifestyle
The following questions are lifestyle related questions
- In the last 3 months have you had a tattoo?
- In the last 3 months have you had skin or ear piercing?
- In the last 3 months have you had sex with a man who, in the last 12 months, had sex with another man? (Female)
- In the last 3 months, have you had sex with a man? (Male)
- In the last 6 months have you had acupuncture?
- In the last 6 months have you had electrolysis?
- In the last 6 months have you had an injury from a needle or come in contact with someone else's blood?
- In the last 12 months have you taken illegal steroids with a needle?
- In the last 12 months have you had or been treated for syphilis or gonorrhea?
- In the last 12 months have you been in jail or prison?
- In the last 12 months have you used cocaine?
- 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?
- In the last 12 months have you had sex with anyone who has ever taken illegal drugs with a needle?
- In the last 12 months, have you had sex with anyone who has HIV/AIDS or has tested positive for HIV/AIDS virus?
- At any time since 1977 have you taken money or drugs for sex?
- Have you ever taken illegal drugs with a needle even one time?
- Have you, in your past or present job, taken care of or handled monkeys or their body fluids?
- Did you make your last donation or last attempted donation at Héma-Québec?