OMNI Blood Center
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Blood Donor Registration Form
Name
Age
Sex
Male
Female
Dependent Name
Blood Group
Select Blood Group
A+
A-
B+
B-
AB+
AB-
O+
O-
Address
Education Qualification
Occupation
Marital Status
Mobile Number
Last Donated Date
Last Blood Donation Type
Voluntary
Replacement
Patient Name
Hospital Name
Any Reaction
Last Meal Time
Are you willing to donate voluntarily if any one requires blood
Yes
No
Health History
Are you at present in good health?
Did you sleep well last night?
The following condition put you a risk of being infected with HIV(AIDS) and therefor precludes you from donating blood.Unprotected sexual contact with strangers/multiple sexual partners/Commercial sex workersI.V.Drug abuse/Anxiety and Mood DisordersAre you taking any medicine?
Do you have cold, Flu, Cough, Sore, Throat or Acute Sinusitis?
Do you have Fever?
In last 3 days
Have you taken aspirin and other NSAID's?
In Last 7 days
Any skin infection?
Are you suffered with migraine?
In last 15 days
Immunization (Cholera,Typhoid, Diphtheria, Diarrhoea, Tetanus, PlaguePolio and influenza) Swaine flu?
Vaccination (Small pox, Measles, Mumps and Yellow Fever)?
In last 3 months
History of Malaria duly treated?
In last 6 months
Tatoo?
Piercing (Ear, Nose, Lip, Tongue, Navel)?
Minor Surgeries?
Swollen Glands Weightloss Continuous Low-grade Fever?
Any Dental Extraction?
Are you suffered with Dengue and Chikungunya?
Are you visited ZIKA/West Nile Virus effected area?
In last 12 months
You and your family members received transfusion of blood and its components?
Close contact with individual suffering with Hepatitis?
You and your family member effected with Hepatitis B Injection?
Rabies Vaccination?
Major Surgeries?
Syphilis?
Are suffered with Thypoid?
GI Endoscopy/Acid Peptic disease?
Permanent Diferral
Cancer?
Heart Disease/Chest pain?
Abnormal bleeding Tendencies?
Diabetes-Controlled on Insulin?
Positive tes for Hepatitis-B and Hepatitis-C?
Chronic Nephritis?
Signs and Symptoms Suggestions of AIDS/HIV?
Kidney Diseases?
Chronic Liver Disease?
Tuberculosis?
Jaundice?
Polycythemia Vera?
Asthma?
Epilepsy?
Leprosy?
Schizophrenia?
Endocrine Disorders?
G6PD Deficiency?
Conjunctivitis/Osteamyelitis/Leishmaniasis?
Autoimmune disorders/Bleeding disordersMaglignancy/Polycythemia Vera/Hemoglobinopthies/ Severe Allergic disorders?
Medications-Salicylates/Antibiotics/Ketoconazole/Antibelminthic DrugsTiclopiding/Clopidogrel/Piroxicam/Acitretinor Isotretinoin/Finasteride/Dutasteride/Radioactive Contrast Material/Insulin/Any medication?
Vaccination to Japanese Encephalitis, Papilloma Virus, Meningococcal ad penumococcal Virus,?
Anti Arrhythmic/Anticonvalsion/Anticoagulant/Antithyroid/drugs/Cytotoxic Drugs/Cardiac Failure Drugs.?
Receipt of orgam stem cells/Tissue Transplant Blood Donors having delayed faints/Consecutive faints?
Respiration?
Risk Behavior?
Travel and Residence?
Minior non specific symptoms?
Chronic Sinusitis?
Open Heart Surgery/Cancer Surgery?
For Women
Pregnant or recently delivered?
Any abortion in last 6 months?
Breast Feeding(up to one year after delivery)?
Date of last Menstrual Period?
*Have you tested positive with COVID 19-Yes/No. If yes date of Covid positive? ?
*Have you taken Covid 19 Vaccination. If yes date of Vaccination?
Physical Examination
Weight
Hb
Pulse
Vein Puncture Site?
Blood Pressure
Temp.
Reason For Rejection
Tube No Of the Bag
Any Adverse reaction in donor during/ After Phiebotomy
Submit