| Document Date: 2014-07-06 20:09:01
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City Reading / / Company I130 (identify previous malaria residency) Yes No Malaria Travel / Yes No B9 Travel / Section C. Travel / / Country Isle of Man / Northern Ireland / Falkland Islands / Australia / United Kingdom / Scotland / Wales / / Facility Blood Donor Centre / / IndustryTerm needle site / blood products / heavy machinery / / MedicalCondition bruise / cuts / leptospirosis / familial insomnia / syphilis / HIV / chest pain / chickenpox / genital herpes / shingles / rheumatoid arthritis / Chagas’ disease / Status Malaria / thyroid disorder / hepatitis C / hepatitis B / temporary numbness / low blood pressure / injury / miscarriage / hepatitis / bowel disease / illness / Tiredness / lupus / infections / head injury / No C9 Had chest pain/angina / Q fever / infertility / abdominal pain / iron deficiency / Yes No Previous malaria / Creutzfeldt-Jakob disease / cancer / acne / kind including melanoma / Fainting / malaria / CJD / stroke / diabetes / fever / pain / Nerve irritation / vomiting / autoimmune disease / diseases / rheumatic fever / blood clot / AIDS / epilepsy / Infection / cough / thrombosis / serious illness / Gerstmann-Straussler-Scheinker syndrome / tuberculosis / blood disorder / / MedicalTreatment blood transfusion / ear piercing / acupuncture / vaccinations / / NaturalFeature Channel Islands / Ross River / / OperatingSystem L3 / / Organization Human Research Ethics Committee / Blood Donor Centre / Australian Red Cross Blood Service / Blood Service / / / Position general practitioner / female sex worker / dentist / / Product ibuprofen / M-16 / M-9 / /
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Donor questionnaire Thank you for coming to give blood today. Your donation could save the life of someone or help them through an operation (surgical procedure). The Australian Red Cross Blood Service is committed to pr