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Donor Recruitment Form
Pre-Qualifying Questions
1. Have you been diagnosed with diabetes and are on medication or require insulin injections
Yes
No
*If yes – the cannot register and the following message should be reflected
2. Are you HIV Positive
Yes
No
*If yes – the cannot register and the following message should be reflected
3. Have you had or are currently receiving treatment for cancer.
Yes
No
*If yes – the cannot register and the following message should be reflected
PERSONAL INFORMATION
FIRST NAME *
LAST NAME *
NRIC/FIN/Passport No*
SXXXX
Date of Birth *
Contact No/s *
EMAIL ADDRESS: (Please provide a valid address) *
Sex *
Male
Female
Citizenship *
Singapore Citizen
Permanent Resident
Others
Ethnicity *
Chinese
Indian
Malay
Others
Father’s Ethnicity: *
Mother’s Ethnicity: *
MAILING ADDRESS: (Blk/Apt/House No. & Street Name)
Unit No: (If applicable)
Postal Code:
OTHER CONTACT DETAILS
Name *
Contact No *
E-mail(Optional) *
Name *
Contact No *
E-mail(Optional) *
DONOR MEDICAL EVALUATION
1. Have you ever been refused as a blood donor? *
Yes
No
2. Have you ever received a blood transfusion *
Yes
No
Please indicate with a TICK next to condition(s) which you have ever had or are currently having:*
1) Anaemia (more than one occurrence)
7) Eczema and/or Hives
13) Hypertension
2) Asthma/Breathing Problems
8) Gout
14) Irritable Bowel Syndrome (IBS)
3) Severe-Chronic Back Pain
9) Heart Murmur
15) Thyroid Disease
4) Blood Clots/Deep-Vein Thrombosis
10) Hepatitis
5) Depression
11) High Blood Pressure
6) Excessive Bleeding (with the exception of menstrual cycle and bleeding gums)
12) High Cholesterol
Are you on any long term medication or have a condition which is not mentioned above? *
Yes
No
Please indicate the name of the condition or medication *
Is the condition stable and well controlled with medication *
Yes
No
Your Consent
Name
date
Signature
A DONOR FOR EVERY PATIENT
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